Seizures and Syncope

Prehospital Emergency Care: Seizures and Syncope

Overview

  • Authors: Joseph J. Mistovich, Keith J. Karren, Howard A. Werman, MD

  • Textbook Edition: Twelfth Edition

  • Chapter Focus: Seizures and Syncope

Learning Objectives

  • Learning Readiness: Page 685 includes EMS Education Standards, Chapter Objectives, and Key Terms.

  • Purpose of Lecture Presentation vs. Textbook Reading Assignments.

Setting the Stage

  • Lesson Topics Overview:

    • Seizures

    • Syncope

Case Study Introduction

  • Situation: EMTs Ana Salinas and Loren Dyer respond to a residence report of a seizure.

  • Details:

    • Patient: Male in early 30s, appears unresponsive.

    • Clinical Signs: Increased respiration, copious oral secretions, incontinence.

    • Witness Account: Patient experienced a seizure while playing cards, fell from chair.

Assessment Priorities

  • First Priorities:

    • Patient assessment and care strategies.

  • Additional Information Needed:

    • Patient's seizure history and details of current incident.

  • Transport Requirement:

    • Assess if patient needs hospital transport.

Introduction to Seizures

  • Definition:

    • A seizure is a sudden onset of random continuing electrical impulses in the brain.

    • Characterized by temporary alterations in brain function leading to changes in mental status and behavior.

Pathophysiology of Seizures

  • Primary (Unprovoked) Seizures:

    • Cause: Genetic or unknown.

    • Types:

    • Generalized Seizures: Impact both hemispheres.

    • Partial Seizures: Affect one hemisphere.

      • Simple Partial Seizures: Retain awareness.

      • Complex Partial Seizures: Impaired awareness.

    • Examples of Generalized Seizures:

    • Tonic-clonic seizures, Absence seizures, Myoclonic seizures, Tonic seizures, Atonic seizures, Febrile seizures.

  • Secondary (Provoked) Seizures:

    • Cause: Underlying medical conditions.

    • Typically generalized seizures.

Common Causes of Secondary Seizures

  • **Medical Conditions:

    • High fever

    • Noncompliance with seizure medication

    • Epilepsy

    • Infection

    • Poisoning

    • Hypoglycemia (low blood sugar)

    • Hyperglycemia (high blood sugar)

    • Traumatic brain injury

    • Shock

    • Hypoxia

    • Stroke

    • Drug or alcohol withdrawal

    • Dysrhythmias

    • Hypertension

    • Pregnancy complications (eclampsia)

    • Electrolyte imbalances

    • Hyperthermia

    • Idiopathic causes (unknown)

Status Epilepticus

  • Definition:

    • Generalized motor seizures lasting more than 30 minutes or consecutive seizures without responsiveness.

  • Importance:

    • Considered a life-threatening emergency.

Types of Seizures

  • Generalized Seizures:

    • Characteristics:

    • Tonic-clonic seizures involve the cerebral hemispheres and reticular activating system; patient remains unconscious.

    • Stages of Generalized Tonic-Clonic Seizures:

    • Aura

    • Loss of consciousness

    • Tonic phase

    • Hypertonic phase

    • Clonic phase (convulsion)

    • Postictal state.

  • Generalized Tonic-Clonic Emergency Care:

    • After seizure, reassure patient, conduct assessment.

    • Follow protocols if the patient refuses treatment.

    • Be vigilant for status epilepticus as a medical emergency.

  • Other Generalized Seizure Types:

    • Absence seizure: Brief lapse of consciousness.

    • Myoclonic seizure: Brief involuntary muscle jerks.

    • Tonic seizure: Stiffening of the body.

    • Atonic seizure: Sudden loss of muscle tone.

    • Febrile seizure: Related to high fever in children.

  • Partial (Focal Onset) Seizures:

    • Characteristics:

    • May involve abnormal movements and consciousness preservation in simple partial seizures (focal onset aware seizure).

    • Can progress to generalized.

    • Complex Partial Seizures:

    • Lasts 30 seconds to 2 minutes; patient may appear awake but unresponsive, may display purposeless behavior or verbal repetitions.

Approach to Seizure Activity Assessment

  • Scene Size-Up: Observe for trauma, poisoning, medical conditions.

  • Primary Assessment:

    • Evaluate airway, breathing, circulation, and transport priority.

    • Situations that warrant priority: unresponsiveness, poor airway/breathing/circulation, status epilepticus, history of pregnancy or drug/alcohol use, seizures in water.

  • Secondary Assessment:

    • Evaluate for trauma signs, weakness, or paralysis, measure vital signs, check glucose, and gather a history for hospital staff.

Emergency Medical Care for Seizures

  • Clinical intervention:

    • Protect the patient from injury, position laterally if postictal, ensure airway is clear, suction if needed, consider positive pressure ventilation if respiratory failure is suspected. Maintain oxygenation.

    • Be prepared for the occurrence of further seizures during transport and perform reassessment often.

Syncope


  • Definition:

    • Sudden, temporary loss of consciousness due to interruption of cerebral perfusion.


  • Causes:

    • Can indicate serious medical conditions; notably, increased parasympathetic influence experienced by older patients when standing too quickly.


  • Differentiation Between Syncope and Seizures:

    Syncope

    Seizure


    Usually begins in standing position

    May begin in any position


    Symptoms: light-headed, dizzy

    May have aura or sudden onset


    Loss of consciousness returns quickly when supine

    Loss of consciousness persists and gradually returns


    Possible muscle twitching

    Convulsive activity present


    Skin usually cool, moist, pale

    Skin can be warm, sweaty

    Management and Assessment of Syncope

    • Primary and Secondary Assessment:

      • Keep the patient supine, assess for serious underlying causes, and encourage transport.

      • Look for potential triggers like recent head injury, metabolic imbalances, dehydration.

    Pediatric Seizure Considerations

    • Possible Causes:

      • Epilepsy, head injury, infections, oxygen deficits, drug overdoses, metabolic abnormalities, brain tumors, and hypoglycemia.

      • Febrile seizures:

      • Occur due to fever, typically seen in children.

    • Assessment:

      • Use the AVPU scale to gauge alertness. Differentiate between seizures and syncope.

    Case Study Conclusion

    • Summary of Events:

      • Patient Dan was turned onto his side, suctioned, presenting responsiveness to pain.

      • Vital signs: Adequate breathing, warm moist skin, no cyanosis, 99% oxygen saturation.

      • History indicates under-management of prescribed medication (carbamazepine).

      • Patient exhibited altered mental status and required transport despite improving during transport to hospital.

    Summary of Key Points

    • Seizures:

      • Result from abnormal electrical activity in the brain.

      • Can be categorized as generalized or partial seizures, with status epilepticus representing a critical emergency.

    • Syncope:

      • Results from temporary cerebral perfusion interruption; may have benign or serious underlying causes.

    References

    • Textbook Citation: Prehospital Emergency Care, Twelfth Edition, Pearson Education, Inc., 2024.