EMS Protocol Of The Week - Seizures

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I will start this EMS protocol of the week with a brief story…

 

You know that uncomfortable time when you’re out enjoying your day, then all of a sudden you hear someone yelling “we need a doctor!” and your like oh god is that me? Am I supposed to go help? The first time this happened to me, I actually was NOT a doctor…yet  I was in my 4th year of med school and was on the subway, and a man in my car started having a seizure. In my head I was like should I get up and do something because technically I’m not a doctor…but I was also telling myself well if this man is having a seizure there’s really not much that can be done without any medications or equipment except for protecting him from injuring himself. Then I hear “someone start CPR!!” At that point I got up and was like “No please don’t do that!” The man stopped seizing, the subway arrived at a station, and EMS was able to take over. 

 

In the ED, when someone seizing is brought in, our main concerns are terminating the seizure if necessary and airway.

 

What can EMS do for someone in the field that is seizing?

1.     Protect pt from injury

2.     Airway – patient positioning, NPA (do not use OPAs), advanced airway if needed (paramedics only)

3.     Provide O2

4.     Measure BGM

What meds can be given from paramedics?

-       Midazolam 0.2mg/kg IV/IN/IM (max dose 5mg)

-       Lorazepam 0.1mg/kg IV/IM/IN (max dose 2mg)

-       Diazepam 0.2mg/kg IV (max dose 5mg)

When does online medical control (OLMC) get called?

-       If seizure activity persists despite 2 doses of SAME med at SAME dose

Anticonvulsant meds should be administered as soon as possible, and IV access is the preferred route. Always remember to check the glucose, and also consider eclampsia as a possible cause! And lastly, don't perform CPR on someone who has a pulse :) 

And as always, if you want more information, you can go tot www.nycremsco.org

carpe diem. 

Jennifer Wolin, MD

Emergency Medicine PGY-2 Resident Physician

Maimonides Medical Center

Case of eclampsia in your resus bay

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Diagnosis:

  • new-onset tonic-clonic, focal, or multifocal seizures in the absence of other causative conditions (eg, epilepsy, cerebral arterial ischemia and infarction, intracranial hemorrhage, drug use), 

  • typically but does not have to be present in the presence of preexisting hypertensive disorder of pregnancy (preeclampsia, gestational hypertension, HELLP syndrome)



Presentation:

  • Hypertension 

  • Headache (persistent frontal or occipital headaches or thunderclap headaches)

  • Visual disturbances (scotomata, loss of vision [cortical blindness], blurred vision, diplopia, visual field defects [eg, homonymous hemianopsia], photophobia)

  • Right upper quadrant or epigastric pain 

  • Asymptomatic 



Management:

  • Start with ABCs

  • Consider alternative causes of seizures based on additional information other than eclampsia: hyponatremia, ICH, hypoglycemia, etc.

  • Usually eclamptic seizures subside on its own

  • If pt is seizing => administer Mg Loading dose 4-6 g IV over 15 to 20 minutes. An alternative dose/route is magnesium sulfate 5 g intramuscularly into each buttock for a total of 10 g

  • Followed by Maintenance dose – magnesium sulfate 2 g/hour as a continuous IV infusion to women with good renal function.

  • If pt is in status => in cases refractory to magnesium sulfate (patient is still seizing at 20 minutes after the bolus or more than two recurrences), administer sodium amobarbital (250 mg IV over three minutes), thiopental, or phenytoin (1250 mg IV at a rate of 50 mg/minute). In this case pt will need to be intubated.

If need to consider intubation:

  • Medications:

    • Induction - consider propofol (category B)

      • You want to avoid: Etomidate - lowers seizure threshold and Ketamine - worsens HTN

 

    • Paralytics - rocuronium or succinylcholine, yet both of the medications are category C so use minimal dose to reach the desired effect, avoid additional doses

pregnancy medications.jpg



Next consider hypertensive control if BP diastolic pressures greater than 105 to 110 mmHg or systolic blood pressures ≥160 mmHg:

  • Labetalol - 20 mg IV gradually over 2 minutes.

  • Hydralazine - 5 mg IV gradually over 1 to 2 minutes.

  • Nifedipine immediate release - 10 mg orally.

  • Nicardipine (parenteral) - The initial dose is 5 mg/hour intravenously by infusion pump and can be increased to a maximum of 15 mg/hour.

Proceed with labs, consider HELLP syndrome labs, type and screen, fluids. 

Call OB/GYN early

The definitive treatment for eclampsia is prompt delivery.