Case Study #6: Seizure

prehospitalresearch.eu/

March 15,
2014

Patient & Apparent Chief Complaint

A 65 year old female presents to ambulance crew after call from her husband stating
patient having possible CVA. Upon arrival patient is found to be having a tonic-clonic
seizure.

History
Patient could not verbalise to husband when he woke up. He tried to talk to her, and
stated she was making an effort to talk back to him but could not make sounds. The
patient was lying in actively seizing upon arrival of ambulance crew.

Initial Clinical Findings

Airway – unobstructed
C Spine – not suspected, no MOI
Breathing – regular
Circulation – Pulse present, irregular; skin colour flushed, cap refill normal (>2 sec)
Disability – LOC before ambulance arrival; patient unable to talk, actively seizing

Clinical Impression
Seizure
Query CVA/TIA

SAMPLE History
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 A – No known allergies
M – Currently taking Epanutin (anti-convulsant), Aspirin, Rouvastatin and Eltroxin
P – History of TIAs, numerous previous seizure episodes resulting in hospitalisation
(? epileptic in nature), hypercholesterolaemia
L – Dinner 8pm the evening previous
E – Husband stated patient had eyes open upon waking but unable to verbalise

Observations
Pulse rate 134bpm
Pulse rhythm Irregular
ECG rate 126
ECG rhythm A Fib, unifocal PVCs
Resp rate 12 per minute, normal, regular
Resp quality Equal air entry bilaterally
SpO2% 99% on 100% O2 via NRB
Cap Refill <2secs
BP 176/68
Pupils PEARRL, size 6
GCS 7/15 (E4, V2, M1)
BGL 9.0mmol/l

Pre-hospital care & management

O2 @15lpm commenced via non-rebreather mask. Diazepam 5mg PR administered as
patient actively seizing. Transferred to ambulance, further 5mg of Diazepam PR was
administered. 12 lead ECG obtained during post-ictal phase. IV access gained in right
dorsum. GCS reduced to 3/15, patient unresponsive. NPA (Size 6mm) inserted into left
nostril, tolerated. En-route to hospital patient had 6 further tonic-clonic seizures – 5mg
Diazepam PR & 5mg Diazepam IV administered, seizures resolved. Suction provided as
snoring respirations evident, large amounts of saliva building up in mouth. Ventilations
assisted as RR<10 per minute. Resuscitation equipment prepared as patient having runs
of Ventricular Tachycardia. Total 15mg Diazepam PR and 5mg Diazepam IV administered
pre-hospital.

In-hospital care & management

Triaged as Category 1 (Life-Threatening Condition) with Unconscious, Seizures, ? CVA.
Brought directly to Resus room. Aggressive airway management commenced.
Lorazepam 5mg IV administered. Patient RSI’d to secure airway. Urinary catheter
inserted. Sent for CT Brain. No intra-cerebral haemorrhage found on CT scan. Patient
sent to ICU on ventilator, remained sedated. Poor prognosis, same discussed with family
by medical team.

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Identification of all interventions initiated and rationale
Pulse oximetry – to monitor oxygen saturation levels in the blood
Vital signs (HR, RR, SpO2, BM) – to gain a baseline set of vital signs for reference
Diazepam – anticonvulsant medication, to stop seizure activity
Nasopharyngeal airway – to protect the airway due to decreased level of
consciousness
Suction – to clear the airway of saliva due to patient’s inability to maintain own
airway
Pulse oximetry – to monitor oxygen saturation levels in the blood
Supplemental oxygen – to re-oxygenate patient
Assisted ventilations – to provide adequate oxygenation to patient’s tissues as RR
<10
3 Lead ECG – to identify any life-threatening arrhythmias
12 Lead ECG – to identify any life-threatening arrhythmias or ECG changes
indicative of myocardial damage (secondary to hypoxia etc.)
IV access – to allow for IV medications to be administered
CXR – to identify aspiration, pleural effusion etc. that may increase morbidity
Blood tests – to identify any electrolyte imbalances etc.
Urinary catheter – to monitor urinary output to ensure adequate renal function
CT Brain – to identify any cerebral haemorrhage or infarct that may be indicative of
cause of altered LOC/seizures

Learning Outcomes

Initial therapy choice in treatment of seizures

Benzodiazepines are the agents of first choice in management of seziures (Dionisio,
2013). Both diazepam and lorazepam are members of the benzodiazepine group of
medications.

The ability of Paramedics of all grades to control patients who are actively seizing is an
area that needs attention in some systems. Paramedics being able to provide midazolam
and/or diazepam through various additional routes such as intranasal, per rectum,
buccal or intramuscular would result in improved outcomes for patients.

Lorazepam
A 2008 review by Appleton et al. found that intravenous lorazepam is at least as
effective as intravenous diazepam and is associated with fewer adverse events.
IM administration of lorazepam is more reliable and is the recommended
medication to be given IM if required (Munne, 1990)
Prasad et al. (2005) stated that in patients experiencing status epilepticus,
lorazepam is better than diazepam for cessation of seizures, and has a longer
duration of effect and should be the first therapy of choice for patients
experiencing status epilepticus.
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 Lorazepam has a much longer duration of anti-convulsant action than diazepam
and has an equivalent onset of action (Cock & Schapira, 2002)

Diazepam
Some caregivers and parents are
already trained in the administration
of PR diazepam.
Diazepam administered per rectum
is shown to be as effective as
diazepam given intravenously (Lahat
et al., 2000), although bioavailability
varies considerably from patient to patient.
Per rectum administration is also shown to have a lesser respiratory depressive
effect than IV administration.
IM administration of diazepam is erratic and may be significantly delayed.

Midazolam
Rainbow et al. (2002) found that intranasal midazolam can control seizures as
effectively as diazepam in the prehospital setting.
Intranasal midazolam can also result in a comparable time to cessation of seizures
to that of intravenous diazepam (Lahat et al., 2000)
Wolfe & Macfarlane (2006) found that intranasal midazolam can provide better
seizure control than PR diazepam, and is easier for paramedics to administer to a
patient who is actively seizing.
A number of authors (Scott et al, 1999; Queally, 2007; Wilson et al., 2004;
Humphries & Eiland, 2013) also found that patients and caregivers found
intranasal midazolam to be more socially acceptable than per rectum
administration of diazepam, as well as re-confirming the view it was more
convenient for paramedics to access the intranasal route than the per rectum
route.
Queally (2007) concluded that buccal midazolam may be useful in the community
setting in the treatment of prolonged and serial seizures and the prevention of
status epilepticus.
Chamberlain et al. (1997) concluded that IM midazolam is an effective
anticonvulsant for children with seizures and an important alternative when IV
access is not available.
Where intravenous access is unavailable there is evidence from one trial that
buccal midazolam is the treatment of choice (Appleton et al., 2008)

PHECC CPGs state Diazepam 5mg IV (repeat to a max of 10mg) as the first choice therapy
for actively seizing patients. The JRCALC guidelines (2006) also recommend Diazepam
5mg IV (repeated to a max of 10mg) as the first choice therapy for seizure management.

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The provision of buccal and/or intranasal midazolam to all Paramedics is therefore a
recommendation, and would result in the ability of Paramedics to provide patients who
are actively seizing with an immediate, safer resolution to their seizure state.

Status epilepticus
Status epilepticus is usually defined as 30 minutes of uninterrupted seizure activity.
However, varying definitions exist, ranging from 5-30 minutes in duration. Another
definition is “an epileptic seizure that is sufficiently prolonged or repeated at a
significantly brief interval so as to produce an invarying and enduring epileptic condition”
(Gastaut, 1973) Status epilepticus is associated with significant morbidity and mortality.

Mortality associated with status epilepticus has been reported at between 18% and 23%
(Logroscino et al., 1997) The ability of Paramedics to intervene in cases of status
epilepticus with appropriate pharmacological interventions, thus reducing the mortality
associated with it is an important aspect of prehospital care.

Seizures in patients presenting with CVAs

CVAs account for approximately 10-55% of symptomatic seizures in the 55-plus age
group, and in a number of studies accounting for a larger percentage as age increases
(Annergers etc al., 1995; Cossu et al., 2012; Tchalla et al., 2011). A number of studies
have shown that post-ischaemia seizures (i.e. post-CVA seizures) are associated with an
increased mortality rate (Arboix et al., 2003)

Results regarding the impact of ischaemia induced post-CVA seizures on mortality

outcome are however, inconsistent at best. According to Camilo & Goldstein (2004)
experimental studies to date suggest that seizure-like activity in the presence of cerebral
ischemia can significantly increase the size of cerebral infarct and can impair long-term
recovery.

Airway management in the actively seizing patient

The management of the airway in the actively seizing patient is the priority of care and is
paramount to a successful patient outcome. Basic manoeuvres, a nasopharyngeal airway
and suction of secretions in the oral cavity if required are the basic tenets to successful
airway management in the seizing patient (Graham & Gordon, 2001; AAOS, 2005; Elling et
al., 2007). It is important for practitioners to remember that basic management of the
airway can be as successful, if not more than advanced management in the actively
seizing patient.

References (non-Pubmed)
AAOS (2005) Emergency Care and Transportation of the Sick and Injured 9th Edition.
Massachusetts: Jones & Bartlett

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Elling B, Caroline N, Smith M (2007) Nancy Caroline’s Emergency Care in the Streets, 6th
Edition (UK Edition). London: LWW

Munne P (1990) Diazepam: International Programme on Chemical Safety – Poisons

Information Monograph 181.
[http://www.inchem.org/documents/pims/pharm/pim181.htm] Accessed 10th November
2013.

Queally C (2007) The use of buccal midazolam in emergency seizure management in

epilepsy British Journal of Neuroscience Nursing (3) 6; 272-275

References

1.
Dionisio S1, Brown H, Boyle R, Blum S. Managing the generalised
tonic-clonic seizure and preventing progress to status epilepticus: a
stepwise approach. Intern Med J. 2013 Jul;43(7):739-46. PMID: 23614871.

Seizures are a commonly encountered medical problem. Seizure protocols have been
shown to be effective by avoiding inappropriate over- and undertreatment, but are not
presently utilised in many centres in Australia. We outline a stepwise approach to
effective seizure management based on timely inves […]

2.
Humphries LK1, Eiland LS. Treatment of acute seizures: is intranasal
midazolam a viable option? J Pediatr Pharmacol Ther. 2013
Apr;18(2):79-87. PMID: 23798902.

Seizures in the pediatric population commonly occur, and when proper rescue
medication is not administered quickly, the risk of neurologic compromise emerges. For
many years, rectal diazepam has been the standard of care, but recent interest in a more
cost-effective, safe alternative has led to the […]

3.
Chamberlain JM1, Altieri MA, Futterman C, Young GM,
Ochsenschlager DW, Waisman Y. A prospective, randomized study
comparing intramuscular midazolam with intravenous diazepam for the treatment of
seizures in children. Pediatr Emerg Care. 1997 Apr;13(2):92-4. PMID: 9127414.

To compare treatment of ongoing seizures using intramuscular (IM) midazolam versus

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intravenous (IV) diazepam. […]

4.
Scott RC1, Besag FM, Neville BG. Buccal midazolam and rectal
diazepam for treatment of prolonged seizures in childhood and
adolescence: a randomised trial. Lancet. 1999 Feb 20;353(9153):623-6. PMID: 10030327.

Convulsive status epilepticus is the most common neurological medical emergency and
has high morbidity and mortality. Early treatment before admission to hospital is best
with an effective medication that can be administered safely. We aimed to find out
whether there are differences in efficacy and […]

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prehospital setting: diazepam or midazolam? J Paediatr Child Health.
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To determine which is the most effective and safe treatment for controlling seizures in
children out-of-hospital: diazepam or midazolam. […]

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therapy for status epilepticus. Br J Clin Pharmacol. 2007
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To determine whether a particular anticonvulsant is more effective or safer than another

or placebo in patients with status epilepticus, and to summarize the available evidence
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Logroscino G1, Hesdorffer DC, Cascino G, Annegers JF, Hauser WA.
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Studies evaluating short-term mortality among people who experience status epilepticus
(SE) have produced conflicting results. Most studies are derived from clinical series with

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results affected by unspecified follow-up period and select referral of cases. This study
was planned to evaluate short-te […]

8.
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of intranasal midazolam with intravenous diazepam for treating
febrile seizures in children: prospective randomised study. BMJ. 2000 Jul 8;321(7253):83-
6. PMID: 10884257.

To compare the safety and efficacy of midazolam given intranasally with diazepam given
intravenously in the treatment of children with prolonged febrile seizures. […]

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Injectable benzodiazepines are commonly stocked on ambulances for use by

paramedics. We evaluated the stability of lorazepam and diazepam as a function of
storage temperature. Diazepam (5 mg/mL) and lorazepam (2 mg/mL) injectable
solutions were stored for up to 210 days in clear glass syringes at th […]

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treatment of convulsive status epilepticus (CSE), with improved seizure outcome, and a
lower incidence of side-effects. Many published guidelines however still recommend
diazepam. […]

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12.
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Although a long-recognized clinical phenomenon, there remain many questions

regarding the epidemiology of seizures and epilepsy after ischemic stroke, their effect on
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13.
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M. Prognostic value of very early seizures for in-hospital mortality in
atherothrombotic infarction. Eur Neurol. 2003;50(2):78-84. PMID: 12944711.

We studied the influence of very early seizures (within 48 h of stroke onset) on in-hospital
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prospective hospital-based stroke […]

14.
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We determined the incidence of seizures due to acute CNS insults for residents of
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person-years (United States 1970 population as stan […]

15.
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Sardinia, insular Italy, represents a particular epidemiological setting to investigate

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16.
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