BY MICK MESSOLINE
Seizures are one of the more common EMS dispatches. Although most patients stop seizing prior to the fire department’s arrival, some seizures continue after intervention. By definition, these patients are critical and require a great deal of attention.
A seizure is a temporary change in behavior or consciousness caused by abnormal electrical activity in one or more neuron groups in the brain. A status or recurrent seizure is continuous seizure activity lasting 30 minutes or longer, without regaining consciousness. Although the definitions of both seizure and status seizure are important, the causes are far more significant to prehospital providers. Knowing the causes of seizures will help the first responder establish a treatment plan and minimize surprises.
Seizures have multiple causes. Some are medical; others are environmental or trauma related. Common causes include stroke, head trauma, toxins, hypoxia, drug overdose, eclampsia (pregnancy related), tumor, infection, metabolic, epilepsy, hypoglycemia, and hypoperfusion. When considering the many causes of seizures, the most important point to remember is that seizures that continue without resolution are true emergencies. The actions of a competent first responder make the ultimate difference between positive and negative patient outcomes.
When arriving at a seizure patient’s side, it is important to gather a complete history of the event, including the patient’s seizure history and prescribed medication; the occurrence of seizures; what the seizure looks like; possibility of cyanosis (bluish discoloration of the lips or skin); length of seizure; and the body parts affected by the seizure (localized or generalized). Did the patient bite his tongue or experience incontinence? Is there a recent history of head trauma, fever, headache, or neck stiffness? Are there other medical problems (i.e. heart disease, diabetes, or stroke)?
The information you gather when taking the history may be all the hospital has on which to base its treatment. History taking is vital, and you must complete it in conjunction with your assessment. Most fire departments dispatch several members on EMS calls; work as a team, with one person gathering history (including medications) and other crew members assessing and treating the patient.
Patient assessment is a vital part of managing seizure patients. After ensuring scene safety, the first priority is airway. The next step is to evaluate a level of consciousness (LOC). AVPU is a good mnemonic device for categorizing a patient as one of the following:
- A – awake and alert.
- V – responsive to verbal commands.
- P – responsive to painful stimuli.
- U – unresponsive.
Along with airway and LOC, note any injury mechanism and the need for C-spine immobilization. After completing your initial assessment and appropriate care, move on to a focused exam.
During the focused exam, additional signs may prove helpful when no patient history is available. Patients taking phenytoin to control seizures often develop gingival hypertrophy (an overgrowth of tissue that appears as swollen gums). This finding is helpful in patients unaccompanied by friends, family, or personal information to substantiate a history of seizure disorder. Other findings of importance include lingual trauma (tongue lacerations) and incontinence. Also evaluate seizure patients for hypotension, hypoxia, and hypoglycemia. Pupil evaluation may result in discovering anisocoria (unequal pupils), which may point to an increase in intracranial pressure. Be wary of anisocoria in patients with no other findings; as a baseline physical exam finding, 20 percent of the population has unequal pupils. Note abnormal findings in your focused physical exam. Treat findings that require immediate intervention. Although history gathering and good assessment are important, proper intervention at the appropriate time is critical.
Treating a seizure patient is very difficult. Good basic life support (BLS) management is key to delivering a viable patient to the next level of care. The first priority in caring for a patient in seizure is protection. Be sure that he is clear of objects in the environment that may inflict further harm; if necessary, move him to a safer area. If an actively seizing patient is breathing but cannot maintain an open airway, use an appropriate airway adjunct. The most common airway obstruction in unconscious adults is the tongue. Try repositioning the head. If that does not work, select an appropriate airway adjunct. The best choice is a nasopharyngeal airway (NPA). This adjunct is easy to insert in most patients and quickly resolves airway obstruction caused by the tongue.
After securing the patient’s airway, provide supplemental oxygen. Patients with good respiration after opening the airway must be given oxygen. A nonrebreather mask at 10-15 liters per minute is appropriate. If the patient’s respiration is inadequate, assist with a bag valve mask at a rate of one breath every five to six seconds with high-flow oxygen. Attach and administer until adequate ventilations are being delivered. Never withhold oxygen from a seizure patient. Seizures result from brain problems. If this problem is unresolved and the seizure continues after first responders’ arrival, your patient will need oxygen therapy.
Another potential issue with a seizing patient is suctioning to clear the airway; this results from increased secretions, oral trauma (from tongue or lip biting), or vomit. Always have some form of suction available and ready for use. Continuously seizing patients are very difficult to suction. Suctioning attempts must not exceed 15 seconds in adults and five seconds in pediatrics. During a seizure, it may be difficult to suction using a rigid suction device (i.e. yankuer suction handle). Seizure patients may have a clenched jaw, and attempts at mouth suction may damage or break teeth. Use a soft suction catheter inserted through the NPA. Select the catheter size (diameter) based on NPA size. Only suction when removing the catheter, and oxygenate your patient prior to and following all suctioning attempts.
Once you have maanaged airway and breathing, get a solid base set of vital signs. Frequently reevaluate, note, and relay these and any changes to the next level of care. Depending on your local protocols and training, you may obtain a blood glucose level. This could be diagnostic, as hypoglycemia may appear in a status seizure. If glucometry is available and the patient has a low blood glucose level, treatment options are limited. Intravenous glucose or glucagon injections with an emergency kit are the only prehospital environment options.
Good advanced life support starts with good BLS. Anytime a first responder provides superb patient care, every provider in the treatment chain will have an easier time continuing care. A BLS provider focused on the immediate needs of a seizure patient greatly reduces the chance of a poor outcome. All levels of EMS must recognize and address immediate life threats. First-arriving responders must ensure that the patient is in an area clear of hazards.
As on the fireground, there should be little in EMS that flusters a prepared professional. So be prepared, be confident, and be the reason your patient arrives at the hospital without complications.
MICK MESSOLINE has been a firefighter/paramedic and EMS educator with the Sacramento (CA) Fire Department since 1999. He began his career in 1985 with the Fairmount (CO) Fire Protection District and spent several years with the Denver (CO) Paramedics.
