Objectives / Learning Targets: The learner who successfully completes this lesson will be able to demonstrate understanding of the following concepts:

Transcription

1 Boone County Fire District EMS Education-Paramedic Program EMS 270 Medical Cases-Seizures Resources Seizures screencast Seizures Flowchart and Seizures Flowchart Video Explanation Objectives / Learning Targets: The learner who successfully completes this lesson will be able to demonstrate understanding of the following concepts: General pathophysiology of Seizures. Field assessment and management of seizures at the ALS level. Resource Materials and Notes: Seizures are characterized by unconsciousness and generalized twitching of all or part of the body. There are types of seizures that you should learn to recognize: generalized, partial, and status epilepticus. Focal (partial) seizures are either simple (no loss of consciousness) or complex (loss of consciousness). Focal seizures can progress to generalized seizures. The term grand mal seizures refers to a generalized / full-body seizure. This video shows an example of a patient experiencing an aura which prompts her to notify nursing staff. She then experiences a full-body generalized seizure followed by a rather typical post-ictal phase. Learning points are: The aura gives her and you, the caregiver, some warning of a seizure. This may allow you to take some protective actions during your care and transport of this patient. Be sure to ask about an aura and prompt your patient to warn you if they experience their aura. Auras typically involve a taste, smell, sound or vision of something that is not perceived by others. Post-ictal patients may have a need for suction or simple airway management. The term tonic-clonic activity refers to periods of generalized stiffening (the tonic phase) and then jerking (the clonic phase). The term status epilepticus refers to a single very long seizure lasting 5-10 minutes or longer (exact time definitions vary between sources) or multiple seizures without a full recovery between the seizures. Most seizures last between 3 and 5 minutes and are followed by a postictal state in which the patient may be unresponsive, have labored breathing, have hemiparesis, and may have been incontinent. It is important for you to recognize the signs and symptoms of seizures so that you can provide the emergency department staff with information as you transport the patient. Patients frequently present to EMS during the postictal phase.

2 Boone County Fire District EMS Education-Paramedic Program EMS 270 Medical Cases-Seizures Resources Some seizure patients may experience an aura prior to their seizure. This is actually a partial seizure and may include smells, tastes, visual disturbances or other sensations. Not all patients will have an aura. Watch this video for an excellent example of tonic-clonic activity, deviation of the eyes, inability to swallow excess saliva, the post ictal phase with labored breathing and some cyanosis (breathing during a seizure is not effective) and combativeness as she arouses after the seizure. Watch this video for another view of tonic-clonic grand mal generalized seizure activity, oral trauma and post seizure combativeness followed by extreme fatigue and drowsiness. FYI -common anti-epileptic drugs include Gabapentin, Carbatrol; Epitol; Equetro;, carbamazepine, phenytoin, Dilantin, Lamictal, Tegretol, pregabalin, Lyrica., Topamax, valproic acid, Trileptal, Keppra Watch this video on Vagal Nerve Stimulators (VNS) as an adjunct to medications or for cases that are resistant to medication therapy (some sources indicate that around 30% of epileptic patients are not controlled by meds alone). The patient talks about medication therapy and the side effects and shows you her scars as well as where the implant is positioned. She also talks about an aura and how she can use magnets to activate the VNS. During the video, she causes the VNS to activate using a magnet and you can see the impact on her. Although every detail on how the VNS prevents or terminates seizures is not known, the underlying theory is that the vagus nerve can be stimulated by the device thereby transmitting impulses into both sides of the brain which provides some action to prevent or terminate seizure activity. Many patients experience significant side effects from their anti-epileptic drugs. In addition, their cost is a burden. Therefore, a fair number of EMS responses for seizures turn out to be patients with known seizure disorders that are not currently medicated per their prescriptions. ALS management includes administration of benzodiazepines via IV / IO or possibly IN or IM routes. Medications used include diazepam (Valium), midazolam (Versed) and lorazepam (Ativan). See the drug cards for each of these for more information. Optional---See this resource site for deeper info on epilepsy.

3 Seizures

4 Definition and Cause Abnormal neuronal activity in the brain Causes are unclear Maybe faulty wiring Maybe faulty signaling (neurotransmitters)

5 Prevalence About 2 million Americans have seizures Roughly 1 in % of those are controlled with meds and other treatments

6 Some Types / Triggers Febrile Eclampsia Hypoxia Epilepsy Hypoglycemia Head Trauma Drugs / Alcohol

7 First Seizures May or may not be from a seizure disorder / epilepsy MUST be evaluated by a physician Always rule out hypoxia and hypoglycemia

8 Febrile Seizures Related to a fever / rapidly rising temperature, most have fever of and seizure occurs in the first day of the fever The cause of the fever / source of infection may be serious in some cases (meningitis) Usually does not mean epilepsy but 30% will have a second febrile seizure Most commonly in young children (6mths to 5 years particularly toddlers) (1 in 25 kids)

9 Eclamptic Seizures Probably related to issues with immune response to the placenta although unknown. Pre-eclampsia = HTN, edema, headache, proteinuria, visual problems / loss of vision Serious condition for mother and fetus; emergent c- section delivery Typically resolve after delivery---not epilepsy

10 Partial Seizures About 60% of epileptics have these Simple (aura)---see, hear, smell, feel sensations that are not real; normal LOC Complex---altered LOC but usually only last a few seconds

11 Generalized Seizures Atonic (weak / limp / collapse) Tonic (stiffening) Clonic (jerking) Tonic / Clonic (grand mal is older term) Absence (petit mal---older term) Myoclonic (jerks or twitches)

12 Preventive Treatment Medications Vagal Nerve Stimulators Surgery

13 Medications carbamazepine (Tegretol) valproate (Valproic Acid, Depakene, Depakote) lamotrigine (Lamictal) oxcarbazepine (Trileptal) phenytoin (Dilantin) clonazepam (Klonipin) phenobarbital tiagabine (Gabitril) gabapentin (Neurontin) topiramate (Topamax) levetiracetam (Keppra) felbamate (Felbatol) primidone (Mysoline)

14 Vagal Nerve Stimulator Surgically implanted device 5 year battery life usually Reduces frequency of seizures May allow reduction in medication dose Unclear mechanism

15 Status Epilepticus Multiple seizures back to back or a continuous seizure longer than about 5 min. True emergency Progressive hypoxia About 75% of these do not have epilepsy Causes may be tumors, trauma

16 Considerations Bring in your narcs IV site that won t be compromised Secured IV First-time seizures are a BIG DEAL SpO2, T, Glucose, BP

17 Take Away Points Protect---don t restrain during seizure Manage airway & breathing when post-ictal Rule out hypoxia and hypoglycemia causes Carefully cool the febrile seizure patient / medical control for antipyretics