3.12. CONVULSIONS

(The information is an adapted version of the original text, taken from an instruction based on the principles of evidence-based medicine)

Related Names

Epileptic status, attack of fever, convulsions, eclampsia.

Purpose of assistance

1. Quick stop by the court at the pre-hospital stage.
2. Minimization of the likelihood of adverse events during treatment with seizures at the pre-hospital stage.
3. Minimizing the likelihood of repeated seizures during transportation.

Patient description

Assistance for seizures due to injury, pregnancy, hyperthermia or toxin poisoning should be provided in accordance with the guidelines given, which are specific to each condition.

Inclusion criteria

Court activity after the arrival of medical staff or the onset of new/repeated court is more than 5 minutes.

Exclusion criteria

None.

Patient care

Condition assessment

1. History:

a) duration by the court;
b) previous history of seizures, diabetes or hypoglycemia;
c) characterization by the court;
d) initial frequency and duration of seizures;
d) focus during the onset of seizures, the direction of ocular deviation;
e) simultaneous presence of symptoms such as shortness of breath, cyanosis, vomiting, urinary incontinence or defecation, fever;
f) whether any of the outsiders provides medications for stopping by the court;
e) what drugs the patient is currently using, including anticonvulsants;
g) recent changes in dosage or non-compliance with the schedule of use of anticonvulsants;
h) history of injury, pregnancy, heat exposure or toxins.

2. Overview:

a) airway patency;
b) breathing sounds, respiratory rate and ventilation efficiency;
c) signs of perfusion (pulse, capillary filling, skin color);
d) neurological status (SCG, nystagmus, pupil size, focal neurological deficiency or signs of stroke).

Treatment and intervention

1. If there are signs of airway obstruction and head thrust, jaw extension, change of body position and/or use of suction does not help – use oropharyngeal air duct (in the absence of gag reflex) or nasopharyngeal air duct.

2. Apply pulse oximeter and/or capnograph to monitor oxygenation/ventilation parameters.

3. Provide oxygen if necessary, the goal of oxygen therapy is to achieve saturation rates of 94-98%. In case of ventilation/oxygenation failure, use an AMBU bag that is connected to the oxygen injection mask.

4. Evaluate perfusion.

5. Assess neurological status.

6. Routes of administration of medications

a) the intranasal/i.v. method is a more optimal option than the rectal, i.v. or i.v. method only if the care provider has the appropriate skills; if none of these routes of drug administration (nasal, IV, IV, IV) is available to the care provider due to lack of appropriate knowledge and skills, rectal use of diazepam at a dose of 0.2 mg/kg (maximum dose – 10 mg) is acceptable;
b) obtaining IV access is not necessary during the treatment of seizures, only if necessary.

7. Treatment with anticonvulsants:

a) in the absence of IV access: midazolam 0.2 mg/kg (maximum dose – 10 mg), preferably IV, or nasally;
b) if there is access to the vascular system (IV or IV):

• • • • diazepam 0, 1 mg/kg IV or IV, maximum 4 mg;
      • lorazepam 0, 1mg/kg IV or IV, maximum 4 mg;
      • midazolam 0, 1mg/kg, IV or IV, maximum 4 mg.

8. Glucometry:

a) in the presence of active seizures – check the level of glucose in the blood;
b) if the value is below 3.3 mmol/l (60 mg/dL), provide assistance in accordance with the instruction “Hypoglycemia.”

9. Remember the possibility of using magnesium sulfate in the presence of seizures during the third trimester of pregnancy or after childbirth (see. instruction “Eclampsia/Preeclampsia”).

10. With febrile convulsions, after you have stopped the convulsions, perform the following manipulations, as they ease the symptoms, but do not stop the seizures:

a) administer paracetamol 15 mg/kg, the maximum dose is 650 mg, the routes of administration are rectal/iv/iv/c (if the patient cannot swallow) or oral (if the patient can swallow)
AND/OR
b) ketorolac 1 mg/kg, the maximum dose is 15 mg IV (if the patient cannot swallow) OR ibuprofen 10 mg/kg, the maximum dose is 600 mg orally (if the patient can swallow)
AND/OR
c) remove excess clothing layer
AND/OR
d) apply a cold compress to the body.

11. Consider receiving a 12-lead ECG after cessation of seizures in patients without a history of seizures to determine a possible cardiac cause.

Patient safety

1. Trained personnel of EMF specialists should be able to prescribe medications without direct contact with medical guidance, however, it must be remembered that more than 2 doses of benzodiazepines increase the risk of airway malfunction.
2. Be cautious, weigh the risks/benefits of delaying treatment before arriving at the hospital and/or consult medical guidance if the patient has received two doses of benzodiazepines from outsiders and/or pre-hospital care workers.
3. Patients with hypoglycemia who receive assistance for seizures in a “field” setting should be taken to the hospital, regardless of whether their state of consciousness has recovered after treatment.

Useful information for training

Key points

1. Many problems with breathing/respiratory tract during seizures can be solved without intubation or installation of air ducts. Use these manipulations for those patients to whom less invasive manipulations do not help.

2. For children with epileptic status who require prehospital administration of medications, trained EMF workers should be able to administer medications without clear control by medical management.

3. During a new manifestation of seizures or seizures that do not respond to treatment, consider the following possible causes of the appearance of seizures: trauma, stroke, electrolyte imbalance, exposure to toxins, eclampsia during pregnancy, hyperthermia.

4. Variations in safe and effective doses of benzodiazepines can be found in the relevant literature:

a) the doses of anticonvulsants indicated above are typical for the preparations and routes of administration indicated in this guideline;
b) offering one dose instead of a wide range is explained by the need to standardize the typical dose in case the EMF may need to switch to another drug due to limited resources.

5. Recent evidence supports the safe use of midazolam (IV) and this procedure is as safe as administration of lorazepam (IV) to stop seizures in prehospital conditions.

Relevant evaluation results

The presence of fever with convulsions in children younger than 6 months and older than 6 years is not associated with simple febrile convulsions, therefore it is necessary to conduct an examination for the possible presence of meningitis, encephalitis or other causes.

Key elements of documentation

1. Court activity during transport and court start/stop time.
2. Focus by judgment, direction of eye deviation.
3. Simultaneous presence of symptoms such as shortness of breath, cyanosis, vomiting, incontinence/feces, fever.
4. Number of administered drugs and routes of administration – both by third parties and medical personnel.
5. Neurological status (SCG, nystagmus, pupil size, focal neurological deficits, or signs of stroke).
6. Glucose level.

Criteria for the effectiveness of care

1. Frequency of glucometry.
2. Time for prescribing anticonvulsants.
3. Respiratory failure rate.
4. Frequency of recurrence of seizures.