Seizure Secrets

Attack One responds to an evening call for a child seizing. It’s a short response time: The patient is on the front ramp of the station, and the report comes from someone who walked in the front door. The concerned individual, a man in his 40s, leads the crew out the door to a van parked on the front concrete. One crew member runs to get pediatric equipment. In the backseat is a very large “child,” actively seizing.

“How old is this young man?” asks the paramedic.

“Twenty-one,” says the older man, who identifies himself as the patient’s father.

The paramedic squeezes into the back of the car but finds too little room to work—the patient will have to be moved out of the car for evaluation and treatment. Colleagues from the station all come out to the front ramp, grab a stretcher and backboard and struggle to move the still-seizing patient out of the backseat.

They quickly get him onto a backboard and on the stretcher, and the crew applies oxygen and begins to evaluate him. The tonic-clonic movements continue. They open his mouth with an oral airway. The paramedic peels the long sleeve off the patient’s arm and searches for a vein to start a line. “Everyone, let’s make sure we watch the blood and secretions,” she advises. “And let’s get masks for everyone on the crew.”

The EMTs look at each other with confusion but follow the orders. They notice that the paramedic has stopped looking for a vein and is questioning the father. “How long has he been seizing?” she asks. “Has he been ill recently? What kind of medical problems does he have?”

The father answers: “He’s been seizing for about 5 minutes. It started as we drove to the hospital—he said he was sick and needed to go. He hasn’t said he was sick until today. I don’t think he has any medical problems, but he doesn’t talk much about it. He lives by himself in an apartment but came home a day ago because he said he wanted to return to the house with his mom and me.”

The paramedic grabs the drug box and finds the midazolam in the locked compartment. She loads the syringe with a dose, then places a small atomizer device on the end and sprays the medicine into the patient’s right nostril. The medic looks at both arms and the man’s neck. She checks the vital signs herself and places her bare forearm on his forehead. She carefully listens to his chest. Within moments he stops seizing and is somnolent. His breathing is assisted with 100% oxygen.

“Sir, we’re going to take your son to the hospital down the street,” the medic tells the father. “Please proceed safely there, not following the ambulance. Your son has stopped having a seizure and will not wake up for a little while. We’ll let the emergency department staff explain the testing and treatment he’ll need. We will be using our lights and siren but driving safely to the hospital.”

Saying very little, she quickly directs the crew to load up the patient, and they proceed quickly to the hospital. She insists every crew member in the back of the ambulance don a mask, goggles, gown and gloves.

Hospital Management

The ED is advised of the patient en route, and the physician and nurses are also in protective wear on EMS arrival. They transfer the patient onto the ED cart and switch the bag-valve mask apparatus over to their oxygen source. The patient’s eyes are now opening on occasion. The staff works quickly to undress the patient, and after an unsuccessful attempt to find an IV site in an arm, the physician inserts a line into a large vein in the patient’s neck.

The EMT crew members are interested in hearing about the paramedic’s decisions after she’d examined the patient so quickly. Once they are in a private area, away from the patient’s family, she explains:

“I thought it was a little strange that he had a long-sleeve shirt on when the evening is so hot. When I cut off his shirt, he had big track marks from IV drug abuse all the way up the arm, and on his other arm. He felt warm to me right away, but then it was clear when I felt his forehead. A person who’s having his first seizure, has a high fever and is an IV drug abuser usually has a dangerous infection of some type, so it’s best to protect everyone involved in his care. It’s obvious his father knew nothing about that, and it’s much better for the ED staff to do the necessary testing and explain the whole course of events to the family. But it is important for us to take precautions for the emergency providers and not alarm the family until more information is available.”

The crew has to return to service, but the emergency physician is on for the night shift and promises to contact the paramedic before the night is over with information about the patient. As it turns out, he can share the information face to face: About two hours later the crew brings another patient to the ED, and the physician tells them the original patient has a brain infection caused by the drug abuse. It is not the form of meningitis caused by bacteria and will not require follow-up for the emergency crew.

The patient also has pneumonia, which was likely the reason for the low oxygen saturation level seen by the Attack One crew. Fortunately, he’s now regained consciousness and will be admitted to the ICU.

The emergency physician also said he’d had a lengthy discussion with the father and let him know the cause of the illness and other problems associated with intravenous drug abuse. The father was caught completely by surprise, explaining that the son had gone to college after graduating from high school and had been working and living with friends. He lost his job about a month ago and had just returned to his parents’ house when he was ill. The father wanted to know if this all could have happened in the last month, and the physician told him it appeared the drug use had been going on for a longer time.

The patient had a very difficult hospital course but was finally discharged with follow-up at a drug-counseling facility. His parents took him into their home with the condition that he could not have any of his old friends in, needed to stay clean and had to maintain good status in college.

Case Discussion

Sudden and unexpected seizure activity in a child of any age is a frightening experience for parents. If the patient continues to have seizure activity in the presence of the EMS crew, they should take measures to control it as soon as possible. The use of intranasal midazolam, which delivers the antiepileptic medication directly to the blood and cerebrospinal fluid via the nasal mucosa, is safe, inexpensive, easy to learn and provides better seizure control than diazepam.^1,2 The atomization device is an excellent method to administer medications without the need for an intravenous line.

References

1. Silbergleit R, Durkalski V, Lowenstein D, et al.; NETT investigators. Intramuscular versus intravenous therapy for prehospital status epilepticus. N Engl J Med 2012 Feb 16; 366(7): 591–600.

2. Lahat E, Goldman M, Barr, J, Bistritzer T, Berkovitch M. Comparison of intranasal midazolam with intravenous diazepam for treating febrile seizures in children: prospective randomised study. BMJ 2000 July 8; 321(7,253): 83–86.

James J. Augustine, MD, FACEP, is medical advisor for the Washington Township Fire Department in the Dayton, OH, area. He is director of clinical operations at EMP Management in Canton, OH, a clinical associate professor in the Department of Emergency Medicine at Wright State University in Dayton, and an editorial advisory board member for EMS World. Contact him at jaugustine@emp.com.