1. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training DOT National Standard EMT-Intermediate/85 Refresher DOT National Standard EMT-Intermediate/85 Refresher Welcome!

2. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Allergic reaction Possible overdose Near-drowning ALOC Diabetes Seizures Heat & cold emergencies Behavioral emergencies Suspected communicable disease Allergic reaction Possible overdose Near-drowning ALOC Diabetes Seizures Heat & cold emergencies Behavioral emergencies Suspected communicable disease Airway & Breathing –Ventilatory support –Cardiac arrest Post arrest resuscitation –Cardiovascular Compromise

3. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training MEDICAL EMERGENCIES Seizures Pathophysiology Epidemiology PE & Diagnostic Findings S/S Differential considerations Tx

4. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training perspective A seizure is an episode of abnormal neurologic function caused by an inappropriate electrical discharge of brain neurons Epilepsy is a clinical condition in which an individual is subject to recurrent seizures A seizure is an episode of abnormal neurologic function caused by an inappropriate electrical discharge of brain neurons Epilepsy is a clinical condition in which an individual is subject to recurrent seizures

5. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training perspective The term epileptic does not refer to an individual with recurrent seizures caused by reversible conditions

6. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training perspective Etiology of Status Epilepticus: common causative disorders: –Metabolic disturbances –Infectious processes –Withdrawal syndromes –CNS lesions –Intoxication Etiology of Status Epilepticus: common causative disorders: –Metabolic disturbances –Infectious processes –Withdrawal syndromes –CNS lesions –Intoxication

7. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training epidemiology US –Epilepsy & seizures affect more than 3 million Americans of all ages –Approximately 200,000 new cases occur each yr, of which 40-50% will recur & be classified as epilepsy –Overall approximately, 50,000-150,000 cases will reach status epilepticus US –Epilepsy & seizures affect more than 3 million Americans of all ages –Approximately 200,000 new cases occur each yr, of which 40-50% will recur & be classified as epilepsy –Overall approximately, 50,000-150,000 cases will reach status epilepticus

8. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Type of seizures Generalized seizures (consciousness always lost) Partial (local) seizures Unclassified (due to inadequate info) Generalized seizures (consciousness always lost) Partial (local) seizures Unclassified (due to inadequate info)

9. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Type of seizures Generalized seizures (consciousness always lost) –Tonic-clonic seizures (grand mal) –Absence seizures (petit mal) –Others (myoclonic, tonic, clonic, atonic seizures) Generalized seizures (consciousness always lost) –Tonic-clonic seizures (grand mal) –Absence seizures (petit mal) –Others (myoclonic, tonic, clonic, atonic seizures)

10. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Type of seizures Partial (local) seizures –Simple partial (no alteration of consciousness) –Complex partial (consciousness impaired) –Partial seizure (simple or complex) with secondary generalization Partial (local) seizures –Simple partial (no alteration of consciousness) –Complex partial (consciousness impaired) –Partial seizure (simple or complex) with secondary generalization

11. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Type of seizures Generalized seizures (consciousness always lost) –Tonic-clonic seizures (grand mal) Begin w/ abrupt loss of consciousness In a typical attack, the pt suddenly becomes rigid, trunk and extremities are extended, and pt falls to the ground Generalized seizures (consciousness always lost) –Tonic-clonic seizures (grand mal) Begin w/ abrupt loss of consciousness In a typical attack, the pt suddenly becomes rigid, trunk and extremities are extended, and pt falls to the ground

12. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Type of seizures Generalized seizures (consciousness always lost) – Tonic-clonic seizures (grand mal) Pts are often apneic during this period & may be deeply cyanotic They often urinate & may vomit As the rigid (tonic) phase subsides There is increasing coarse trembling that evolves into a symmetric, rhythmic (clonic) jerking of the trunk & extremities Generalized seizures (consciousness always lost) – Tonic-clonic seizures (grand mal) Pts are often apneic during this period & may be deeply cyanotic They often urinate & may vomit As the rigid (tonic) phase subsides There is increasing coarse trembling that evolves into a symmetric, rhythmic (clonic) jerking of the trunk & extremities

13. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Type of seizures Generalized seizures (consciousness always lost) – Tonic-clonic seizures (grand mal) As the attack ends, the pt is left flaccid & unconscious, often w/ deep, rapid breathing (postictal phase) Typical attacks last from 60-90 sec Bystanders generally overestimate the duration of the seizure Consciousness returns gradually, & postictal confusion & fatigue may persist for several hours or more Generalized seizures (consciousness always lost) – Tonic-clonic seizures (grand mal) As the attack ends, the pt is left flaccid & unconscious, often w/ deep, rapid breathing (postictal phase) Typical attacks last from 60-90 sec Bystanders generally overestimate the duration of the seizure Consciousness returns gradually, & postictal confusion & fatigue may persist for several hours or more

14. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training s/s, physical exam & assessment, diagnotics, monitoring, management, pertinent positives Generalized seizures (consciousness always lost) –Tonic-clonic seizures (grand mal) – Absence seizures (petit mal) –Others (myoclonic, tonic, clonic, atonic seizures) Generalized seizures (consciousness always lost) –Tonic-clonic seizures (grand mal) – Absence seizures (petit mal) –Others (myoclonic, tonic, clonic, atonic seizures)

15. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training s/s, physical exam & assessment, diagnotics, monitoring, management, pertinent positives Generalized seizures (consciousness always lost) – Absence seizures (petit mal) Very brief, generally lasting only a few seconds Pts suddenly lose consciousness w/o losing postural tone. They may appear confused, detached, or withdrawn & current activity ceases May have staring & eyelid twitching They do NOT: –Respond to voice or other stimulation –Exhibit voluntary movements –Or lose continence Generalized seizures (consciousness always lost) – Absence seizures (petit mal) Very brief, generally lasting only a few seconds Pts suddenly lose consciousness w/o losing postural tone. They may appear confused, detached, or withdrawn & current activity ceases May have staring & eyelid twitching They do NOT: –Respond to voice or other stimulation –Exhibit voluntary movements –Or lose continence

16. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training s/s, physical exam & assessment, diagnotics, monitoring, management, pertinent positives Generalized seizures (consciousness always lost) – Absence seizures (petit mal) Attack ceases abruptly, and the pt is able to resume previous activity without postical symptoms Both the pt and witness may not be aware of what has happened Classic absence seizures happen in school-aged children –100 times or more a day –Usually resolves as the child grows older Generalized seizures (consciousness always lost) – Absence seizures (petit mal) Attack ceases abruptly, and the pt is able to resume previous activity without postical symptoms Both the pt and witness may not be aware of what has happened Classic absence seizures happen in school-aged children –100 times or more a day –Usually resolves as the child grows older

17. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training s/s, physical exam & assessment, diagnotics, monitoring, management, pertinent positives Partial (local) seizures – Simple partial (no alteration of consciousness) Due to electrical discharges beginning in a localized region of the cerebral cortex The discharge may remain localized or may spread to involve nearby cortical regions or the entire cortex Focal seizures are generally thought to be secondary to a localized structural lesion of the brain Partial (local) seizures – Simple partial (no alteration of consciousness) Due to electrical discharges beginning in a localized region of the cerebral cortex The discharge may remain localized or may spread to involve nearby cortical regions or the entire cortex Focal seizures are generally thought to be secondary to a localized structural lesion of the brain

18. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training s/s, physical exam & assessment, diagnotics, monitoring, management, pertinent positives Partial (local) seizures – Simple partial Consciousnes & mentation are not affected It is possible to deduce the likely location of the initial cortical discharge from the clinical features at the onset of the attack –Unilateral tonic or clonic movement limited to one extremity = focus in motor cortex –Visual symptoms = occipital focus Partial (local) seizures – Simple partial Consciousnes & mentation are not affected It is possible to deduce the likely location of the initial cortical discharge from the clinical features at the onset of the attack –Unilateral tonic or clonic movement limited to one extremity = focus in motor cortex –Visual symptoms = occipital focus

19. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training s/s, physical exam & assessment, diagnotics, monitoring, management, pertinent positives Partial (local) seizures – Complex partial (consciousness impaired) Partial (local) seizures – Complex partial (consciousness impaired)

20. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training s/s, physical exam & assessment, diagnotics, monitoring, management, pertinent positives Partial (local) seizures – Complex partial Focal seizure in which consciousness or mentation is affected Alterations in thinking & behavior Are commonly misdiagnosed as psychiatric problems because the symptoms can be so bizarre Symptoms: automatisms, visceral symptoms, hallucinations, memory disturbances, distorted perception, and affective disorders Partial (local) seizures – Complex partial Focal seizure in which consciousness or mentation is affected Alterations in thinking & behavior Are commonly misdiagnosed as psychiatric problems because the symptoms can be so bizarre Symptoms: automatisms, visceral symptoms, hallucinations, memory disturbances, distorted perception, and affective disorders

21. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training s/s, physical exam & assessment, diagnotics, monitoring, management, pertinent positives Partial (local) seizures – Complex partial (consciousness impaired) Automatisms - simple repetitive purposeless movements - lip smacking, fiddling with clothing or buttons, or repeated short phrases Visceral symptoms - sensation of butterflies Affective symptoms - intense sensation of fear, paranoia, depression, or, rarely elation or ecstasy Partial (local) seizures – Complex partial (consciousness impaired) Automatisms - simple repetitive purposeless movements - lip smacking, fiddling with clothing or buttons, or repeated short phrases Visceral symptoms - sensation of butterflies Affective symptoms - intense sensation of fear, paranoia, depression, or, rarely elation or ecstasy

22. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Partial (local) seizures – Partial seizure (simple or complex) w/ secondary generalization A focal seizure discharge may spread to involve both hemispheres, mimicking a typical generalized seizure Partial (local) seizures – Partial seizure (simple or complex) w/ secondary generalization A focal seizure discharge may spread to involve both hemispheres, mimicking a typical generalized seizure s/s, physical exam & assessment, diagnotics, monitoring, management, pertinent positives

23. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Consider differential diagnosis Syncope Pseudoseizures Hyperventilation syndrome Movement disorders - dystonia, etc Migraine headaches narcolepsy Syncope Pseudoseizures Hyperventilation syndrome Movement disorders - dystonia, etc Migraine headaches narcolepsy

24. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Treatment Scene Size Up ABCs & spinal immobilization Physical exam, assessment, diagnostics, monitoring, verbal survey Oxygen Determine cause of seizure: altitude, heatstroke, trauma, fever, lesion, etc IV Scene Size Up ABCs & spinal immobilization Physical exam, assessment, diagnostics, monitoring, verbal survey Oxygen Determine cause of seizure: altitude, heatstroke, trauma, fever, lesion, etc IV

25. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Treatment Usually little is required during the course of an actual seizure other than to protect the pt from injury Turn pt on side to reduce risk of aspiration Suction airway PRN Usually little is required during the course of an actual seizure other than to protect the pt from injury Turn pt on side to reduce risk of aspiration Suction airway PRN

26. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Treatment Status epilepticus can occur in pts w/ hx of seizures or it can be the first epileptic event Most common cause: subtherapeutic antiepileptic levels, preexisting neurologic conditions (CNS infection, trauma, hemorrhage or stroke, anoxia or hypoxia, metabolic abnormailities, &/or alcohol or other drug withdrawal Status epilepticus can occur in pts w/ hx of seizures or it can be the first epileptic event Most common cause: subtherapeutic antiepileptic levels, preexisting neurologic conditions (CNS infection, trauma, hemorrhage or stroke, anoxia or hypoxia, metabolic abnormailities, &/or alcohol or other drug withdrawal

27. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Treatment Status epilepticus is continuous or intermittent seizures for > 5 minutes w/o recovery of consciousness After 5 minutes of continuous activity, seizures become less likely to spontaneously terminate, less likely to be controlled with antiepileptic drugs & more likely to cause neuronal damage Therefore, tx for status epilepticus should be initiated in all pts with continuous activity lasting > 5minutes Status epilepticus is continuous or intermittent seizures for > 5 minutes w/o recovery of consciousness After 5 minutes of continuous activity, seizures become less likely to spontaneously terminate, less likely to be controlled with antiepileptic drugs & more likely to cause neuronal damage Therefore, tx for status epilepticus should be initiated in all pts with continuous activity lasting > 5minutes

28. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Treatment Status epilepticus –Midazolam (Versed) Adults –IV: 2mg slow IVP q 3 minutes PRN seizure (max 10mg) –IN: 2mg via MAD q 3 minutes PRN seizure (max 10mg) –IM: 5mg q 10 minutes prn seizure (max 15mg) <10 yrs –IV: 0.1mg/kg (max 2mg) q 3 min PRN seizure (max 5 doses) –IN: 0.1 mg/kg (max 2mg) via MAD q 3 minutes PRN seizure (max 5 doses) –IM: 0.15mg/kg (max 5mg) q 10min PRN seizure (max 3 doses) Perform glucose determination & treat hypoglycemia PRN Status epilepticus –Midazolam (Versed) Adults –IV: 2mg slow IVP q 3 minutes PRN seizure (max 10mg) –IN: 2mg via MAD q 3 minutes PRN seizure (max 10mg) –IM: 5mg q 10 minutes prn seizure (max 15mg) <10 yrs –IV: 0.1mg/kg (max 2mg) q 3 min PRN seizure (max 5 doses) –IN: 0.1 mg/kg (max 2mg) via MAD q 3 minutes PRN seizure (max 5 doses) –IM: 0.15mg/kg (max 5mg) q 10min PRN seizure (max 3 doses) Perform glucose determination & treat hypoglycemia PRN

29. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Treatment Status epilepticus –Acetaminophen Consider in pediatric (< 6yrs) seizures if child is febrile & has regained normal mental status –PO: 0-6 yrs 20mg (max 1,000mg) PO q 4-6hrs, not to exceed 4,000mg/24hrs Status epilepticus –Acetaminophen Consider in pediatric (< 6yrs) seizures if child is febrile & has regained normal mental status –PO: 0-6 yrs 20mg (max 1,000mg) PO q 4-6hrs, not to exceed 4,000mg/24hrs

30. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Differential diagnosis In the field: A lcohol E pilepsy I nsulin O verdose U remia T rauma I nfection P sychosis S troke In the field: A lcohol E pilepsy I nsulin O verdose U remia T rauma I nfection P sychosis S troke

31. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Perspective Pathophysiology Epidemiology PE & Diagnostic Findings S/S Differential considerations Tx Perspective Pathophysiology Epidemiology PE & Diagnostic Findings S/S Differential considerations Tx

32. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Questions? References –Marx, John A. ed, Hockberger & Walls, eds et al. Rosen’s Emergency Medicine Concepts and Clinical Practice, 7th edition. Mosby & Elsevier, Philadelphia: PA 2010. –Tintinalli, Judith E., ed, Stapczynski & Cline, et al. Tintinalli’s Emergency Medicine A Comprehensive Study Guide, 7th edition. The McGraw-Hill Companies, Inc. New York 2011. –Wolfson, Allan B. ed., Hendey, George W.; Ling, Louis J., et al. Clinical Practice of Emergency Medicine, 5th edition. Wolters Kluwer & Lippincott Williams & Wilkings, Philadelphia: PA 2010. References –Marx, John A. ed, Hockberger & Walls, eds et al. Rosen’s Emergency Medicine Concepts and Clinical Practice, 7th edition. Mosby & Elsevier, Philadelphia: PA 2010. –Tintinalli, Judith E., ed, Stapczynski & Cline, et al. Tintinalli’s Emergency Medicine A Comprehensive Study Guide, 7th edition. The McGraw-Hill Companies, Inc. New York 2011. –Wolfson, Allan B. ed., Hendey, George W.; Ling, Louis J., et al. Clinical Practice of Emergency Medicine, 5th edition. Wolters Kluwer & Lippincott Williams & Wilkings, Philadelphia: PA 2010.