Bieber Posted September 30, 2011 Share Posted September 30, 2011 (edited) You are working in a smaller city on the outskirts of a county with two level I trauma centers in the principle and much larger city (about twenty minutes from your location) when you and your paramedic partner are dispatched at around 2000 for a patient complaining of a seizure. You drive emergency traffic to the scene and arrive to find the patient, a 23 year old male, lying on the bed of his third floor apartment actively seizing (grand mal, currently in the clonic stage if you care to know). BLS fire personnel are already on scene and have safely removed any hazards from the patient and applied oxygen (15 lpm via NRB) to him. The patient's mother advises that the patient has a history of seizures and was brought to the hospital by EMS earlier today for the same reason, given dilantin, and discharged. She also advises that the patient began seizing approximately 10 minutes prior to her calling 911 and suffered three seizures prior to the arrival of fire. Fire personnel advise the patient has seized two times since their arrival, with each seizure lasting approximately 1-2 minutes. Good luck. -Bieber Edit: Added a couple of details. Edited September 30, 2011 by Bieber Link to comment Share on other sites More sharing options...
Kiwiology Posted September 30, 2011 Share Posted September 30, 2011 (edited) Give him some midaz, tell mum to keep an eye on him and leave him at home Oh, and remind him to actually take the bloody meds the doctor gives him so I don't have to waste my time coming back to him This is what happens when I'm in a shitty mood Edited September 30, 2011 by kiwimedic Link to comment Share on other sites More sharing options...
Vorenus Posted September 30, 2011 Share Posted September 30, 2011 (edited) I guess he`s an epileptic. What medication does he get and how many fits has he regularly in a week/month. If there`s a major discrepancy (which`ll propably be the case), I`m taking him in. Did the mother already give him any anticonvulsive medication? Also: is there anything different about the seizures or his general behaviour? Did the mother notice anything (that would point into the direction of a neurological incident beside the known epilepsy) I`d take a round of vitals, keep the oxygen on him, give him an i.v., start with 10 mg Diazepam. If he stops fitting - get him in the truck and let`s go. Edited September 30, 2011 by Vorenus Link to comment Share on other sites More sharing options...
HERBIE1 Posted September 30, 2011 Share Posted September 30, 2011 I'd want to know any other PMH, WHY the person has a seizure disorder(prior head trauma, metabolic issues, lesions, etc), recent health issues, possible contributing factors such as a history of alcohol or drug abuse, compliance with meds, how well controlled the seizures have been up to this point, was there a recent change in medication and/or dosage, DX from prior hospitalization(was the PT subtherapeutic with their medications, ) trauma history, etc. I have found that often with seizures, the history generally tells the story of why the person is now having problems. Link to comment Share on other sites More sharing options...
DwayneEMTP Posted September 30, 2011 Share Posted September 30, 2011 As above, but I'd also like to know if this is a new dilantin script, or did they medicate him because he ran out of his, or forgot to take it, etc. If this is chronic, for how long? Was the condition initiated traumatically? As stated above this is going to boil down to a thorough history. An honest history. This is an excellent example of needing to be confident that your patient will lie to you. Previous/current history, current/recent drug/alcohol use, medication compliance, number/duration of seizure activity should all be regarded with significant suspicion. Good scenario Beib's... Dwayne Link to comment Share on other sites More sharing options...
Bieber Posted October 1, 2011 Author Share Posted October 1, 2011 (edited) Well, Dwayne walked into the apartment and now the mom is crying. Haha, just kidding. Our multinational team of skilled medical providers is able to calm her down somewhat and obtain a semi-thorough history. PMH: Epilepsy, poorly controlled but never this severe before (first time status episode was earlier this morning, usually seizes about 3 times a week with no complications resulting from those seizures). Mom also states he's been "sick" lately. Mother adamantly denies any recent trauma. Meds: Unknown seizure medication (does not take it due to financial constraints), also supposed to be on some sort of antibiotic starting with a K. ("K... Kef... Kef-something?"). Mother denies any illicit drug use but states he was taking diphenhydramine recently to help him sleep. Allergies: Penicillin. And because you are an astute and also very handsome paramedic, you wisely have your partner get a BP in between seizures ("GET A BP QUICK WHILE HE'S NOT SEIZING!"), and also because you are a skillful (and did I also mention handsome?) paramedic, you successfully obtain an IV 18 ga in the left forearm in between seizures. Vitals are as follows: HR: 125 EKG: Sinus tachycardia, no ectopy. BP: 132/88 SpO2: (between seizures) 98% on 15 lpm O2 BGL: 80 mg/dL You push the diazepam, and the patient continues to seize! However you do note a slight decrease in the strength of and a lengthening of the interval between the patient's seizures. Edited October 1, 2011 by Bieber Link to comment Share on other sites More sharing options...
HERBIE1 Posted October 1, 2011 Share Posted October 1, 2011 Well, Dwayne walked into the apartment and now the mom is crying. Haha, just kidding. Our multinational team of skilled medical providers is able to calm her down somewhat and obtain a semi-thorough history. PMH: Epilepsy, poorly controlled but never this severe before (first time status episode was earlier this morning, usually seizes about 3 times a week with no complications resulting from those seizures). Mom also states he's been "sick" lately. Mother adamantly denies any recent trauma. Meds: Unknown seizure medication (does not take it due to financial constraints), also supposed to be on some sort of antibiotic starting with a K. ("K... Kef... Kef-something?"). Mother denies any illicit drug use but states he was taking diphenhydramine recently to help him sleep. Allergies: Penicillin. And because you are an astute and also very handsome paramedic, you wisely have your partner get a BP in between seizures ("GET A BP QUICK WHILE HE'S NOT SEIZING!"), and also because you are a skillful (and did I also mention handsome?) paramedic, you successfully obtain an IV 18 ga in the left forearm in between seizures. Vitals are as follows: HR: 125 EKG: Sinus tachycardia, no ectopy. BP: 132/88 SpO2: (between seizures) 98% on 15 lpm O2 BGL: 80 mg/dL You push the diazepam, and the patient continues to seize! However you do note a slight decrease in the strength of and a lengthening of the interval between the patient's seizures. "does not take it due to financial constraints" Noncompliance with medications is probably the biggest reason we get called for seizure patients, followed closely by folks drinking alcohol, taking their medications, and then wondering why they still have their seizures. Very rarely do we see new onset epilepsy- but febrile seizures are incredibly common- generally at least one patient per day. Here it is. Now it's time to get tough with the family and ask how much they love their family member. Ask them if they would enjoy having to care for a brain damaged 23 year old brother/son/etc. I realize there are financial constraints but more often than not, the issue is not the money. Apathy, screwed up priorities are generally the real reason why someone does not take their medications. Nasty as it may sound, I have asked families of repeat customers- and patients after they wake up- if their beer/flat screen TV/ designer clothes are more important than taking their medication and possibly preventing their deaths or severe mental disabilities. Sorry, but sometimes tough love is warranted. Does it work? Sometimes, and I figure if it gets just one person to do what they should, its worth it. 1 Link to comment Share on other sites More sharing options...
DwayneEMTP Posted October 2, 2011 Share Posted October 2, 2011 What Herbie said.... But also, you mentioned that the bezo didn't break the seizure, so I'm guessing that there is more to this story than we've uncovered so far? Dwayne Link to comment Share on other sites More sharing options...
mobey Posted October 2, 2011 Share Posted October 2, 2011 I use Midazolam, but since we started with Diazepam, lets give another dose! Also... just prior to that 2nd diaz, lets slip in an NPA (just want to be sure this is not a pseudoseizure) Link to comment Share on other sites More sharing options...
Bieber Posted October 2, 2011 Author Share Posted October 2, 2011 Herbie, you're absolutely right. I don't know the statistics, but anecdotally the number one cause of uncontrolled seizures is poor medication compliance either due to financial reasons or some other factor. Dwayne, there just might be! Stay tuned. Mobey, I actually gave Ativan 'cause that's all we have (currently, heard we're supposed to be getting Valium (back)), but to give you guys the scenario I had, let's say that the additional Valium fails to completely suppress the patient's seizure activity. Between seizures his vitals are stable and about what you would expect from a patient post-seizure, and he does not react to the NPA. So, the kicker, why is this patient in status? Are there any other questions you want to ask the patient's mother? What do you want to do now? Time to move or do you want to continue to stay and play? Link to comment Share on other sites More sharing options...
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