42 y/o M – Seizure

I’m going to illicit responses from the readership on this one…

Case

You are called to the scene for a 42 year old male having a seizure. On arrival you find a family member talking to the patient, who was placed in a left lateral recumbent position for recovery. You leave your partner and the assisting engine crew to go and grab a vial of midazolam and a mucosal atomizer. When you return, the patient is now up and fighting off 4 grown men. When he is finally wrestled to the ground and restrained, you move in and administer 5 mg of midazolam IN (intranasal). After what seems like an eternity, the patient finally stops fighting and is able to walk with assistance to the cot, and is quickly moved into the ambulance. The patient’s mental status slowly returns en route and you are able to finally obtain vital signs and a brief H&P:

BP: 144/86
HR: 122, sinus tachycardia without ectopy
RR: 22 regular, decreasing in rate with passing of the postictal phase
Blood sugar: 112 mg/dL

PMHx: asthma when he was younger, now takes no medications, allergic to Demerol only. No previous seizure history in either the patient or his biological family.

Pt is a healthy looking adult male, skin is hot, flushed, and diaphoretic which dissipated over time. No fever is noted. Pupils are dialated and sluggish, no JVD is noted. No pain on movement of the neck. RR is rapid but a regular depth for someone who just ran a literal marathon. The lung fields in all fields are clear, heart tones are normal. The abdomen is soft and non-tender to palpation, incontinence of urine is noted, + pulse, motor, and sensory. Pt is slightly sedated from midazolam use.

What’s your differential diagnosis and treatment scheme? Don’t be shy!

  • The Happy Medic

    Good case. I have similar folk in my area. Most have presented postictal initially but became violent quickly. Not because they were upset, but it was just a kind of reactionary self preservation action.I do like your IN options, I'm stuck only with O2 and Narcan up the nose.The vitals afterwards fit both your description of the action and the action of the meds.Differential Dx of first time seizure, need more PMH/Description of event prior to EMS arrival for more.Monitor for recurrence of seizure activity, take another EMT in the back should restraints be necessary.I would need IV access to dose again if needed, ECG, O2, recheck BGL and watch the pupils.Presentation matches protocols for nearest facility.Will we get a follow-up?

  • HybridMedic

    I'll follow up next Friday.The IN option is great, we use it for sedation on combative/seizure patients we can't control for an IV. I've used versed, glucagon, narcan… I'd like to see us go to fentanyl, but it is a way off.

  • Ambulance Driver

    What's your Glucagon IN dose? Same as IM? How fast is the onset of effects?As far as differential dx, really need more info. Recent trauma? Substance abuse? Recent illness? Headaches, visual disturbances, anything that might indicate an intracranial lesion?And yes, IN Fentanyl is da bomb. Unfortunately, The Borg no longer carries it. I used it a lot when I worked for PGHNSTRACH, though.

  • HybridMedic

    Same as IM dose, just split between each nostril, and pt had some general malaise for a few days up to the event.

  • Christopher

    IN Glucagon in adults should really be 2mg, but that sort of usage makes the bean counters cringe :)My only critique would be it sounded like too many people hanging out with the postictal guy. The patient likely was only combative because 4 grown men were strapping him down.Shortly after getting my EMT-B, I fought with a bear of a man. We wrestled him to the ground to "keep him from hurting himself." Which sounds funny in retrospect. Then I took a class from a great teacher (WEMT, Justin Padgett) and asked him what I could have done better. I believe his exact words were, "sounds like he just needed a lil TLC." Yet to wrestle anyone since.So I would minimize people with the patient, give him space, and wait for him to orient before getting them strapped into anything. Scene time may be longer, but I'll take the QA flag.As for this patient, differentials besides he just has sz could be s/s of brain cancer or maybe SAH (although I'd expect him to look awful).

  • HybridMedic

    I like the IN route, and I feel that we should be carrying fentanyl for both IN/IV use. It is far superior to morphine in that you get the wonderful effects but very few of the bad.This case was rather interesting because it caught everyone off guard. Management of a seizure is pretty straight forward, protect the patient from harm, raise the seizure threshold, move to definitive care if necessary. The causes are many, and you'll see why in a few days.