Paramedic Stuff – Notes on Epilepsy

Something I didn’t do last week, but definitely needs to be done this week: *clears throat* These posts are written because I like to organise my thoughts. Maybe someone of a similar bent will happen across them, discussion will happen, and I’ll learn something. It’s like public note taking, almost. Nothing, and I repeat, nothing in this post, or any of my other Paramedic Stuff posts, are meant to be taken as actual medical advice. If you think you have epilepsy, see your doctor. If you think you have anything, see your doctor. If you want to write about a character who has epilepsy, or about a health professional who is maybe dealing with a character who has epilepsy, feel free to use this information. Be aware that I am a student, and as such, you could probably find someone with more expertise to tell you about all the things.

That being said, let’s move on.

Quite a few cases regarding epilepsy, and what how to recognise epilepsy (and how to tell the difference between a seizure and a collapse that came about from a panic attack), came up in my last round of placement. Our medical unit is this year, so I basically went in blind as to what to look for and what to expect. This post seeks to rectify this. Most of the information has been summarised from questions I asked in regards to the cases I witnessed, and from Kumar and Clark’s Clinical Medicine, Seventh Edition.

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So basically, if you follow this diagram through – epilepsy is the tendency to have seizures, and those seizures occur when there is an electrical discharge in the brain. This discharge relates the to failure of synaptic inhibition, which is a fancy way of saying that your brain cells keep passing along an electrical message when they shouldn’t. This electrical discharge can either be in one part of your brain, creating what’s called a partial seizure, or it can be on both sides of your brain, causing a generalised seizure. It can start as a partial seizure and become a generalised one. Partial seizures can either happen while the person experiencing them is aware, or while they are unaware. Generalised seizures seem to always have an accompanying loss of awareness.

This makes sense, if you think about it. A partial seizure is only happening in one point of the brain. Therefore if it happens in the motor cortex, (the part of the brain that controls motor function), you’ll get jerking on one side of the body. But it shouldn’t effect other parts of your brain. In the same way, a burst of electrical activity in your temporal lobe is going to ruin your personal awareness, but it’s not really going to effect your motor functions.

A generalised seizure, however, effects all parts of the brain, thus you have both the physical effects and the effects on awareness.

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And here are the types of seizures. This is particularly interesting to me in light of my placements because I had no idea how to tell if someone was recovering from seizure activity, or if they had something else going on. As paramedics, the only type of seizure we can have any effect on is your classic tonic clonic seizure. For that ALS paramedics use IM midazolam. Everything else is a “Check their GCS, check if they’ll need intubation, if so, call MICA, if not, off to the hospital” sort of thing, as far as I can tell.

History will be important in these cases, I think. Also experience when it comes to figuring out what else it could be. So, to fit it into a clinical approach model:

  • General dangers to oneself and the patient
  • Is the patient actually fitting? Check that the airway is patent, touch them to have a quick check of their perfusions status (skin colour, temp, whether it’s dry or clammy).
  • If airway is patent, check the quality of the seizure (so basically determine if it’s a generalised tonic-clonic, which I can actually do something about).
  • If a tonic clonic seizure, treat as per guideline.
  • If not – go through all the obs, get and ECG, an SPO2, temp, blood glucose. Figure out if there’s anything physiologically pertinant
  • If there is, fix it. If there isn’t and the patient is coming out of their postictal phase, go through the whole assessment again, starting with a GCS.
  • Remember that a GCS less than nine is an indication for MICA and intubation, so be very sure of that GCS.
  • Check with the pt, friends, family if this is their normal seizure presentation. If it is, consider referring them onto their normal GP. If it isn’t, take them to hospital.

This is obviously not an exhaustive list, and is for more my notes than anything else. But I like the idea of having at least some framework to build on, because I felt it’s lack in the last cycle of placements.

Feature image attributed to  Maureen Flynn-Burhoe (aka ocean.flynn), taken from: http://flic.kr/p/4JtaPE, used under creative commons licence, some rights reserved by the creator

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