Teaching Points :::: Seizures

[Ace844]

Teaching Points :::: Seizures

Hello Everyone,

Since there has been a lot of on going discussion and questions about 'Seizures' I thought that I'd take the time to do a teaching post on the subject. If anyone else has helpful educational teaaching material to contribute to this then please fee free. This post will start as a short Q&A 'bulleted point' formated type post and evolve from there as I and others have time to update and continue it. I will touch only briefly on the pharmacology in this first post.

First I want to refer you all to these links on related discussions here. there is alot of anecdotal and 'factual' information available in all of them for you to peruse and learn from. Here they are::

http://www.emtcity.com/phpBB2/viewtopic.php?t=5031

http://www.emtcity.com/phpBB2/viewtopic.php?t=372

http://www.emtcity.com/phpBB2/viewtopic.php?t=4797

http://www.emtcity.com/phpBB2/viewtopic.php?t=1183

http://www.emtcity.com/phpBB2/viewtopic.php?t=4269

http://www.emtcity.com/phpBB2/viewtopic.php?t=4497

http://www.emtcity.com/phpBB2/viewtopic.php?t=4423

http://www.emtcity.com/phpBB2/viewtopic.php?t=4382

http://www.emtcity.com/phpBB2/viewtopic.php?t=3817

http://www.emtcity.com/phpBB2/viewtopic.php?t=3727

http://www.emtcity.com/phpBB2/viewtopic.php?t=3614

http://www.emtcity.com/phpBB2/viewtopic.php?t=3574

http://www.emtcity.com/phpBB2/viewtopic.php?t=3097

http://www.emtcity.com/phpBB2/viewtopic.php?t=2667

http://www.emtcity.com/phpBB2/viewtopic.php?t=2812

http://www.emtcity.com/phpBB2/viewtopic.php?t=2568

http://www.emtcity.com/phpBB2/viewtopic.php?t=810

http://www.emtcity.com/phpBB2/viewtopic.php?t=2048

http://www.emtcity.com/phpBB2/viewtopic.php?t=340

Now on with the post!

SEIZURES

1.) What is a seizure?

Seizures are the result of excessive or chaotic discharge from cerebral neurons. Although most clinicians call the resulting effect (e.g. jerking movements, staring, etc..) a seizure, the seizure is actually the neuronal activity itself. The observalble manifestation is called seizure activity.

The importance of seizures is obvious. Something is interfering with the normal functioning of a group of neurons. Studies that control for the buildup of metabolic by-products show that it is the abnormal electrical activity itself, not the buildup of metabolic by-products, that cause neuronal damage and death. For an unknown reason, the hippocampus seems especially susceptible to this type of damage.

2.) How do I recognize a seizure?

This is not as obvious as it may seem.Seizures can present in a variety of ways depending on the size and location of the area of the brain involved. Generally seizures fall into Four catagories: Focal, Generalized, and Focal with Secondary generalization, Atypical seizures. A Focal seizure is confined to a particular area of the brain and effects only a given area of the body. A generalized seizure manifests itself by seizure activity which involves the entire body. A focal seizure with secondary generalization initially effects only one area of the brain, which then spreads to involve the entire area of the brain. The initial manifestation is isolated to a particular body area but spreads to involve the entire body. Atypical seizure activity is much more difficult to recognize. If a seizure has occurred but has stopped before you as a clinician are seeing the patient you should look for secondary signs including; post-ictal confusion, incontinence of urine and or feces, biting or trauma to the buccal mucosa, and secondary trauma.

CLASSIFICATION OF SEIZURES

Generalized

A.) Tonic-Clonic ( Grand Mal): (Manifestations): +LOC, followed immediately by tonic contractions of muscles,

then clonic contraction of muscles (jerking) which may last for several minutes or more. A period of disorientation

(post-ictal period) occurs after tonic-clonic activity.

B.) Abscence (Petit mal):(Manifestations): Sudden loss of awareness with cessation of activity or body position

control. This period usually lasts for seconds to minutes and is followed by a relatively short post-ictal phase.

C.) Atonic (Drop Attacks):(Manifestations):Complete loss of postural control with falling to the ground soemtimes

causing injury. Usually occurs in children.

Partial or Focal

A.) Simple Partial:(Manifestations): Multiple patterns are possibledepending on the area of the brain affected. If

the motor cortex is involved, the patient will have contraction of the corresponding body area.If non-motor areas

of the brain are involved, the sensations may include parathesthias, hallucinations, deja vu, certain smells,

sounds,

tastes, etc..

B.) Complex Partial:(Manifestations): Usually there is a loss of ongoing motor activity with minor motor activity,

such as lip smacking, and walking aimlessly.

Partial with Scondary Generalization

Initial manifestations are the same as partial. However the activity progresses to involve the entire body, with

loss of postural controland possibly tonic-clonic muscle activity.

3.) What is "Status Epilepticus"?

An 'epileptic seizure that is so frequently repeated or so prolonged as to create a fixed and lasting epileptic condition'. traditionally this defination applies if the seizure lasts longer than 30 mins. or is occurring for greater than 5 minutes or has multiple bouts of seizure activity with no inter-ictal recovery. Current reccommendations and descriptions are that occurring for greater than 5 minutes or has multiple bouts of seizure activity with no inter-ictal recovery and is unlikely to spontaneously stop should be considered 'Status Epliepticus'. treatment should be started with in this 5 minute time frame.

Patients in whom 'Status epliepticus' is diagnosed require a thorough and extensive work up and evaluation. This should include a complete evaluation to identify and treat any underlying and reversable precepitating causes of the 'status epilepticus' and rapid intervention to terminate the abnormal neuronal activity. full medical support to prevent medical complications from the seizures or their therepy (i.e.respritory depression, aspiration, rhabdomylosis, hyperpyrexia, etc..) is important.

4.) How are seizures stopped?

If a seizure lasts longer than 5 minutes, immediate intervention is indicated. In traditional medicine, the ususal sequence is diagnosis, then treatment. Often in Emergency medicine, it is necessary to diagnose and treat simultaneously. In an emergent condition, do not wait until after taking the history, and doing a complete physical examination, and ordering or doing ancillary testing before addressing on going seizure activity.

[marq=left:ff3dfcac0a]SEIZURES DAMAGE THE BRAIN; THE LONGER THEY ARE ALLOWED TO CONTINUE, THE MORE DAMAGE OCCURS.[/marq:ff3dfcac0a]

5.) What is the initial approach to a patient who is having seizure activity?

As always not including the universal scene safety, BSI-PPE, and having all necessary equipment the clinician should address the patients ABC's, addressing all the vital signs. (below I will cover the treatment basics)

Airway and Breathing:: You should first direct your attention to the patients airway and I will also address breathing here as well since they go hand in hand. Some specific considerations and things to pay particular attention to in this patient population are; airway patency, potential presence of foreign objects, aspiration risks- (blood, vomit, hypersecretions, in the airways, etc..) Breathing adequacy and frequency. For NEARLY ALL Seizure patients should at least be provided with supplemental oxygen therepy, suction as needed, because of the increased metabolic and O[sub:ff3dfcac0a]2 [/sub:ff3dfcac0a] demands-requirements physiologically which this patient is experiencing, due to many factors including excessive muscle contractions. Next, if the patient is experiencing full body tonic-clonic seizure activity, or status epilepticus, etc.. their diaphragm and intercostal muscles are either paralyzed, or contracting chaotically! THUS YOUR PATIENT IS NOT BREATHING ADEQUATELY, NOT TAKING ADEQUATE TIDAL VOLUME BREATHS, AND IS NOT BREATHING!! Complicate this further with fluids and or other substances in the airway and the aspiration risk which comes with that and you can see why it is necessary to do all you can withing your scope to place, secure, and ensure an ADEQUATE PATENT AIRWAY FOR YOUR PATIENT!! ( For BLS this could be an OPA or NPA and suction; for ALS this would mean RSI or PAI, and ETI). After palcement of the airway device the patient should be ventilated until they regain their innate respiratory drive or are able to do so adequately on their own. Furthermore, some of the medicines which you are administering also have sedative effects which will effect your patients ability to maintain their own airway. Suctioning should be done during the seizure but the clinician should be awre of the prescence of trismus during seizure activity. ALso the clinician should be careful what objects they place in the patients airway as the patient may bite or clench without warning and then whatver object is causght further becomes a risk for aspiration.

Circulation:: Evaluation of the patients cardiovascular status with determination of HR, B/P, and cap-refill as well as acquisition of an ECG and subsequent correction of all life threatening, and reversable causes, fluid and hydration status evaluation and administration as necessary with IVF, and a FSBS with correction as necessary addresses circulation. Attention should also be paid to the patients temperature and prompt response to abnormalities are important.

The most active interventions requred by the clinician in the setting of a patient experiencing an active seizure is directed ( in no particular order) toward preventing further injury, airway adequacy-patency-protection, treatment of reversable-preventable casues, and prevention of aspiration. Next here are some of the pharm agents used to treat a seizure patient.

Benzodiazepines are the first line drugs of choice for treating seizures that last longer than 5 minutes. Lorazepam is the preferred first-line benzodiazepine for treating seizures because of its apparent increased efficacy and longer half-life in keeping seizure activity from recurring when compared with diazepam. Although it should be noted that even though valium has a shorter half-life, it does decrease the sentivity of the GABA receptors to further 'excitability& repeated neuronal discharge'. Often in clinical practice it is provider-clinician dependent on what each individual uses.

If multiple doses of benzodiazepines fail to stop the seizure activity or benzos are contraindicated in that particular patient. Then one should consider a loading dose of a primary anti-convulsant ( Phenytoin, phenobarbital, fosphenytoin, pentobarbital, propofol, lidocaine). it should be noted that although bezodiazepines will halt or stop the peripheral motor activity "seen" during a seizure they may not actually 'truely' stop the seizure which will still be occuring in the CNS neurons..

Anticonvulsants are drugs most often used to stop seizures or to keep seizures from recurring. These drugs not only keep seizures from recurring in the ED, but as aforementioned are also used to stop seizures refractory to benzodiazepines.

6.) What are the most common causes of seizures by age group?

Most common causes by age group are listed below. Here are some other common and reversable causes for which the clinician should be vigilant for, these include; hypoglycemia, thermic issues, electrolyte abnormalities, and hypoxia.

A.) Infant:

Birth Trauma ( hypoxia, Intra-crainial trauma)

Infection (brain abscess, meningitis, sepsis)

Electrolyte Abnormalities (Hypo-natremia-calcemia-magnesimemia)

Congenital Malformations (intercerebral cysts, hydrocephalus)

Genetic Disorders (inborn errors of metabolisim, pyroxidine deficency)

B.) Child

Febrile Seizure

Idiopathic

Trauma

Infection (meningitis)

C.) Adolescent

Trauma

Idiopathic

Drug or alchol related (acute intoxication or withdrawl syndromes)

Arteriovenous malformation

D.) Young Adult

Trauma

Alcohol

Brain tumor

E.) Older Adult

Brain tumor

Stroke

Intra-cerebral hemmhorrage

Alcoholisim

Metabolic derrangements ( hypo-natremia-calcemia-glycemia-uremia, hepatic failure)

7.) What's important to report and document about the seizure itself?

The history is vitally important!! Here's a great mnemonic to help you; COLD to be sure you have covered the aspects of the seizure itself.

Character:: What type of seizure activity occurred?

Onset: When did it start? What was the patient doing?

Location: Where did the activity start?

Duration: How long sis it last? How long was the post-ictal period, and was there a prodrome or post drome (warning

signs)?

In general, true seizures tend to occur abruptly, are stereotyped ( the basic features are the same from one 'attack' to the next), are not provoked by environmental stimuli, are manefested by movements that are purposelessor inappropriate, and, except for petit mal seizures, are followed by a period of confudion and lethargy ( the post-icatl period). Other important points include the pateints PMHX (especially previous sz hx), alcohol and or other toxic exposures-ingestions, current medications, any history of CNS neoplasms, and history of recent or remote trauma.

8.) Besides the Neurologic exam, what other parts of the P/E are important and why?

A complete head to toe exam is important. In addition to looking for the causes of the seizure the clinician should also be alert for secondary trauma caused by the seizure. the exam is often normal but occassionaly can yield clues as to underlying cause. Specifically examination of the skin might reveal lesions consistent with meningococcemia or other infectious etiologies.

Examine the head for trauma, if nuccal rigidity is found meningitis or subarachnoid hemmhhorage should be suspected. A heart murmur (in the setting where there wasn't one present before or no PMHX) might indicate subacute bacterial endocarditis, with resultant embolization being the cause of the seizure.

The neurologic exam is important. Focal neuro findings, such as focal paresis after the seizure (Todd's Paralysis) may indicate the presence of a focal cerebral lesion (tumor, abscess, cerebral contusion, etc..) as the cause of the seizure. Evaluation of the nerves and the fundi can indicate increased intracrainial pressure.

9.) What ancillary (lab) tests should I order (do) for a seizure patient?

In general the use of ancillary lab tests depends on history and presentation of the patient. In the patient who is on anti-convulsants and has a prior history, and presents with a single unprovoked seizure, the only study useful is a 'serum anti-convulsant level'. If the level is sub-therepeutic, the patient should be given a loading dose of this medication to achieve the appropriate therepeutic level. the decision to evaluate the patient with other ancillary tests (lab and radiologic) should be based on the findings of the H&P. If there are questions about whether the patient had a major motor seizure some of the followign tests are helpful.

A.) Serum Electrolytes

Although the yield is usually quite low , but a screen for metabolic derangements ( NA+, Ca2+, glucose, magnesium, BUN, Creatnine,) are important.

B.) If blood was drwan shortly after the seizure pre-hospital, then have the lab an anion gap value and calculate the anion

gap.

This is determined by a blood sample drwn as close to the time of seizure as possible. A second one may be done

as well on ED presentation to help further establish this trend.

A patient who has had an a major motor seizure will have an transiently increased anion gap (less than 1 hr duration anion

gap increase will be found). The presence of this is good evidence a 'grand-mal seizure has occurred.' if there is no A-gap

acidosis detected, then one may presume that the patient 'DID NOT' have a major motor seizure.

C.) Toxicologic screens

Tox screens targeted for substances which are known to cause seizures 9Cocaine, lidocaine, antidepressants,

theophylienne, and stimulants are among the most common) and should be obtained if there is suficent clinical suspicion.

D.) Prolactin Level

Measurement of a serum prolactin level from a blood sample (drawn approx. 20 minutes post seizure activity) help

differentiatea true seizure from a pseudo-seizure. In true seizures prolactin levels are elevated by at least 2x's where as in pseudo-seizures prolactin levels remain 'WNLs'.

10.) What is a pseudo-seizure and how is it diagnosed?

Pseudo-seizures are seizure like activity with no abnormal underlying electroactivity in the brain. They are difficult to diagnose, even in the ED. Methods which have been shown to work in some cases are as follows:

A.) Suggesting to your patient that the seizure will stop soon.... Then it does... :roll: :shock:

B.) Attempting to distract the patient with loud noises or bright lights during the 'seizure' activity

C.) The hand-drop on the face method

D.) Placement of an NPA causing miraculous recovery and the patients desire to remove it immediately. :wink: 8)

E.) During 'seizure activity' a forward thrusting movement of the pateints pelvis is noted, and their eyes are being deviated

towards the ground no matter what position the head is placed in, and asynchroynous movement of the extremities.

F.) Seizure stoppage post introduction of an Ammonia inhalent in close proximity to or in the nares. :wink:

G.) Have a friend or family member talk to your patient during their seizure thus causing them to open their eyes.

H.) Suggest that you have a new 'anti-seizure drug' in the med box and bolus NACL via hep-loc with great effect. :shock:

Next patients experiencing 'pseudo-seizures' will not have an anion gap acidosis a normal EEG (when taken during focal motor activity), and a normal range prolactin level.

Hope this Helps,

ACE844

[AZCEP]

Consideration needs to be made that while RSI may well stop the motor activity of the seizure, it will not stop the actual seizure activity in the brain. I've witnessed a number of providers wrongly assuming that because the patient is no longer moving, they are not seizing. The sedative agent that is used will greatly determine whether the seizure recurs or remains controlled.

Versed is a very good, rapidly acting agent to break a benzodiazepine responsive event, but it does not last long enough to prevent recurrence. Ativan has a much longer duration, but it's onset is also significantly slower. Valium is a good middle ground, and still the most commonly used agent. If prolonged sedation is the goal, break the seizure with Versed, then add some Ativan in shortly thereafter.

A close watch on vital signs must be maintained for these patients that have been given a paralytic. Heart rate, in particular, can help you to determine whether the sedation has worn off, or the seizure has recurred. A short acting paralytic, such as Succinylcholine, will also cause a situation where you may have to re-dose due to it's short duration. An unacceptable amount of damage can be done by a provider trying to limit motion of the patient, while trying to maintain a secured ETT.

[Ridryder 911]

Maybe, we should start considering true "seizure" med's. I worked at a service that we carried Dilantin and Cerebyx, if the patient was a known seizure patient, and had been on Dilantin, with a hx of < or absent Dilantin. Baseline levels were drawn prior to administration. Treating again the etiology, not just the symptoms.

I agree, so many think because we have stopped the external symptoms the seizure has stopped... "a foolish thinking".. inside the brain maybe still seizing, it is we now just don't see the seizure.

We need to explore and research more treatments for seizure patients and aggressive therapy.

R/r 911

[Just Plain Ruff]

Rid, what are the pitfalls of administering dilantin or the other med you noted without having the actual level before giving it.

More info please? I think it's a great idea but I know many many doctors who would stroke out if I gave dilantin to a patient without knowing the actual blood level first. Drawing the blood is a good first step but what considerations need to be taken.

I've worked for a service that had every med in the book in the ambulance including enough insulin to start a drip. I'm just curious that's all.

hint hint note to self ---- read up on drugs again.

[Ridryder 911]

I do understand the dangers of especially Dilantin tox. etc... the protocols were specific on history of ..."Hx. off non-compliant to Dilantin".. draw and obtain Dilantin level, then start on loading dose... of course monitor, etc..

My medial director was very visionary, since this was over 18 years ago..we performed it quite often, since the number one cause of seizures with hx. of such is non-compliant to med.'s... Yes, it did reduce the seizures, and yes we were allowed to administer muscle relaxants, (Valium, etc..) as well.

Definitely, something that needs formal research, may be a bad idea, or good.. it worked at that system in a very rural, poor economic area....

R/r 911

[AZCEP]

Shame on you Rid!

Back in the box, no cookie for you! Bad, thinking medic!

[whit72]

What are the symptoms of dilantin tox.

I have seen slurred speech, dizziness, loss of balance, and rapid eye movements is there a symptom that is exclusive to dialntin tox. ?

I heard somthing about overgrowth of gums. Is this a true indicator? Is that just a sign of prolonged use?

[Just Plain Ruff]

Rid your med director does sound visionary. I'd have been happy to work under him.

I think that with enough training and the appropriate protocols that this would not be a big deal to admin even now.

I'll have to read up on dilantin and such.

[Ridryder 911]

Yeah, to think he initially hated EMT's.... When he agreed to take over as medical director in that small rural town he described he would, but there would have to be certain criteria. He was from Dublin, Ireland and used to some aggressive treatments... This was in 1985-1988, and we were performing multi lead placement (before XII lead was made prehospital) and RSI, and performed an FDA blind trial study for use of tPA, and O- in the field, as well as central lines.. although the town was only about 10,000 we ran a lot of surrounding areas, so we instituted diversion and field termination procedures as well (some transport times >1 hr). The State Health Dept. hated him, because he was always challenging them to find out why we were not doing something, instead of why we were.

Now, let's be clear not all Paramedics was not able to perform such procedures so we developed Paramedic Level II, (CCP, now) and was closely evaluated by him on written and clinical tests. (We had to work in ER with him as well, with the ER Doc's and rotations)

Yes, it was quite a bit of experience, that I have seen very few imitate, and learned a lot from. I can still hear his Irish brogue saying "...just because your small or rural is NEVER an excuse to give poor care..."

Dilantin tox. can be dangerous, reason being Dilantin was initially a cardiac medication, it has several neurocardiac, etc.. side effects, that one can brush up upon. One neds to remember that is infused by slow IV adm, preferred drip.

Like I said, it may not be the ultimate answer, but at that time in that community it worked great...

Be safe,

R/r 911

[JPINFV]

Just wondering, is there any drug, prehospital or not, that can lower a patients cortisol or Ca level, or increase the intracellular glucose level specifically in neurons?