Challenge: Thinking Outside the Medical Box | Seizure, Perhaps Diabetic

[andrewsc]

Cardiac arrest is an unlikely cause of seizure. When someone's heart stops they may have a couple of brief tonic/clonic movements but not sustained seizure activity. CPR is unlikely to be helpful. Even if the cause was cardiac arrest it is unlikely that CPR alone will result in successful resuscitation. The best survival to discharge stats for out of hospital cardiac arrest are dismal even with rapid paramedic response combined with bystander CPR. The utility of AEDs is a whole other topic but without electricity out of hospital survival in sudden cardiac death plummets.

New guidelines for prehospital CPR is moving away from ABC's and is focusing on circulation. In this scenario clear the airway by placing the patient on their side. A finger sweep is ok if you are certain active seizing has stopped... or lose a finger. Seizing patients will not breathe normally and will likely become cyanotic (blue). When actively seizing the chest wall will be too tense to allow mouth to mouth to be effective. Once seizing has stopped rescue breathing would be appropriate but most seizing patients will start to breathe normally on their own. On board tracheostomies are best avoided (primum non nocere). A bloody mess too.

Support her airway.
Don't let her hurt herself.
Get her some sugar.

[capngeo]

OK so the idea is to STOP the seizure. The Keppra is an anti-convulsant which is a prophylactic treatment to lessen the occurrence of a seizure. I mentioned above that the seizure patient who is not breathing will eventually stop, by either expiring, or from lack of oxygen. In the human body, this is more a case of an excess of carbon dioxide. In effect, the seizure can “sort of” be self limiting (note to the MD’s... I know what you’re thinking, but remember this scenario involves laymen well out of the reach of modern medicine)..... more in a bit

[andrewsc]

Missed doses of keppra.. can't give it to her while actively seizing.

Withdrawal from benzodiazepines, alcohol, other drugs.. can't get oral benzos in actively seizing patient.

I would still try and give her sugar first. If she becomes alert enough to take oral meds give her keppra and her own benzodiazepines.

This is a complicated scenario now that has at least three likely causes for sz.

I think I will fall back on kuru at this point and get that infectious disease consult.

[dinosaur]

he found lebetiracetam (Keppra), Humulin N, Heparin, and Biaxin... a glucometer, an automatic BP cuff, Xanax, Valium and an epi pen hmmm...

that is a lot of meds and i am most definitely not a pharmacist.... and curse you for throwing the epi pen in there.

oh yeah, i would never attempt CPR on someone who is in the middle of a seizure... i was considering doing it during the calm period. but you bring up a great point. if you start CPR on someone you need to be prepared to continue it until either someone relieves you or they die. so starting CPR during a calm period only to get through a cycle or two at BEST and have them start up again forcing you to take a break would be more detrimental to them than it would be helpful.

i definitely didn't consider trismus preventing them from breathing.

i've worked on security staffs for many years in nightclubs and music venues. from doing that job i've had tons of run in's with diabetic issues, but it's never been a situation beyond loss of consciousness, which time and air usually cure.

knowing that the epi pen is there still makes me a little iffy. if they aren't having an allergic reaction jamming them unnecessarily could make things worse. i guess the first thing to do would be to check the name on the epi pen to make sure it belongs to them and it is not for a child or family member whom they care for and just happened to leave in their bag.

**continues to contemplate**

[capngeo]

Originally Posted by andrewsc

On board tracheostomies are best avoided (primum non nocere). A bloody mess too.

Support her airway.
Don't let her hurt herself.
Get her some sugar.

1st Bold: cricothyrotomy is something that works well on TV.... I have done 4 in my career..... only 1 survived! Cut the thyroid artery, and there is more blood than you can deal with in the field (don’t ask how I now this)

2nd Bold: NEVER give ANYTHING by mouth to a person who cannot swallow (unconscious or less than alert)

[capngeo]

Originally Posted by andrewsc

Missed doses of keppra.. can't give it to her while actively seizing.

Withdrawal from benzodiazepines, alcohol, other drugs.. can't get oral benzos in actively seizing patient.

I would still try and give her sugar first. If she becomes alert enough to take oral meds give her keppra and her own benzodiazepines.

This is a complicated scenario now that has at least three likely causes for sz.

I think I will fall back on kuru at this point and get that infectious disease consult.

Good stuff Andrew..... glad you caught the benzos in her bag! True, you cannot give it orally... but what about the “other” end? Remember we are outside the box here, away from anything but your wits and what is on the boat!

To everyone else: Benzodiazepines are drugs like valium, versed, etc. They are sedatives that will stop a seizure. In pediatrics, a lot of seizures are from fever.. regardless the treatment is rectal diastat (valium)!

[andrewsc]

I like your thinking. You have identified our only access however uncomfortable for the squeamish. Pills are not going to be readily absorbed but crushed in sugar water sounds like a great idea.

4 cric's in 25 years.... don't you guys have a king or other rescue device???

[capngeo]

So we know from her meds, she is diabetic, has a seizure history, has some sort of infection, and some sort of blood clotting disorder... perhaps atrial fibrillation (fast irregular heartbeat).

Think of sugar (glucose) as the diesel fuel of the body... seizures use a lot of it up FAST. So, perhaps the reason the patient is not coming fully alert after the normal confusion following a seizure (postictal) is because her blood glucose level is low. But CRAP.... I just said you can’t give anything by mouth to an unconscious person! Now what?

[Duckwheat]

You are probably the most qualified person to answer the question in your scenario capngeo. I have been an emergency medicine physician for 15 years. Outside of the hospital I find that prehospital trained personnel are generally more effective than your average physician. Imagine yourself in the wilderness, on a plane, on a boat... would you rather have an orthopedist taking care of this lady or a paramedic. No offense to the orthopods with nice boats on this site but I will take the paramedic every time.

This is priceless and absolutely true. Let me consult my Dermatologist.

DW/Dave FNP Rural Practice Alaska. You deal with what walks in, boats in, or is flown to your clinic. It has been geat experience. Lay people need to keep in mind a very small number of folks recussitated in the hospital live to leave the hospital.

[dinosaur]

Originally Posted by capngeo

Think of sugar (glucose) as the diesel fuel of the body... seizures use a lot of it up FAST. So, perhaps the reason the patient is not coming fully alert after the normal confusion following a seizure (postictal) is because her blood glucose level is low. But CRAP.... I just said you can’t give anything by mouth to an unconscious person! Now what?

i'm going with andrew on this.. having someone run to the galley and find juice or sugar and some water to mix sounds good. he mentioned crushing the pills and putting them in the sugar water which also sounds good.

have we gotten the patient breathing yet? you mentioned something in a previous page about her breathing being shallow when the seizures abated...

[capngeo]

Originally Posted by andrewsc

I like your thinking. You have identified our only access however uncomfortable for the squeamish. Pills are not going to be readily absorbed but crushed in sugar water sounds like a great idea.

4 cric's in 25 years.... don't you guys have a king or other rescue device???

PERFECT! Exactly what I advised my buddy in this scenario!

2 were due to burns/trauma to the oropharyngeal..... that route was out
1 was laryngospasm due to 4+ Mallampatti and several intubation attempts
1 was anaphylaxis with no anatomy visible due to edema.

we carry LMAs and Igels now... but only the last 7 years or so.. before that crich was the only option if ET failed

[capngeo]

OK, so we stopped the seizures with the valium enema, the blood glucose level is SLOWLY rising with the sugar water that went with the valium.... BUT valium is relatively short lived controlling seizures. The PT also has a risk of respiratory depression if too much is given (lesson here: easy to put in more... hard to take it back out)

[andrewsc]

Nice.
That comment about wanting a paramedic was not just blowing smoke.

In a crisis situation outside a hospital I would want:
a paramedic
EM doc
rural FP
Veterinarian
orthopedist
dermatologist
psychiatrist
florist
pizza delivery guy
....

[dinosaur]

this thread has been ridiculously stimulating... i guess i know where $180 of mine will be going. into the wilderness and remote areas first aid course when it comes up in november. at least until i can decide on whether or not i can afford to partake in the EMS training course.

don't forget andrew, you'll also be needing a shoe salesman. al bundy scored 4 touchdowns in a single game! surely a man of that stature can save some lives!

[capngeo]

LOL..... when I first started out, I delivered pizzas on my days off!

So here’s the rest of the story:
The PT becomes alert enough to consume by mouth although groggy and tired as hell. Turns out she is a retired (medical) US Navy RN who has terminal pancreatic cancer. She signed on as crew to take “one last hurrah” but concealed her medical issues from the owner of the vessel in fear of rejection. Her seizures are a result of the cancer metastasizing from the pancreas to her brain.

She is at this moment on her way to a hospital in Grenada via some sort of military vessel.