two

Seizures are characterized by cyclic muscle rigidity and relaxation and typically last less than five minutes. If a seizure lasts for more than ten minutes, it can be dangerous. There can be delays in getting medical help during a seizure, so it's important to find out how long the seizure has been going on. Seizures can be caused by various factors such as epilepsy, tumors, infections, head trauma, metabolic imbalances, and withdrawal from alcohol or medications. Seizures can be treated with medications, and in some cases, patients may have a vagal stimulator implanted to prevent seizures. Recognizing a seizure and its complications is important, and sometimes patients refuse medical help after a seizure, but it is recommended to seek medical attention. They exhibit bilateral muscle movements characterized by cyclic muscle rigidity and relaxation. Typically last less than five minutes, followed by the post-victal state. A seizure under ten minutes is not necessarily a dangerous thing, but if it lasts for ten minutes or more, that's where I start getting nervous. Especially like whenever I go to a seizure, I'll always call dispatch before I arrive and just say, can you find out the status of the patient? Are they still seizing? Because this is the way I look at it, especially in Worcester. In Worcester, we are like, we used to be first back up and now we're second back up. So a seizure call gets in to Worcester EMS, right? So first thing, the patient starts having a seizure. Somebody's got to recognize it. Usually they fiddle with us a little bit, then they grab the phone and dial 911. So there's a delay there. Patient's still seizing. They call 911. WEMS gets on the phone. Okay, tell me what you have. All right, we'll send it in. WEMS dispatches an ambulance or tries to find an ambulance. After a couple minutes, they don't find an ambulance, so now they call us. They call my dispatch. Now my dispatch has to take that call. Now they have to find and assign a truck to me. Now I have to get it. Now I have to leave. By the time I drive out the door, it's been eight minutes or ten minutes. Now it's going to take me maybe eight minutes to get to the house. So if on my way I call and they say the patient's still seizing, they've been seizing over ten minutes. That's bad. And it's not that I'm going to change my treatment modality. It's not going to mean I'm going to drive less fast because they're done seizing, but it's going to mean a different approach to the patient. If you're seizing, you need to get meds. If you're not seizing, okay, we need to get you an oxygen and transfusion off. Does that make sense? So it's always a good idea to find out how long they've been seizing. The absence, seizure, pulmonary fatigue model lasts for just barely seconds with a brief core recovery and just a brief lapse of memory. You just don't remember the incident. That's all. Status epileptic, if seizures last more than five minutes, you are likely to progress to status epileptic. So you get a ten-minute seizure, or it's even more likely to progress to status epileptic, which is a seizure that continues every few minutes without a person regaining consciousness or lasting longer than 30 minutes. Seizure, beginning post-picture, we'll say seizure again. Seizure, beginning post-picture, we'll say seizure again. And it just keeps going like that. You don't regain consciousness. Or a seizure lasting 30 minutes or more. This is a very dangerous, life-threatening condition when you have seizures that can last 30 minutes. People die. People die from seizures. And most of the time it's because they have seizures and they're not breathing. I mean, I know patients that have seizures for two to three hours. So common causes of seizures. Epileptic congenital origin. I don't know why I have it, I just have it. Structural, things like tumor, benign or cancerous. Does anybody know the difference between a benign and cancerous tumor? Anywhere in the body. A benign tumor is encased in its own sheath. If you have a benign tumor, I can open you up and remove the whole thing en masse. That's why we call it benign. Whereas a cancerous tumor is just cells that grow on their own. And they grow into tissues. So when I do surgery to remove a cancerous tumor, I literally have a pathologist or an oncologist in the surgical room. And as I excise tissue, he puts it under the microscope and sees, yes, that's cancerous, yes, that's cancerous. No, that's not cancerous. Oh no, I know, I've cut it up in that area. That's the difference between a benign and cancerous tumor. Cancerous tumor invades into surrounding tissue. A benign tumor is enclosed in its own case. Is it concerning to cancer? A benign tumor, no. A benign means it's benign. It's not going to move, invade into other tissues. If it does, then it was never benign. Scar tissue from injuries like within the skull, infections, brain abscess, things like meningitis, head trauma. Metabolic, hypoxia, abnormal chemical values. Again, we talked about hyper and hypocapnia, hyper and hyponatremia, hyper and hypocalcemia, hyper and hyponatremia, hypoglycemia, poisoning. Overdose is not uncommon for overdose patients who have seizure history to have a seizure during an overdose. And what do we not do then? Remember? I can overdose, but they seize during an overdose. What am I not giving them? Narcan. Don't give them narcan because it can bring on more and more powerful seizures. And sudden withdrawal from alcohol and medications. One of the few things that human beings can get addicted to that can actually cause death during withdrawal is alcohol. Alcohol withdrawal, they call delirium tremens, can actually cause death. And death is caused by seizures. So if you have someone who's overdosed and they have no heart, and no pulse, no breathing, and they've had a seizure. You just do CPR and transplant. That's it. That's it, CPR and transplant. The risk. The risk outweighs the benefit. If they're in cardiac arrest, I wouldn't give them narcan anyway because if I spray narcan in your nose and I'm doing compressions, I'm not circulating blood through your nasal mucosa. So it's not going to spread it around enough. That's not what CPR does. If it's a hypoglycemia, like diabetic patient, and you don't give them the glucagon, will they die? Hypoglycemia? Yeah, if you have a hypoglycemic patient and you don't treat that, you don't give them some kind of sugar, whether it be glucose or glucagon, they will die. So I had a seizure one time, and I didn't get my glucagon, but eventually I woke up, and then I was like... That's because your body released the glucagon, and you had glycolysis in turn. And so your blood sugar became raised up enough to bring the blood sugar where it needed to be for you to become conscious again. But it can also go the other way. You can burn up all your glycogen stores, and then it doesn't matter how much glucagon your body puts out, you don't have any more glycogen. And then sudden, severe, high fever, primarily in children called febrile seizures. We'll cover those in pediatrics as well. Epileptic seizures usually can be controlled by medications. Most of the time, medications are not... Most of the time, seizure activity with patients who have epilepsy generally are not compliant with their meds. And that's why they have seizures. The meds are designed to keep patients from having seizures. So these are kind of the more common ones. Keppra and Dilantin, those are very common. Phenobarbital, Tegretol, Depakote, Copomax, and Klonopin, those are all medications that can be given for other things. Bipolar, manic, depressive, schizoaffective disorder. But you can also get them for seizures. Another one that you might see is Lamictal. So if you see these in a patient's history, ask them, hey, do you have a seizure history? Especially Keppra or Dilantin. Those are very... Those are most often used to seizure patients. Patients may also have a vagal stimulator. It's an electrical stimulator that's unplanted under the skin like a defibrillator. And it's connected to the vagus nerve. And it sends out a stimulus and maintains the patient from having a seizure. And it works. It takes a... Like let's say you have a patient that's on a heavy dose of Keppra and is still having six or seven seizures a day. They'll go on the vagal stimulator and it might bring them down to one a week. My best friend just did that. She's been on epileptics since she was four. And she just had a surgery done on both sides of the brain where they put a little chip inside of it. And so she just recently had a seizure and then she went for their appointment and then they officially turned it on because they needed reading first. But she usually... She used to have this tiny little teacup dog that was her seizure dog. And it was B.S. because Molly didn't do anything. Molly was just full of anxiety. But, yeah, she always gets seizures. And she had a seizure since? She hasn't... It's been like a week since she got it officially turned on. But like two weeks ago she had it. Oh, okay. She'll get them like if she forgets to take her meds like one night or if she's going through different medications because she's constantly changing meds. Yeah. And things like if you get sick, if you get run down, if you get stressed, if you don't eat right, anything can spur... Some epileptics are very significant. Some epileptic patients. So in terms of recognizing a seizure, recognizing a seizure is occurring and whether the episode is different from the previous one, you're obviously not going to be able to ask the patient because the patient is going to be in a seizure. But you can ask family members or friends, hey, is this what they usually go through? Is this different? Is there any kind of a change? You know, most patients will tell you, yeah, they've had seizures. They have them every now and then. Some people do. Some people once a week have a seizure and they just leave. You shouldn't. Recognizing the postictal state and the complications of a seizure and identify other problems associated with a seizure. A lot of times, we'll do seizure patients and they end up being refusals because we'll do a seizure and then the patient, when we get there, they're either stopping the seizure or postictal. We'll give them oxygen, sit with them, check their vital signs, and they slowly come around. And then once they're awake, then they're like, no, I don't want to go to the hospital. I'm sorry, you really should go to the hospital. No, I don't want to go to the hospital. And you take a refusal. So what I like to do is I get on scene and the patient's postictal. I like to scoop them up and take them to the hospital. So as I'm backing into the ER, they're kind of like, yeah, what's going on? Oh, you have a seizure, sir. Where am I? You're in the ambulance. We're getting you to the hospital. I don't want to go to the hospital. Well, we're here now. Why don't you just go in and get checked out and then you can be released? And the reason why, they should be seen. They shouldn't be having seizures. That's the point of all these treatments. So it doesn't fall into the average hospital? No, because I mean, the patient says, oh, I don't want to go to the hospital. Well, you're here now. You might as well go in. As you're backing up to the ER, they're not going to say, no, I don't want to go in now. So that's not kidnapping because if I consent, they weren't able to give you an answer at that point. I just have a question for you. Yeah. So in EMD, when I was doing seizures for 911, to my knowledge, you have to put the patient on their side and make sure you keep an eye on their breathing. You put them in the left lateral recovery position. Yeah. Keep them on their side. That's what I would tell people. Put the patient on their side and make sure to watch out for the tongue. Make sure that there's nothing in the way. When we get on scene, we're ultimately putting them and just starting putting them on the stretcher. Because you have suction. You can protect the airway. You can put in an NDA. That's what I would do if a patient in post-signal state or somebody's seizing, I'd attempt to put an NDA. You don't want to restrain a seizing patient. When a patient's seizing, having a full tip of quiver, and you hold them down, the muscle can break the underlying bone. You don't want to restrain a patient. But you can put a collar on them, put an NPA in, put oxygen on them, even while they're seizing. And when they stop seizing, now you've got oxygen, now you've got the NPA. What I would do if I have a patient that was really seizing, like more than 10 minutes, and they stopped seizing, I would bag them until they recover or until they go back into a seizure again. Then I throw the non-negative breather on. So if you bag them, even if they go into another seizure, you just oxygenate them. So they've got some oxygenation. You know what I mean? So always have your BBM ready. When they stop seizing, they're post-ictal, mag them a little bit. Give them a few breaths. Just get that oxygen going. Post-ictal state. After the seizure, the muscles relax and the breathing becomes labored. The patient might have hemiparesis. They might have one-sided paralysis. And people think, oh, you're having a stroke. No, it's post-ictal. Most commonly characterized by lethargy and confusion. And again, most often the patient will, there'll be some history of a seizure, whether now or they have a history of it. Some patients will have medical alert bracelets that say seizure, you know, seizure, I have seizures or whatever. Epileptic. Syncope. Seizures are often mistaken for syncope or fainting. Fainting typically occurs when a patient is standing or when they go from bent over to standing up. Especially if they're hypovolemic. And they go from bent over to standing up. We call it orthostatic hypotension. And they go whoop and they go down. That's the most common cause of syncope. Passing out basically. Fainting is because of the change in position. It's positional hypotension. Fainting is not associated with a post-ictal state. Usually you faint and you fall to the ground and your blood pressure equalizes because you're on the ground so your blood doesn't have to fight gravity. And you get perfusion in your brain and you kind of wake up. Altermental status. Sights and strokes and seizures. The most common neurological emergency is altermental status. Our most common cause of altermental status, what do you think it is? Hypoglycemia? Drugs and alcohol. Drugs and alcohol. Patient not thinking clearly or incapable of being aroused. In some cases, the patient will be unconscious and in others, the patient may be alert but confused. What are we going to do with these patients? We're going to check their blood sugar and pulse oximetry. We want to make sure their oxygen level is greater than 94. We want to make sure their blood sugar is greater than 70. And then we want to check their blood pressure to see if maybe they're hypovolemic or hypotensive. If we know they're not hypotensive then they're hypoglycemic and they're not hypoxic then there's something else going on. Positive ultimental status. Well, you know the AEIOU tips that I covered. Remember that. But you can have things like hypoglycemia. You can have hyperglycemia. Hypoxemia, which is hypoxia. Intoxication, drugs, alcohol. You can have water intoxication. Delirium, confusion, drug overdoses or alcohol and unrecognized pancreatic. Some patients can fall down and whack, whether they have a syncopal episode they fall down and whack their noodle and then they wake up on the ground and they don't know what happened. Brain infection. Again, meningitis. We talked about that. Body scepter abnormality. Brain tumors and overdose endopoietics. It could be other types of poison. So seeing sides up. Make an early determination whether the cause is medical or trauma. It could be both. I could have had a syncopal episode and whacked my head. I could have had a stroke and fallen down the stairs. Look for threats to safety. To you. Follow standard precautions. Glove, goggles, mask. Remember that patients can vomit. They can be very anxious, anxiety, aggressive, be spitting at you. Consider the need for spinal restriction. When in doubt, put on a collar. It's cheap and easy and well tolerated. They're about ten bucks a piece. Put them on. And call for additional resources early. You're more likely to call for additional resources before you make patient contact. At the moment your patient is altered and you've checked blood sugar, you've checked oxygen, you've checked blood pressure and they're all okay, call ALS. Your primary assessment is level of consciousness and airway breathing circulation. Look for life-threatening conditions and treat them as you find them. Perform your rapid exam and establish priorities of care based upon assessment of patient LOC and XABC. I don't think you've seen that before. X means bleeding. That means for exsanguination, EX. Alright? So, XABC means that I check for bleeding first. If I find a left right knee bleeding, I treat that right away. I don't go right to airway. I put a glove hand on that and I have somebody put a tourniquet on it. That's where arterial bleeds, right? Put your finger in it, stop the bleeding, put a tourniquet on it or you're going to take some, we're going to talk about bleeding, you're going to take some hemostatic agents or hemostatic gauze and you're going to stuff it in the wound, you're going to stop the bleeding. And then airway breathing circulation. Best case, chief complaint, if I don't respond to a patient, you may have to gather the history from friends or bystanders. You're not going to get a history from the patient. If no one is around, look for an explanation for the altermental status. Is there, you know, drug paraphernalia, bottles of alcohol, do you see signs of trauma? Try to determine the events leading to the incident. You may not, you may have no idea what happened. And obtain your sample history if you can. Look for medical alert tags, look for, you know, if you're seeing somebody's home, look for a discharge summary of medications or something along, look for the vial of life. Vital signs. Significant intracranial bleeding leads to a great deal of pressure in the skull compressing the brain. It's going to cause the pulse to slow and the respiration to become adequate and the blood pressure to spike. What do we call that? A spike in blood pressure? A big spike? You've got a spike, you've got a rapid, you've got a marked, marked hypertension with a result in bradycardia, a slow pulse, a Cushing's Triad, slowing pulse and a change in respiratory pattern. You also get changes in pupillary size. Usually one side pupil will begin to dilate. As the blood pressure increases, the pupil will begin to dilate. As the pressure on the brain pushes, or that mass, lesion, tumor, whatever it is starts pushing on that ocular motor nerve, that pupil begins to dilate and become non-reactive. So this pupil is midpoint reactive, this one is dilated and not reactive. And that's a sign of a head trauma because you always check blood sugar on every ultramental status. Stroke assessment. Stroke scales evaluate the face, arm and speech. We're going to talk about the BFAST mnemonic and that's the one you see all the time on TV. Facial droop, arm drift, slurred speech, time. BFAST just evaluates facial droop, arm drift, slurred speech, and facial droop. And you say to the patient, repeat after me, the sky is blue in Cincinnati. So it could be a Boston Stroke Scale, repeat after me, the sky is blue in Boston, whatever you want. You don't even ask them to do that, you just ask them to repeat after you. You guys on the computerized, like on our Zol EPCR, you can access all of these. You can use any one you want. So the BFAST, we balance, is a patient experience of sudden loss of balance and inability to walk. We talk about walking, or you can't stand. Is that new or is that baseline? Eye, changes in vision, lots of vision, double vision, we call that diplopia, or no side or top vision. It's one of the reasons why not only do we do the eight points of conjugate gaze, but we do the other two. If you don't know, it's a stroke. If you don't know, they don't know. Fantastic. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I