Advanced Medical Life Support

Chapter 10

Seizures and Seizure Disorders

Introduction
Seizures are among the earliest known and still least understood afflictions. They herald dozens of anomalies, ranging from head injury to hypoxia and from epilepsy to hypoglycemia.
10-2

Topics
Anatomy & Physiology
Updated Classification & Terminology

Pathophysiology
Differential Diagnosis

Assessment & Management Priorities

10-3

C ASE S TUDY
Situation
You and your partner are covering an evening football game at a local high school when you are summoned by a police officer for a fan who is having a seizure.

As you thread your way through a crowd of people, you encounter a 35-year-old man who is apparently having a seizure on the ground.

10-4

C A S E S T U D Y F O L L O W-U P
Situation
History
Patient has been actively seizing x 10 minutes. Per wife, patient has just been weaned off of Dilantin for Sz. disorder; no seizures x 2 months.

Patient felt fine when he arrived at game; went for refreshments, began feeling funny, sat down & began seizing. Convulsions persisted until your arrival.
10-5

Nature of Consciousness
Arousal (state of wakefulness)
Mediated by reticular activating system Can exist independently of awareness

Awareness
Provided by cerebral hemispheres Self Surroundings Response to surroundings

10-6

Anatomy & Physiology

A seizure can occur anytime an area of brain tissue is injured, deprived of nutrients, or irritated. Determining the cause of a seizure depends on accurate observation and description.

10-7

Cranial Anatomy
The Brain & Its Membranes
Dura mater Pia mater Arachnoid membrane

Cranium

Dura mater Arachnoid membrane Pia mater

Cranium Brain

Foramen magnum Spinal cord

10-8

Regions of the Brain

Thalamus
Hypothalamus Cerebrum

2 Cerebral hemispheres

DIENCEPHALON

Midbrain Pons

Cerebellum

BRAINSTEM Medulla
oblongata
10-9

Updated Classification & Terminology

Generalized: involves both hemispheres,
possible loss of consciousness Absence (kids & adolescents)
- Sudden loss of awareness - Prompt recovery of normal awareness - No recollection of event

Tonic-clonic

- Sudden loss of consciousness & motor function - At least some disruption of respirations - Postictal phase involving fatigue, gradual recovery w / amnesia
10-10

Updated Classification & Terminology (continued)

Partial: involves 1 hemisphere; may appear
localized Simple
- Onset usually sudden - No loss of consciousness - May affect motor, sensory, autonomic function - Onset usually follows aura - May involve episodic behavioral changes - Loss of conscious contact with surroundings - May be mistaken for psychiatric emergency

Complex

10-11

Pathophysiology
Abnormal excessive discharges of cerebral neurons trigger:
250x normal ATP consumption 250% increase in cerebral blood flow 60% rise in O2 consumption 20% increase in lactic acid

10-12

Differential Diagnosis
Seizures can be idiopathic or secondary to other disorders that fall into the following basic categories:
CNS injury / dysfunction Metabolic disturbance Infection
10-13

Differential Diagnosis of Seizures

CNS Injury or Dysfunction

Head Trauma
History!
- Mechanism of injury - Pattern of mentation

Physical Exam Neurologic exam

- Respiratory signs - Level of response - Ocular signs - Sensory & motor function
10-14

Differential Diagnosis of Seizures

CNS Injury or Dysfunction (continued)

Medical Dysfunction
Structural lesion (seldom presents acutely) Stroke Be aware of time!
- Unilateral facial findings Current therapies are effective - Ocular signs in treating some stroke patients. - Hemiparesis - Generalized signs may occur late or (if insult is profound) early Free blood (highly irritating)

10-15

Differential Diagnosis of Seizures

CNS Injury or Dysfunction (continued)

Metabolic Disorders
Hypoperfusion Hypoxia Hypercapnea Hypo / hyperglycemia Electrolyte disturbances (highly irritating) Drug concentrations (therapeutic & non-therapeutic) Alcohol withdrawal Poisons/abnormal metabolyte levels

10-16

Important to Note...
In addition to recreational substances, many therapeutic medicines have seizures as side-effects. Watch for:
Aminophylline (theophylline) Lidocaine Phenothiazines Physostigmine Tricyclic antidepressants Some antihypertensives
10-17

Important to Note...
Sudden changes in the serum concentration of an anticonvulsant medication is a common cause of seizures. Examine the patients person & surroundings for:
Dilantin (phenytoin) Phenobarbital Zarontin (ethosuximide) Tegretol (carbamazepine) Depakene or Depakote (valproic acid) Mysoline (primidone) Clonopin (clonazepam) Tranxene (clorazepate) Felbatol (felbamate) Neurontin (gabapentin)
10-18

Differential Diagnosis of Seizures

CNS Injury or Dysfunction (continued)

Infectious Diseases
Meningitis: viral / bacterial infection of meninges
- Common in kids but also present in adults - 50-60% fatal if untreated

Encephalitis: brain infection

Similar Signs:
- Fever - Nucchal rigidity - Headache - Photophobia - LOC Coma - Dehydration
10-19

Assessment & Management Priorities

Respect the immense variety of causes for seizures, and remember that some of them may pose a threat to you.
10-20

Assessment & Management

Scene Size-Up

Once you have ensured your own safety, remove any obstacles that could injure the patient.

10-21

Assessment & Management

Initial Assessment
Still seizing or not, the first priority of care for a seizure patient is aggressive and vigilant airway management. Nasal airway
Suction PRN High-flow, high-concentration O2 Be ready to ventilate.
10-22

Assessment & Management

Focused History & Physical Exam (Postictal Patient)

SAMPLE Questions
S igns & symptoms A llergies M edications P ast medical history L ast oral intake E vents prior to illness

Confusion Bites in the mouth Incontinence Evidence of fall

Bystanders history
10-23

Assessment & Management

Focused History & Physical Exam (Postictal Patient)

SAMPLE Questions
S igns & symptoms A llergies M edications P ast medical history L ast oral intake E vents prior to illness

Remember, an allergy may be the underlying cause of seizures.

10-24

Assessment & Management

Focused History & Physical Exam (Postictal Patient)

SAMPLE Questions
S igns & symptoms A llergies M edications P ast medical history L ast oral intake E vents prior to illness

Consider under-dosing or non-use of prescribed anticonvulsants. Consider seizures as sideeffects of some prescribed & street substances.
10-25

Assessment & Management

Focused History & Physical Exam (Postictal Patient)

SAMPLE Questions
S igns & symptoms A llergies M edications P ast medical history L ast oral intake E vents prior to illness

Seizures?

Brain injury / disorder?

Hypoglycemia?

Diabetes?
Metabolic disorders?
10-26

Assessment & Management

Focused History & Physical Exam (Postictal Patient)

SAMPLE Questions
S igns & symptoms A llergies M edications P ast medical history L ast oral intake E vents prior to illness

Anticipate vomiting, prevent aspiration.

10-27

Assessment & Management

Focused History & Physical Exam (Postictal Patient)

SAMPLE Questions
S igns & symptoms A llergies M edications P ast medical history L ast oral intake E vents prior to illness

Obtain history of event from patient, if possible. Consult with bystanders.

10-28

Assessment & Management

Focused History & Physical Exam (Seizing Patient)

Stop the seizure/prevent recurrence.

Control ABCs. Diazepam, 2-5 mg slow IVP over 3-5 min.
(repeat q5 min. up to 20 mg max) -- OR,

Lorazepam, 2 mg/min. slow IVP

(not to exceed 0.1 mg/kg total)

Investigate & treat etiology.

Check blood glucose level, consider D50W (thiamine?)
10-29

Assessment & Management

Complex Partial Seizures

Approach slowly from rear/side. Speak calmly, explaining your moves.

Avoid violating patients space.

Gently isolate patient from danger.

Remain with patient until normal mentation returns.

10-30

Treatment Pathway for Siezures

Scene Size-up
Protect patient /move obstacles Initial Assessment Insert N-P airway, administer O2, assist ventilations PRN, check pulse. Focused History & Physical Exam Postictal? Take SAMPLE history Perform rapid physical exam Monitor ABCs, vitals Reassuure & support Actively seizing?

Generalized Tonic-Clonic Seizure?

Complex Partial Seizure?

(continued)
10-31

Treatment Pathway for Seizures (continued)

Generalized Tonic-Clonic Seizure? Admin. diazepam or lorazepam to stop seizure. Check Hx of diabetes, ck. blood glucose. If low, admin. D50W IV push. Follow local protocal re thiamine. Prevent recurrence of seizures by treating probable cause. Complex Partial Seizure? Approach patient from side or rear. Speak calmly, advise patient of your actions. Avoid touching patient. Gently guide patient away from dangerous environment, remain with patient until normal mentation returns.

10-32

C A S E S T U D Y F O L L O W-U P
Situation
You and your partner are covering an evening football game at a local high school when you are summoned by a police officer for a fan who is having a seizure.

As you thread your way through a crowd of people, you encounter a 35-year-old man who is apparently having a tonic-clonic seizure on the ground.

10-33

C A S E S T U D Y F O L L O W-U P
Situation
History
Patient has been actively seizing x 10 minutes. Per wife, patient has just been weaned off of Dilantin for Sz. disorder; no seizures x 2 months.

Patient felt fine when he arrived at game; went for refreshments, began feeling funny, sat down & began seizing. Convulsions persisted until your arrival.
10-34

C A S E S T U D Y F O L L O W-U P
Assessment & Treatment
Impression: prolonged full-body tonic-clonic seizure. Rx: Move crowd back, protect patients head, insert nasal airway & administer on 100% O2 via non-rebreather mask. IV inserted in forearm, 5 mg diazepam admin. slow IVP & seizure subsides. Oropharynx suctioned briefly. Vitals: P=96, bounding; R=14, shallow; BP=132/60. ECG reveals NSR. Blood glucose=142 mg/dl. Patient responding to voice, but disoriented. No evidence of trauma.
10-35

C A S E S T U D Y F O L L O W-U P
Assessment & Treatment Outcome
Patient agrees to transport, which is uneventful.

Patient regains normal mentation. States he has recently been weaned off of Dilantin, felt fine tonight, has no recollection of event.
Physician readjusts patients meds; he does well.

10-36