Management of prehospital seizure patients by paramedics

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Also posted over at Rogue Medic (now at EMS Blogs).

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Why look at seizures?

In a 2001 multicenter study, patients presenting with seizures or complaints related to seizures represented 1.2% of all ED visits.¹ The majority of these patients (71%) utilized emergency medical services (EMS) for transport and care. An even greater number (84%) had interventions during EMS transport or in the ED that included airway attention, establishing intravenous (IV) access, and medication administration, and 55% received antiepileptic medications.^[1]

It does seem as if seizures are over-represented in EMS and it seems that seizures require some very aggressive care.

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The secondary objective was to identify other characteristics related to these cases that would help to ascertain the utility of specific ALS procedures.^[1]

Of all of those interventions, such as 55% received antiepileptic medications, which ones are most important and why?

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500 consecutive adult seizure patients over a period of 9 months produced only 97 patients for analysis. Seizures are frequent. One of the advantages of research is that it allows us to acquire some of the experience of much more frequent patient contact than we would in a busy career. 97 seizure patients is not a lot. If I only see one seizure patient a month, this is 8 years of experience, but does one seizure patient a month reflect your system? Would one a week be more like it? At one a week, this is only 2 years experience.

Why do I spend time explaining this?

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These patients represent a heterogeneous group of patients including those with generalized seizures, focal seizures, and pseudo-seizures.^[1]

With a very varied group, small numbers can be expected to produce results that are not representative of a much larger population. The idea is right, but the numbers are not. 500, or a thousand, would be much better for averaging the many variables. If your experience does not match what is described, here, don’t get upset. This does not match my experience, either.

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You can click on the tables for larger versions.

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That seems normal. I do not recall a lot of patients who are confused or who remain confused for more than a few minutes after arrival on scene.

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Six patients had glucose levels (BGLs) less than 80 mg/dL (range 68–79 mg/dL), which was the protocol cutoff for treatment with dextrose or glucagon; blood glucose values at this level are herein referred to as hypoglycemia. All of these patients had an IV line attempted, though only one (BGL = 69 mg/dL) received dextrose and none received glucagon. However, only one of the untreated patients had a BGL less than 70 mg/dL (BGL = 68 mg/dL) and was in an alert, conscious state. The patient who did receive dextrose and one of two hypoglycemic patients with an unsuccessful IV attempt (BGL = 76 mg/dL) had recurrence of seizure activity in the prehospital setting.^[1]

There is so much about this that raises questions, rather than answering questions. Were the seizures of any of these patients attributed to the hypoglycemia? Did any of these patients have a history of seizures due to hypoglycemia? What was learned about them in the hospital?

2/6 hypoglycemic patients (33.3%) had repeat seizures, but overall 28/97 patients (28.9%) had repeat seizures, only 17 of them (17.5%) out of the hospital.

Should we compare the hypoglycemic patients with the overall seizure patients? With only 6 hypoglycemic patients, and only 56 had BGL measured (64.4%), changes of just a single patient will completely change the apparent significance. What if, instead of 2 hypoglycemic patients having seizures, only 1 did (16.7%)? Or what if 3 did (50%)? Or what if 4 did (66.7%)? Or what if none of them did (0.0%)? And how many of the patients, who did not have BGL measured, had repeat seizures and hypoglycemia?

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The hospital data are not helpful for learning more about the hypoglycemic patients. Did the hospital check BGL on every patient? Probably. Go to an ED (Emergency Department) for anything non-traumatic and expect to have a blood sugar checked.

Does that mean that we should make every medical EMS call ALS, just to check BGL?

This could be the Mechanism Of Idiocy Injury that could help minor medical calls leapfrog past trauma in ALS over-triage.

Just stop thinking and start making everything ALS, because what if we miss one?

If it saves just one life (even though maybe a dozen who would otherwise have lived will now die), it’s worth it! Go ALS!

Or we could fly all of these patients, just in case, because What if . . . ?

Anyway, back in the real world, we just don’t know what to do with the data on hypoglycemia. What about the data on repeat seizures? Some seize. Based on this study, are we able to predict which patients will have repeat seizures? No. Are we able to tell which patients have pseudo-seizures? No. Are we able to tell which patients need ALS, based on this study? No.

All but one of the 10 patients who were treated with diazepam had a less-than-alert level of consciousness (n = 7), additional prehospital seizure activity (n = 7), or both (n = 5).^[1]

Maybe, we do have a good hypothesis for another study. Does the alert patient benefit from ALS?

Even if the repeat seizure patient has the full ALS workup of IV, ECG, and BGL before the repeat seizure, does it make any difference in outcome? Would any of this really prevent a seizure?

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Overall, instead of revealing inappropriate care, this review emphasized the difficulty with creating a homogeneous protocol for such a diverse group of patients.^[1]

That does appear to be the case.

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We recommend further study with emphasis on concrete outcome measures to determine the impact that specific ALS interventions have on this group of patients.^[1]

That is a good idea.

What is the right treatment for a seizure? This may be the wrong question. Maybe we should ask what the right treatment should be for a patient with no history of seizures and a decreased level of consciousness? Or what is the right treatment for a patient with a focal seizure that has been evaluated in the ED several times before? Et cetera.

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Footnotes:

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^[1] Management of prehospital seizure patients by paramedics.
Martin-Gill C, Hostler D, Callaway CW, Prunty H, Roth RN.
Prehosp Emerg Care. 2009 Apr-Jun;13(2):179-84.
PMID: 19291554 [PubMed - indexed for MEDLINE]

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