Seizures - letting go or intervene?

[Bernhard]

I recently overheard a talk between a nurse and an epilepsy patient, where the nurse states, that "nowadays we don't do something when a patient seizures, just wait and monitor". She actually said this twice in the talk and acted like this was actual knowledge and commonly known in the medical field. The talk was about the patient with a known epilepsy, wanting to debate the procedures in a (his) possible emergency. It is a neurological ward, the nurse is the chief nurse on this ward.

Unfortunately I couldn't ask the nurse for some real source of this statement.

At home I checked the most-recent national seizure guidelines, covering pre-clinical as well as hospital treatment, and they give a fast intervention as standard (drugs, oxygene, ...), with the target to break the seizures as soon as possible. However, those guidelines are from 2008 (last updated/revised, originally they are from 2002).

Does anyone know about new treatment strategies to simply wait for a seizure to stop for itself?

Some years ago I had several discussions with fresh medics from one specific school, who told me that giving no oxygene in seizure would terminate it earlier, so giving oxygene would be false treatment. After beeing confronted with 1) guidelines and 2) the question for the base of their statement, the discussions usually went silent soon. Some neurologists I asked and finally, our organizations state-wide chief medical director made clear, oxygene still is within the treatment plan of seizures if indicated by cyanosis and/or low SpO2-readings.

So I smell another strange thing here, only now it's not some fresh minted medic from just one school with a possible misunderstood teacher, but the well respected chief nurse of a neurological ward...

As soon as I have the chance and time, I will get back to this nurse or someone other of this hospital/ward to check things, but maybe someone already has some insight here. Would be great!

[Bieber]

The most recent info I've read still calls for the treatment of seizures lasting longer than five minutes, citing that neurological damage is suspected to occur after about 20 minutes of continuous seizure activity. As far as withholding oxygen, someone smarter than me is going to have to explain that because it's my understanding that seizures rapidly burn through brain oxygen and glucose stores, which is why we give supplemental oxygen to both actively seizing patients as well as those who are postictal.

[mobey]

_{I have heard discussion about this as well.}

_{The pop-cooler chat I heard was the theory of allowing a single seizure in a known epileptic continue for 5-10 mins before interveining. The idea is that a seizure may resolve and we can spare the patient from unessesary medication administration and hospitalization due to the sedative effects of those drugs.}

_{I have no evidence to solidify this, nor do I know of it being an actual practice out there. It is just something overheard from a Doc talking to a MD student.}

[DwayneEMTP]

All seizures are not created equal, right? Perhaps they didn't have Grand Mal seizures but focals? Or not true brain storm seizures at all but were investigating seizures of another origin? Not sure....

Even Grand Mal seizures vary in intensity and duration...Could it have been from that point of view? Less aggressive, short duration history still under investigation?

[croaker260]

There is a big difference with SZ in a patient with KNOWN severe SZ history with a single continues SZ , who has multiple SZ a day (the patient you would typically expect on a neuro ward) and the patient who has no previous Hx, or who has a mild SZ history but who has been previously well controlled.

Most of the patients /patients care givers whom I see with severe SZ history have a 20 minute and/or refractory to diastat rule. If the patient does not respond to diastat, or goes on for 20 minutes, then we (EMS) get called with the expectation we may intervene. This is based on guidance from one of our areas neurologist who specialized in pediatric neurology. It seems to be a common approach.

Any patient who fits outside this demographic described above... I would be much more likely to intervene quickly, including the "unknown history" patients, the chronic alcoholics, drug involved patients, patients with multiple SZ who are previously well controlled, adult febrile patients, etc.

Now a little bit of "street smatz": it is actually pretty rare to see a SZ in the field in an epileptic (meaning the high functioning well controlled patient, not the who is near bedridden with multiple medical issues). They tend to have resolved PTA of EMS in 90% of cases, so just seeing a SZ raises my index of suspicion simply because its outside the norm for even this class of patient. This is not evidence based, simply observation based, but it may keep you from overlooking something serious.

Edited January 13, 2012 by croaker260

[Bernhard]

Thank you so far, maybe she meant to wait some time before intervening.

Our guidelines (which are national guidelines and valid for hospital care as well) state to intervene in a status only, which is defined as more than 5 minutes of generalized or more than 20 minutes of focal seizures. When we arrive as EMS and still see a seizure, then it most probably lasted longer than 20 minutes...

In a neuro ward this is another case, they see seizures from the beginning. But the nurse didn't sound like she talks about just the constraint of 5 minutes until intervention (they were discussing generalized seizures). The patient was very irritated. OK, may have to ask for their protocols to find out more.

[krumel]

First I have a very strong feeling that I know the nurse your talking about... Give me a PM.... And I guess I know the school of the "young one" as well....As I once (yeaaaaaaarrrrrsss) ago went there to I asked back then whats the scientific base for this thesis...And there simply is none....

But back to topic:

I definitly go the way croacker described in his post.... Consider the fact that something made people call EMS.... You (normally) don't get called for an known epileptic patient who is known to have 20 seizures a day.... You may see those patients in a transfer...But you then will know before....

When you get called usually something already went wrong.... Which means a known and medication-controlled epilepsy patient is having "a bad day" and has seizures again or something else made people not to exspect a seizure....

When you then consider the fact that you as an EMS Provider need some time to arrive on scene.... By then it is for sure a "status" or "intervention-worth seizure"...

And as far as I know the worlwide common oppinion (beside some nurses) is: a status/ongoing/longgoing seizure needs fast intervention... and in case of a hypoxia (which normally is the case) some O's..

Edited January 13, 2012 by krumel

[AZCEP]

All seizures are not created equal, right? Perhaps they didn't have Grand Mal seizures but focals? Or not true brain storm seizures at all but were investigating seizures of another origin? Not sure....

Even Grand Mal seizures vary in intensity and duration...Could it have been from that point of view? Less aggressive, short duration history still under investigation?

Well done sir.

That was what I was thinking as I read the original post. God forbid we have to think about what we are doing though.

[aussiephil]

I also note here that this comment was made by a nurse in a neuro ward. A nice, clean, well lit, well controlled environment................

Thinking about the prehospital environment & thinking about where we find our patients & how long they have been seizing for, is it appropriate to compare treatments offered in a neuro ward to what we do pre hospital?? I mean that same pt in a neuro ward will have medical attention almost immediately. If they were at home, medical attention is maybe 15 minutes away.

[Bernhard]

Had the opportunity to see a patient from this same hospital, didn't meet the nurse in question, though. The patient seized (generalized epileptic seizure) and the doctors intervened at once, breaking the seizures.

My world is in order again.