paramatt_

second line seizure medications

Recommended Posts

 

1 hour ago, Ruffmeister Paramedic said:

IN the end, we were able to get the tube but not after some very very tense minutes.  She never lost oxygenation but we paralized her and then had a very difficult time intubating her.  Took about 10 minutes to fully secure the tube but all her numbers and color was what you would expect from oxygenating her well.  This patient made the CRNA earn his on call pay.  But I was sure we were going to code her.  But someone was watching over her that night.  She had no negative issues based on our intubation attempts except for some scratches on her soft palette.  She should be about 15 years old now.  

That's probably one of the most horrible situations you can be in, especially with a pead. I suppose if her oxygenation deteriorated you would have been looking at a surgical airway.. It sounds like you guys did a great job nevertheless, and with a favorable outcome.

Good chance for a side question..it is reasonably common to have poor airway control on seizing patient's, especially those with trismus, even if its just short term...anyone have any good airway management techniques in such situations? I'm a fan of high-flow nasal cannula with lateral positioning if possible.

Share this post


Link to post
Share on other sites
On 1/29/2017 at 5:11 PM, paramatt_ said:

 

That's probably one of the most horrible situations you can be in, especially with a pead. I suppose if her oxygenation deteriorated you would have been looking at a surgical airway.. It sounds like you guys did a great job nevertheless, and with a favorable outcome.

Good chance for a side question..it is reasonably common to have poor airway control on seizing patient's, especially those with trismus, even if its just short term...anyone have any good airway management techniques in such situations? I'm a fan of high-flow nasal cannula with lateral positioning if possible.

I'll often insert a NPA in addition to O2, patient positioning, frontline benzo's, and all the usual assessment pieces (vitals, BGL rhythm, etc.). In the end it all come's down to suspected cause. TBI's are going to have a much lighter RSI trigger than say a known epileptic with a history of poor medication compliance.

Share this post


Link to post
Share on other sites

Hello,

I have attached a YouTube link showing the challenges of a status patient in the field (starts around the 2:15 mark).

Interesting stuff.

All the best,

David

Share this post


Link to post
Share on other sites

In 15 years, I've only had one pt not respond to a dose or two of benzos and we ended up RSI'ing him.  Just remember when you RSI status that just because the body movement has stopped, doesn't mean the brain activity has stopped.

  • Like 2

Share this post


Link to post
Share on other sites

We have had some interesting results since we swapped to Ketamine as our primary induction agent with our status patients. Where previously they were unresponsive to Midazolam, they often cease seizing on induction. As we do not routinely paralyse our status patients unless their seizure activity prevents their oxygenation, so the tube is maintained with sedation alone.

Previously when our induction was Fentanyl/Midazolam, you would get brief periods where the patient would cease seizing but then recommence and you were often bolusing midazolam during transport on top of you sedation.

I love Ketamine so much, can't remember life before ketamine (I don't want to remember it either)

Edited by BushyFromOz
  • Haha 1

Share this post


Link to post
Share on other sites
On 11/6/2017 at 4:52 PM, BushyFromOz said:

We have had some interesting results since we swapped to Ketamine as our primary induction agent with our status patients. Where previously they were unresponsive to Midazolam, they often cease seizing on induction. As we do not routinely paralyse our status patients unless their seizure activity prevents their oxygenation, so the tube is maintained with sedation alone.

Previously when our induction was Fentanyl/Midazolam, you would get brief periods where the patient would cease seizing but then recommence and you were often bolusing midazolam during transport on top of you sedation.

I love Ketamine so much, can't remember life before ketamine (I don't want to remember it either)

Ditto regarding the maintenance of paralysis in our service. We avoid it if at all possible with these patients. I've found Ketamine/Propofol for maintenance of sedation (plus or minus a loading infusion of phenytoin) really give any further seizure activity the old one two punch.

Share this post


Link to post
Share on other sites
On 1/29/2017 at 6:11 PM, paramatt_ said:

it is reasonably common to have poor airway control on seizing patient's, especially those with trismus, even if its just short term...anyone have any good airway management techniques in such situations?

Paralysis.

Share this post


Link to post
Share on other sites

Recently, one of our crews responded to a 30 year old female seizing.  Upon arrival, they found she was one week postpartum and they called me for backup.  We worked her up as eclampsia and gave six mg of magnesium and ten mg of versed but she never stopped seizing.  They had initially suctioned her and assisted respirations with a BVM but when I arrived she was breathing and I had the paramedic student keep the BVM sealed and do a jaw thrust.  Sat was 100% and ETCO2 was 40.  I did not want to intubate her without RSI drugs so we maintained her for the 15 minute transport.  Turned out she had a brain tumor with a malignant biopsy result.  Sad in more ways than one.   

Remember what Doc said:  Paralysis does not stop the seizure, you just can't see it.  Good second line drugs are keppra and propofol.  Of course keppra isn't found prehospital and if you use propofol, you better intubate.   

Spock

Share this post


Link to post
Share on other sites

Create an account or sign in to comment

You need to be a member in order to leave a comment

Create an account

Sign up for a new account in our community. It's easy!

Register a new account

Sign in

Already have an account? Sign in here.

Sign In Now