Neuro Scenario 6 Seizure PDF

[Neuro Scenario \#6 Seizure] ***Instructor Information***: This scenario is for a seizure patient who seizes with EMS but stops on own, not requiring medication (no benzos required). **[Dispatch information:]** Called to a non-medical alcohol rehab facility at 1pm for a 48-year-old male seizing. C...

[Neuro Scenario \#6 Seizure] ***Instructor Information***: This scenario is for a seizure patient who seizes with EMS but stops on own, not requiring medication (no benzos required). **[Dispatch information:]** Called to a non-medical alcohol rehab facility at 1pm for a 48-year-old male seizing. Caller is support worker there, reports patient had 6 minute "grand mal" seizure but has stopped. No head or neck trauma with seizure. **[Event Information Size-up prior to arrival:]** *Student should consider the following categories based on dispatch information. Can add or change considerations (hazards, needed resources) throughout scenario as more information becomes available.* [ ] - **PPE:** Universal precautions, consider contact/droplet - **Scene time:** 1pm - **Environment:** Summer, early afternoon. Cafeteria of private rehab facility. - **Hazards:** None apparent at this time - **Number of patients:** 1 as per dispatch - **Consider appropriate resources:** Can consider medical back-up (another ambulance or fire) due to high-risk complaint (decreased LOC) - **Mechanism of injury/illness:** Seizure. **After arrival to scene:** - **Scene/bystander information:** - Door is open with staff member waiting for you, gestures you to cafeteria. *If asked: staff member states that patient started seizing from standing but landed on buttock and then to ground, no visible impact to head or neck during fall.* **[General Impression]:** *Only give the following information if asked for* - **Age: 48** - **Sex:** male - **Height and weight:** 5'7" 185 pounds (student should calculate kg as required) - **Position:** Lying in recovery position on ground. Head supported by a bunched-up blanket with a staff member kneeling beside. - **Level of activity/distress:** Patient eyes closed, chest rise with spontaneous respirations, patient eyes are closed, face reddish and dusky. - **Skin colour/condition:** Dusky, warm, diaphoretic. - **Obvious injuries (angulations/bleeding):** none **[Initial Approach: ]** - **Consider c-spine:** *Not required. If student does apply hard collar, patient starts snoring when rolled on to back.* - **LOC:** Eyes closed. No response to verbal or gentle stimuli. Moans/incomprehensible speech to painful stimuli and starts coughing with frothy sputum. Does not obey commands. - **Airway:** Patent when on side, small to moderate amount of frothy sputum noted and intermittent snoring respirations. - ***Airway intervention*:** *Consider suction to help patient clear secretions. To correct snoring, use manual maneuvers, or can insert NPA for decreased level of consciousness but still responsive to pain.* - **Breathing:** 24/min. Adequate chest rise with deep spontaneous respirations. - **Breathing intervention:** *Consider supplemental oxygen by n/c or NRB.* - **Circulation:** Radial pulse present regular at 124/min. - **Deadly wet check:** appears incontinent of urine, no bleeding noted. **[Decision: ]** - **Critical/Stable:** Critical Medical (decreased level of Consciousness). **[Delegate] (for critical medical patient):** - **Oxygen:** consider supplemental oxygen, does not require ventilations at this point. - **Vascular access:** if vascular access obtained at this time: saline lock or TKVO; not administer fluid until complete head-toe and get history, vital signs back (not enough information yet for treatment of administering fluid, and it is not required at this time). - **Vital signs:** If asks for vital signs on scene: HR, RR, SPO2, BP, T, BGL - **4-lead/12-lead:** Will delay scene time - **SAMPLE, Social history, family history** - **Prepare additional equipment:** N/A **Rapid Survey:** +-----------------------------------+-----------------------------------+ | Head (expose, inspect, palpate) | Flushed skin, diaphoretic. Scant | | Check pupils. | blood to mouth. Pupils round, | | | equal and sluggish at 5mm. | +===================================+===================================+ | Neck (expose, inspect, palpate) | No remarkable findings. **If | | | asked for**: No tracheal | | | deviation, mild JVD bilaterally | | | while lying on ground. | +-----------------------------------+-----------------------------------+ | Chest (expose, inspect, palpate, | No remarkable findings. Stable, | | ausc. Breath sounds/ heart tones | no tenderness on palpation. | | ) | Breath sounds present to all lung | | | fields with mild expiratory | | | wheezes to lower lobes | | | bilaterally. *If asked: no change | | | in heart tones* | +-----------------------------------+-----------------------------------+ | Abdomen (expose, inspect, | Soft non-tender. | | palpate) | | | | *If asked:* -Has had vomiting and | | | diarrhea in past couple days per | | | staff, none today. | +-----------------------------------+-----------------------------------+ | Pelvis (expose, inspect, palpate) | Urinary incontinence noted. | +-----------------------------------+-----------------------------------+ | ↓Extremities (expose, inspect, | Warm, dry. Circulation and | | palpate) | sensory intact x2, when patient | | | moves no apparent deficits but | | | unable to follow commands. | +-----------------------------------+-----------------------------------+ | ↑ Extremities (expose, inspect, | Warm, dry. Circulation and | | palpate) | sensory intact x2, when patient | | | moves no apparent deficits but | | | unable to follow commands. | +-----------------------------------+-----------------------------------+ | Back (expose, inspect, palpate) | No remarkable findings on backIf | | ***Consider auscultate if | asked for: breath sounds clear | | decreased*** | throughout lung fields. | +-----------------------------------+-----------------------------------+ **[Review of delegated information:]** *only give information that had been delegated for* **Vital signs:** *\*BP is equal bilaterally if requested* **LOC** **HR** **RR** **BP** **SPO2** **BGL** **Temp** **ETCO2** -------------------- --------- -------- ------------ ---------- --------- ---------- ----------- **Painful (AVPU)** **126** **24** **153/86** **92%** **7.3** **37.0** **40** **ECGs: 4-lead:** Sinus tachycardia. **12-lead:** Non-diagnostic (no ST changes) HISTORIES (SAMPLE, Social Hx, Family Hx): - **S:** Decreased level of consciousness after witnessed seizure activity lasting 6 minutes. Patent airway in recovery position, snoring when rolled on back. Has been in facility for 2 days. - **A: (pt. cannot answer, facility staff does if asked**) NSAIDs allergy - **M:** **(pt. cannot answer, facility staff does if asked**) Takes cholesterol medication. Chronic alcohol use approximately 48 oz/day x 20 years off and on, last drink 2 days ago. Smoker. No drug use. No history of seizures. - **L: (pt. cannot answer, facility staff does if asked**) Breakfast around 8am. Wasn't hungry at lunch. *If requested:* Denies known change with bowel movements lately, he's unsure any chance of pregnancy/last menstrual period. (pt. shakes head no if asked) - **E:** **(pt. cannot answer, facility staff does if asked**) "He wasn't feeling well so didn't eat lunch. Was a bit shaky walking back to his room when he started seizing." **Family history:** Facility staff does not know. Thinks his father might have drank alcohol heavily. **Social History: (pt. cannot answer, facility staff does if asked**) alcohol use approximately 48 oz/day x 20 years off and on, last drink 2 days ago. Smoker. No drug use. No known emergency contact on file. Lives alone. ***[OPQRST if patient has pain/other acute severe symptom such as difficulty breathing]*** *[**\*\*student must request this info:** ]* - **Onset:** Seizure started while patient was walking. - **P (anything provokes/alleviates symptom):** Resolved without treatment after 6 minutes. - **Quality of symptom:** unknown. - **Radiating/movement of symptom:** unknown. - **Severity of symptom:** No seizure activity noted at present. - **Time symptoms started:** Approximately 10 minutes ago when they called 911 **[Treatment/Reassessment: ]** +-----------------------------------+-----------------------------------+ | Initial treatments (on scene) | General: | | | | | | - Oxygen- should consider | | | supplemental oxygen. | | | | | | - Vascular access prepared if | | | the patient seizes again | | | | | | - No medication needed at this | | | time as the patient is not | | | actively seizing | +===================================+===================================+ | Reassess after treatments on | **Reassess** if any treatments or | | scene | medications given on scene (other | | | than oxygen). | | | | | | **N/A for this patient.** | | | | | | ***Repeat vital signs if | | | requested:*** | | | | | | HR-122, RR- 26, BP- 160/92, | | | ETCO2-38, T- 37.1, SPO2- 91% room | | | air/98% if on O2 | | | | | | 4-lead ECG showing regular sinus | | | tach. | | | | | | 12-lead: non-diagnostic, no ST | | | changes | +-----------------------------------+-----------------------------------+ | Transport | Move to ambulance and leave | | | scene. | | | | | | - Consider calling to | | | pre-notify hospital while | | | leaving scene. (*patch | | | criteria at end of scenario, | | | can be done at any time)* | | | | | | Shortly after moving patient in | | | to ambulance, patient has | | | generalized seizure. If 15L NRB | | | in place, leave in place. | | | | | | As student starts to prepare | | | medication (midazolam) the | | | seizure stops on its own within | | | 30 seconds. | +-----------------------------------+-----------------------------------+ | Reassess after moves | **Reassess:** | | | | | | **LOC- decreasing level of | | | consciousness, no response to | | | pain** | | | | | | A. Snoring much louder than | | | before. | | | | | | B. More breathing attempts | | | observed than chest rise. | | | | | | C. Face becoming dusky. Patient | | | less tachycardiac to radial | | | pulse. | | | | | | ***Repeat vital signs if | | | requested:*** | | | | | | HR-120, RR- 28, BP- 168/91, | | | ETCO2-43, T- 37.0, SPO2- 93% O2 | | | per NRB | | | | | | **\*\*If recheck BGL**: 4.3 | | | mmol/L. | | | | | | 4-lead ECG showing sinus | | | tachycardia. | | | | | | 12-lead: non-diagnostic, no ST | | | changes | +-----------------------------------+-----------------------------------+ | Secondary head to toe | **Head**-Pupils equal, round and | | | sluggish at 5mm. *Some blood | | | noted in mouth, small wound to | | | side of tongue.* | | | | | | *if supine with no airway | | | maneuvers*: Snoring. | | | | | | *If NPA inserted:* Patent. | | | | | | **Neck**- no changes noted. | | | | | | **Chest-** Air entry present to | | | all lung fields. Mild expiratory | | | wheezes noted to bilateral lower | | | lobes. | | | | | | **Abd-** soft non tender. | | | | | | **Pelvis**- Urine and bowel | | | incontinence. | | | | | | **Lower extremities:** | | | Circulation intact | | | | | | **Upper extremities:** | | | Circulation intact | | | | | | **Repeat v/s if requested**: HR- | | | 110, BP- 158/72, SPO2- 92%, | | | ETCO2-36, T- 37.0 | | | | | | 4-lead ECG showing sinus | | | tachycardia | | | | | | 12-lead: non-diagnostic (no ST | | | changes) | +-----------------------------------+-----------------------------------+ | Additional treatments | Ongoing reassess, check on | | | interventions (oxygen only). | +-----------------------------------+-----------------------------------+ | Patch to receiving facility | *Patch should include the | | | following components:* | | | | | | Age, sex, history (history of | | | chief complaint and past medical | | | history, assessment findings, | | | treatment and treatment response, | | | and time to destination. | +-----------------------------------+-----------------------------------+ [**(Instructor) Discussion/debrief**: ] 1. **What are some differential diagnoses based on the dispatch information:** - Known epilepsy - Brain tumor/malignancy - CVA or intracranial hemorrhage - Alcohol withdrawal. - Hypoglycemia. - Trauma. - Substance overdose. - Syncope misinterpreted by bystanders as a seizure **2. What information from initial presentation, assessment, history and vital signs, diagnostics to move from the various differentials to find a provisional diagnosis?** - Alcohol withdrawal: History of chronic alcohol ingestion. When was last drink? Has patient had alcohol withdrawal seizures in the past? - Hypoglycemia: Ate breakfast. Early BGL normal. - Trauma. Witnessed fall from standing on to hips/buttocks with no trauma visualized to head. - Substance overdose. Possible. Check pupils and ask about access to different substances. 3. **What are the priorities of treatment based on the provisional and differential diagnosis?** Although we cannot definitively diagnose the cause of a seizure (or even if a seizure had occurred pre-EMS arrival), the priority is managing the patient's Airway, Breathing and Circulation. When we approach any patient- we must consider is the airway is open and clear, not open, or threatened. This patient has an open airway (possibly threatened). Hopefully the patient condition will improve if the decreased level of consciousness is post-ictal, but this is not known (condition would worsen if hypoglycemic, overdose, trauma, intracranial hemorrhage or mass). - Accurate assessment and reassessment of the patient condition is crucial. Are there signs of trauma to the head or neck? Even if a staff member reports no trauma, this may not be accurate. Observe for environmental hazards, such as sharp corners of tables, chairs, or hard surfaces with corresponding visible injuries on the patient. It is not wrong to establish spinal immobilization and treat as a trauma until imaging can determine any internal injuries, especially with a patient who cannot report events or areas of pain. A fall from standing can result in significant traumatic injuries. Will the patient tolerate being rolled out of the recovery position? If the patient develops an upper airway obstruction after being rolled on to back or to establish spinal immobilization, you must intervene: jaw thrust, trial NPA or OPA insertion. If upper airway obstruction does not improve after these initial maneuvers, consider definitive airway management such as blind insertion airways or endotracheal intubation. - Protect yourself from potential communicable disease. Recent vomiting and diarrhea may be from alcohol withdrawal, but may be due to a communicable disease such as COVID-19 or gastroenteritis. - Consider possible comorbidities in this case such as liver dysfunction (from the chronic alcohol use) which may be undiagnosed, or cardiomegaly. This will cause a higher likelihood of abnormal glycemic control, electrolyte abnormalities, decreased clotting, and chronic JVD. - **Early pre-notification to the hospital** so they can get equipment prepared, clear an appropriate treatment space (especially for GCS \< 8/15). ***A good time to call is when you are packaging to leave scene, going out to the ambulance, especially if you have extra resources getting the patient out to the truck. If you wait until you are in the ambulance, reassess the patient and get repeat vital signs- you might be already almost there. Call early from scene as soon as you have enough information.*** 4. **Other considerations in this patient treatment?** - **Blood in the mouth and tongue wound**: This may occur with generalized seizures but are not seen with every seizure. When in doubt, take the word of the people on scene and convey as accurately as possible to the hospital. - **Urinary and bowel incontinence:** Again, these symptoms may occur with seizures, but some generalized seizures do not result in incontinence. The absence of incontinence should not be used to 'rule out' a seizure having occurred.