Case Study 10

The Answer

Assessment

  • Patient had a generalized seizure. 
  • There is no mechanism of injury for spine. 

The Plan

  • Watch the patient during the post-seizure period with specific attention to his arway. 
  • Continue assessment as patient arouses. 
  • Develop an evacuation plan. 

Anticipated Problems

  •  If the patient does not arouse or has continued seizure activity, a rapid evacuation will be necessary.

Comments

Grand mal seizures, a form of generalized seizure, are sometimes preceded by an aura, an event just before the patient seizes that takes the form of vision disturbances, odd feelings, or perceived odors. The seizure begins with a loss of responsiveness. Muscles relax and the patient collapses. There is an alternating period of muscle tension (tonic) and relaxation (clonic) phases.  

Spasm of chest muscles may empty the lungs against a partially closed airway and generate disturbing scream-like sounds. During a grand mal seizure the patient does not breathe, which can result in dangerously low levels of oxygen in the blood (hypoxia). The seizure ends with a period of relaxation and unresponsiveness referred to as the post-seizure or post-ictal period. This can last 10 minutes or more as the patient slowly regains a normal level of responsiveness. 

Treatment 
Treatment for a seizure is supportive and protective care. You cannot stop the seizure without powerful intravenous medications, but you can protect the patient from injury. The violent muscle contractions of a seizure may cause injury to the patient and to well-meaning bystanders who attempt to restrain the patient. Move objects that the patient may hit.  Pad or cradle the head if it is bouncing on the ground. 

A patient in seizure will not swallow the tongue. However, the patient may bite their cheek or tongue. Additionally, the airway may become obstructed by saliva or secretions. Once the seizure starts, do not force the mouth open. Don’t place a bite stick or other object in the mouth. It is likely to do more damage than help. 

When a seizure has subsided, open the airway, assess for injuries, and complete a full assessment. Place the patient on his or her side during the recovery phase to help maintain an open airway.  

In most cases, a seizure runs its course in a few minutes. Repeated seizures, especially repeated seizures in which the patient does not regain responsiveness in between, and seizures associated with another medical problem such as diabetes or head injury, are serious medical conditions.

The Tale Continues

Twenty minutes after your arrival you repeat your assessment. 

Patient Exam: 
Over the next 10 minutes the patient aroused to A+Ox2, then gradually to A=Ox3/4. He denies any pain or tenderness other than to the tip of his tongue.

Vital Signs             

TIME 1500 hrs 1520 hrs
LOR  Pt does not react to pain stimulus. A+Ox4  
HR 100, strong, regular 80, strong, regular
RR 22, regular, noisy 14, regular, unlabored
SCTM Pale, cool, clammy Pink, warm, dry 
B.P. Radial pulses present  Radial pulses present
Pupils PERRL PERRL
T°   Not taken 98°F oral  

History  

Symptoms:  Patient denies.
Allergies: None stated.
Medications: Dilantin for his seizures at 100mg three times daily.  Patient states he took his scheduled dose today and previous days.
Pertinent Hx:  Pt reports a history of seizures secondary to a head injury six years ago; he has not had a seizure in a year.
Last in/out:  Pt stated he is well-hydrated with three liters or water today and ate lunch. Urinated during seizure. Otherwise, normal urine and bowel movement.
Events: Pt hiked four miles, arrived in camp, sat down to rest, and had one seizure.  

Assessment 

  • Patient had a generalized seizure. 
  • There is no mechanism for injury. 
  • Patient has recovered to A+Ox4 post-seizure. 

Plan 

  • Continue to watch the patient during the post-seizure period. 
  • Have the patient take their scheduled dose of anti-seizure medication. 
  • Walk the patient to the trailhead and evacuate. 

Anticipated Problems 

  • Patient has continued seizure activity. 

Comments 
In most cases an isolated seizure in a patient with a history of seizures should be evaluated by a physician but does not necessarily require a rapid evacuation. These occasional seizures are often due to changes in the patient's need for medication or failure to take the medication as prescribed. After recovering from the seizure, the patient should be fed, hydrated, and assessed for any injury that may have occurred during the seizure. 

  

End of the Tale

Jerome rests for an hour, then eats a good meal. He thinks this is an isolated seizure, perhaps due to the change in his activity level, and that if he doubles up on his medication for a short period he’ll be fine. He does not want to be evacuated. You don’t disagree with his perception of the situation, but your program has a set of medical protocols that clearly call for evacuation if a patient has an isolated seizure. If the patient has multiple seizures or seizures secondary to a known medical problem such as a blow to the head or diabetes, then your evacuation should be rapid.  

Jerome feels up to a hike to the road, so you set out late afternoon and arrive at the trailhead by 9:00PM. After being seen by a physician, he is cleared to return home, but not to the field.


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