Treat a Seizing Casualty
INTRODUCTION
One in 200 people has a seizure disorder. You probably know someone yourself. The number of people with seizure disorders is increasing due to the high survival rate of victims from head trauma, meningitis, brain abscesses, and tumors, each of which can result in permanent or temporary symptoms of seizure disorders. These individuals can control their symptoms and be productive members of society due to advances in drug therapy. While functioning as a soldier medic, you will most likely encounter a patient experiencing a seizure.
Terms and Definitions
Seizure - involuntary irregular electrical brain activity manifesting itself in sudden changes in behavior, movement, and/or sensation because of irritated brain cells
Convulsion - the uncontrolled muscular movements that occur during a tonic-clonic seizure
Epilepsy - a disorder characterized by seizures, sensory disturbances, abnormal behavior, loss of consciousness, or all of these
Aura - sensation prior to have a seizure (such as smell, colors, and bright lights)
Tonic phase - It is the time period during a seizure when the body stiffens. The patient may stop breathing and/or lose bowel and bladder control.
Clonic phase - It is the period during a seizure when there is alternating contraction and relaxation of the body muscles. The face and lips often become cyanotic.
Postictal phase - It begins when the seizure has ended. The patient may regain consciousness immediately and is likely to be drowsy and confused. The patient does not remember what happened.
Status epilepticus - two or more seizures without a period of consciousness between each seizure or a seizure lasting longer than 30 minutes
Determine type of seizure
Identify cause of seizure
Failure to take prescribed antiseizure medication; most common cause of seizures in adults
Trauma - may occur following head injury (Has the casualty fallen? Has casualty been hit in the head?)
Congenital brain defect - most often seen in infants and children
Infection - causes swelling or inflammation of the brain (meningitis or encephalitis)
Fever - seen in children 6 months to 3 years of age usually with temperatures above 103 degrees; rarely in older children or adults
Metabolic disorders - irregularities in body chemistry (diabetes/hypoglycemia)
Drug toxicity - drug/alcohol use or abuse or withdrawal
Brain tumor - may manifest as a seizure
Previous trauma - scars on the brain from previous injuries
Idiopathic - An idiopathic seizure is spontaneous. The cause of the seizure is unknown. It often starts in childhood.
Hypoxia - lack of oxygen to the brain
Hypertension - blood pressure is too high; seizures may be associated with cardiovascular accident (CVA)
Signs and symptoms
Generalized seizures
(a) Tonic-clonic seizure (grand mal seizure)
NOTE: "Tonic" is muscle tension (stiffness or rigidity). "Clonic" is the alternating contraction and relaxation of muscles in rapid succession.
(i) May or may not be preceded by an aura
(ii) Loss of consciousness occurs
(iii) Characterized by tonic/clonic seizure activity throughout the entire body
(iv) Lasts several minutes (1 to 3)
(v) Following by a postictal phase (the patient is confused, drowsy, or unconscious)
(vi) Type of seizure that most people associate with epilepsy and other seizure disorders
(b) Absence seizure (petit mal seizure)
(i) Demonstrates temporary loss of awareness to environment
(ii) May appear to be daydreaming or staring into space
(iii) Eyelids may flutter rapidly
(iv) The person may become unresponsive for a few seconds, then, immediately resume the task he was doing prior to the seizure. The Individual is completely unaware that anything unusual has happened.
(v) No tonic or clonic activity
Partial seizures
(a) Simple partial seizure (also called Jacksonian seizure)
(i) Characterized by tonic and/or clonic movements in only one part of the body
(ii) No loss of consciousness
(iii) May progress to a generalized seizure
(b) Complex partial seizure (also called psychomotor or temporal lobe seizure)
(i) Usually preceded by an aura
(ii) No loss of consciousness
(iii) May be characterized by confusion, glassy stare, aimless movement, fidgeting, lip smacking, and chewing. The person may appear drunk or on drugs.
(iv) May progress to a generalized seizure
Status epilepticus
(a) Two or more seizures without a period of consciousness between each seizure or a seizure lasting longer than 30 minutes
(i) Permanent CNS injury is more likely to occur the longer seizures are allowed to progress
(ii) Initiate treatment if continuous seizure activity lasting more than 10 minutes
(iii) The longer the seizure is allowed to continue the more difficult it will be to control
(iv) Tonic/chonic activity present; may cause long bone and spinal fractures
(v) Convulsive activity may gradually lessen over time – giving impression that seizures have been controlled
(vi) Correct diagnosis requires a high index of suspicion, a perceptive physician and sometimes an EEG
(b) Patient does not have time to breathe well or time to recover between seizures (hypoxia)
(c) True medical emergency - receives highest priority for triage and transport in mass casualty situations
Assess the casualty and overview of differential diagnosis
Report a detailed history of the seizure activity
Physical description
(a) Gradual or abrupt onset
(b) Progression of motor activity
(c) Loss of bowel or bladder control
(d) Activity local or generalized
(e) Duration of the attack
(f) Ask patient if they have any recollection of the attack
Clinical context of the seizure activity
(a) Patient known epileptic
(i) Missed doses of antiepileptic or recent alterations in medication
(ii) Sleep deprivation
(iii) Alcohol withdrawal
(iv) Infection
(v) Use of other drugs
(b) No previous history of seizures
(i) Symptoms that might suggest previous unwitnessed or unrecognized seizures
* Blank or staring spells in school
* Involuntary movements
* Unexplained injures
* Nocturnal tongue biting
* Enuresis
(ii) History of recent or remote head injury
(iii) Persistent, severe, or sudden headache
(iv) Concurrent pregnancy or recent delivery – possible eclampsia
(v) History of metabolic derangement or electrolyte abnormalities, hypoxia, systemic illness (especially cancer), coagulopathy or anticoagulation, drug ingestion or withdrawal and alcohol use
General physical examination
Is directed toward discovering any injuries, especially to the head or spine, resulting from seizure.
(1) Possible fractures, sprains and bruises
(2) Tongue lacerations
(3) Assess for precipitating factors. Search for any systemic illness that may have caused the seizure.
(4) Assess vital signs, note temperature
(5) Assess blood glucose level, if equipment available
(6) Assess for motor system coordination, strength and tone
(7) Assess for slurred, very weak or hoarse speech
(8) Assess for jerky, uncoordinated, slumped or slow movements in posture and gait
(9) Assess for incontinence of bladder and bowel
Differential Diagnosis
Many episodic disturbances of neurologic function may be mistaken for seizures.
The following are several of the more important entities that should be considered.
Syncope
(a) Symptoms: may include some or all of the following: dizziness, diaphoresis, nausea, and "tunnel vision"
(b) Patient is usually aware they are going to faint
(c) Can describe onset of attack
(d) Cardiac Syncope may occur suddenly without any warning
(e) Injury or incontinence may occur
Pseudoseizures (extremely difficult to distinguish from true seizures)
(a) Pseudoseizures are psychiatric rather than neurongenic
(b) Associated with conversion disorder, panic disorder, psychosis, and impulse control disorder
(c) May occur in response to emotional upset
(d) Attack will occur with witnesses present
(e) Incontinence, injury, postictal confusion and lethargy are uncommon
Hyperventilation syndrome
(a) Gradual onset
(b) Shortness of breath, anxiety, and perioral numbness
(c) May progress to involuntary spasm or the extremities and even loss of consciousness
Migraines
(a) Similar to aura of partial seizures
Movement disorders
(a) Dystonia, chorea, myoclonic jerks, tremors, or tics may occur in a variety of neurologic conditions
(b) Consciousness is always preserved during movements
(d) Involuntary but can be suppressed by patient
Clinical features that help to distinguish seizures from other kinds of mimicking attacks include:
(a) Abrupt onset and termination
(b) Lack of recall
(c) Movements of behavior during the attack generally are purposeless or inappropriate
(d) Attack is followed by a period of postictal confusion and lethargy (except for petit mal or simple partial seizures)
Provide emergency medical care
Treatment
During a seizure
(a) Position the patient on the floor or the ground. Move the furniture with edges away from the patient (GOAL: prevent self-injury)
(b) DO NOT RESTRAIN the patient during a seizure
(c) DO NOT force anything into the patient's mouth
WARNING: Bite sticks have been bitten and swallowed resulting in an airway obstruction. Teeth and jaws have been broken due to forcing a tongue blade into the mouth. NEVER use fingers to keep the patient's teeth apart.
(d) Observe and record time of onset, duration, characteristics of the seizure, and if the patient was incontinent of stool or urine
CAUTION: If the casualty's teeth are clenched, do not attempt to forcibly open the casualty's jaw. Do not restrain the casualty's limbs during seizures.
After a seizure
(a) Maintain an open airway
(i) Position casualty to maintain open airway
(ii) Clear airway
(iii) Insert airway device to assist with maintaining open airway, if needed
(iv) Support and stabilize cervical spine, if suspected injury
(b) Turn patient on his side if no spinal trauma is suspected and suction his mouth as needed
(c) Administer high-flow oxygen. Use a non-rebreather mask if the patient is breathing on his own. Use BVM with reservoir to ventilate if patient is NOT breathing on his own.
(d) Monitor vital signs
(e) Protect the patient from embarrassment. Cover the patient if exposed or clothes are torn. Keep spectators away from area. If patient loses bladder/bowel control, clean and/or cover the patient as soon as possible.
(f) Establish and maintain intravenous access
(g) Administer IV fluids cautiously
Administer pharmacological interventions
(a) Valium
(i) Therapeutic effects
* Suppress seizure activity in the motor cortex of the brain
* Generalized central nervous system depressant
* Muscle relaxant
(ii) Indications
* To treat grand mal seizures/status epilepticus/seizures lasting greater than 10 to 15 minutes
(iii) Contraindications
* Should not be given during pregnancy - exception may be seizures associated with eclampsia
* Should not be given to patients with hypotension/decreased systolic BP less than 90
* Should not be given to patients with respiratory depression. Respiration less than 10 per minute
(iv) Side effect
* Possible hypotension
* Depression in the level of consciousness
(v) Administration and dosage
* For grand mal seizures/status epilepticus give slow IV in titrated doses. Can be given intramuscular, rectally, or via endotracheal tube if needed. Start with 2.5 mg. Monitor vital signs. If vital signs are stable and patient is still seizing, give another 2.5 mg of Valium slow IV push. Continue until the seizures have stopped. Do not exceed total dosage of 10 mg.
(vi) Incompatibility
* Should not be mixed with any other drug
(b) 50% Dextrose (D50)
(i) Therapeutic effects
* Rapidly restores blood sugar level to normal level
(ii) Indications
* To treat suspected hypoglycemia
* To treat status epilepticus
(iii) Contraindications
* Intracranial hemorrhage
* Known stroke
(iv) Side effects
* Will cause tissue necrosis if it infiltrates
* May precipitate severe neurological symptoms in alcoholics (Wernieke's Encephalopathy)
(v) Administration and dosage
* 50 ml of 50% solution (25 gm) slow IV. Supplied in pre-filled syringes containing 50 ml of 50% solution.
* Determine serum glucose if possible prior to administering glucose
(c) Ativan (Lorazepam)
(i) Indications
* Anxiety disturbances or anxiety states: general anxiety disturbances panic disturbances phobic anxiety disturbances
* Adjustment disturbances with anxiety or stress reaction
(ii) Contraindications
* Assess patient periodically
* Safety and efficacy in children under the age of 12 has not been established
(iii) Dosages
* ADULT dose for anxiety is: 2mg - 3mg daily in 3 - 4 divided doses
* RANGE: 1mg - 6mg daily in divided doses
* ELDERLY/DEBILITATED PATIENTS: Initial dose of 1mg - 2mg/day in divided doses. Adjust as needed and tolerated.
* In elderly and/or debilitated patients and in those with serious respiratory or cardiovascular disease, a reduction in dosage is recommended
* In the case of local anaesthesia and diagnostic procedures requiring patient co-operation, concomitant use of an analgesic is recommended.
* Ativan sl: Dosage of ativan sublingual should be individualized for maximum effect.
CAUTION: The soldier medic must be proficient and competent in drug administration. This includes knowledge of therapeutic effect, indications, contraindications, side effects, how supplied, administration, and dosage of the drugs.
(d) After the seizure activity is over, assess and treat any injuries suffered during the seizure
(e) Expect lethargy, partial consciousness, and disorientation
(f) If possible, try to determine how long the seizure lasted, what the patient did after the seizure, and what the patient was doing prior to the seizure
Transport considerations
Requirements
(a) Patient with a first time or new seizure
(b) Patient with a seizure that caused injury
(c) Patient with respiratory difficulty
(d) Status epilepticus patient - immediate transport
Maintain an open airway
Patient should be transported on his side while being given supplemental oxygen en route to the medical facility
Suction mouth as needed
Monitor vital signs while en route
Provide on-going management
Maintain the casualty on their side, if necessary
Monitor the casualty's airway
Monitor vital signs to include pulse oximetry, if available
Monitor neurological status
(1) Pupil response
(2) Glasgow coma scale
(a) Eye opening
(b) Verbal response
(c) Motor response
Place the casualty in a quiet, reassuring environment, if possible
Monitor IV fluids.
Reassess pharmacological interventions every 15-30 min.
CAUTION: Sudden, loud noises or bright light may cause another seizure
Document seizure activity
(1) Duration of the seizure
(2) Presence of cyanosis, breathing difficulty, or apnea
(3) Level of consciousness before, during and after the seizure
(4) Preceded by aura (ask the casualty)
(5) Muscles involved (type of motor activity)
(6) Incontinence of bladder or bowel
(7) Eye movement
(8) Previous history of seizures, head trauma, and/or drug or alcohol abuse
Evacuate the casualty by ground, if possible
SUMMARY
When a casualty experiences a seizure, assess and treat for possible spinal injury and protect the casualty's airway. It is important to document the seizure episode.