IN treatment of seizures

[ambodriver]

Treat, then assess? We've got multiple hands on scene and competent providers should be able to multitask. I don't see anything wrong with performing a quick H+P and assessing the situation before the drugs go in. In fact, I'd go as far as to say that it should be required.

I also disagree that IV access is contraindicated by active seizures. Of course you should always balance the potential risk to your own safety, but you can get lines on a lot of these patients. Not everyone seizes the same way. It can be done and usually it is of value to have access in place for these patients.

Agreed, I will usually always try to get the IV, and from my experience its possible in most patients.

As far as the nasal atomizer---meh, i've never used it for seizures, narcan is another story though.

[CTXMEDIC]

the aussies did a study on IN fentanyl and found it to be lacking when compared to IV MS.

[jwraider]

fire_911medic since you said you use NPA's often how to you manage the airway when you are using versed IN? Do you drop the NPA after giving the versed?

[fireflymedic]

I'll give the meds first, then drop the NPA for a few reasons - get better absorbtion than if NPA is placed first, you may actually supress the respiratory system more as is a risk with any benzo given (but I have found to be more prominent with versed), and they are going to be post ictal for a while anyway and giving the benzos actually prolongs post ictal time so those are all factors in my decisions. As I mentioned though, if the need arises (such as I totally knock out someone's respiratory or the situation warrants it I will tube). Someone else may have different thoughts, but that's what horse I'm riding.

[jwraider]

Thank you.

I was also wondering if anyone thought the NPA and/or lubricant jelly would mess with the absorption of the IN med.

[fireflymedic]

haven't experienced that problem yet JW - not to say that it might not, just that I haven't had it yet

[FL_Medic]

We can administer 5mg(2.5 in each nare) of versed IN via the MAD (which is great). If they are status Ativan would be administered after.

I love the IN route, I don't know if it makes a difference but I always cover their mouth when I administer it, because I have had them cough, what seemed to be like a lot of fluid out at the same time of administration. IM is just as effective, but you have that big needle. Anytime you can eliminate the use of a sharp, why not?

[p3medic]

One of my last calls of my intership was a status epilepticu. We gave 20 mg valium and 6 mg versed and the chick was thowing my partner off of her in the truck from muscle tremors. He was trying to suction some while I was dropping a nasal ETT. I will always drop a tube on these people if I ever encounter one again. There is something seriously wrong with the electronics upstairs for them to be a status epilepticus. Airway is the first priority. What is the first thing a lot of seizure patients due when you finally get them to stop seizing after this? Throw up. While they may bite an oral tube into, the nasal tube is unlikely to be damaged (dislodged maybe which is why you should reevaluate often). This girl ended up having a tumor the size of a KIWI in the middle of her head. While I wouldn't just do this to any seizure patient, I think the treatment for a SE is to try and stop the seizure. However there may be times when all the drugs you have on board are used up and the seizures continue. Just hope you have a good partner and they drive safe. This chick also pulled out three lines from her hands and arms from her tremors, as the tape wasn't holding well. I kling wrapped the last one in her hand and it came out too over a period of time. To make things worse she was in the second story apartment of a very run down place. It was all that four people could do to get her down the steps in a stair chair while she was still seizing. My first 10 mg of valium and my first 3 mg of versed was in the apartment and the second doses were in the truck en route. This is also where I dropped the tube and established the fourth IV in a chest vein. Her glucose was checked by the EMT after every IV and never dropped below the 90's. This was one of my six true tests during my internship. My Med Dir said we did a great job and so did the preceptor, but I am open for comment on how to alternative treatment. They finally stopped the seizures after giving her etomidate in the ER (we don't carry anything on the truck except Versed and Valium).

Michael

Etomidate has been shown to decreas sz threshold, it wouldn't be the drug of choice in sz management. Propofol would be a much better choice, even versed for sedation. Not saying it is wrong to induce with etomidate, it just wouldn't be my first choice, and if the patient stopped seizing, it probably wasn't the etomidate.

[FL_Medic]

Maybe it was Ativan. Etomidate is used for general anesthesia, and maybe with the benzos given, it stopped the seizure. It would make sense that they probably ended up administering some diprivan as well and intubated the pt.

[fireflymedic]

Etomidate is still frequently used for induction, however, I would be more preferable to use Versed for the pure and simple fact it is going to help suppress seizure activity. If you have the capability, versed drip is preferable to diprivan as diprivan can be a bitch of a drug for transport, though in hospital it is alot more stable. I have seen versed, ativan, and diprivan (propofol) all used for drips for status seizure patients. It is just difficult to maintain a proper titration for propofol (titrate to effect) and maintain sedation. I've seen plenty of patients who were't adequately sedated on diprivan alone. I'm more of a versed drip fan for it's anti seizure properties (I've actually seen several patients seize coming off a propofol drip and it have to be restarted, it's biggest perk is it is quick on and quick off) and then fentanyl for comfort as tubes aren't the most comfortable thing around. That is my personal thing. Take my opinion as you will.

Also, point of interest - ativan is the drug of choice for seizure management as it has the longest half life of any of the meds. Valium is the shortest, so something to consider. With valium, I've found many patients to be fairly resistant, or to be controlled temporarily, then go on to seize again requiring an additional dose, so if I have the option, it's ativan or versed since I've got long transports.

Take care, stay safe.