The patient is now actively seizing. Given the reported history of presumed seizure activity, now with a witnessed seizure and without a return to baseline mental status between the two, she thus meets criteria for status epilepticus. She should be managed per Treatment Protocol 1231 – Seizure.

According to this protocol and in evaluation of a patient with active seizure, the next steps that should be taken are:

• Assess ABC’s and intervene as indicated
• Manage seizure with midazolam IM/IN
• Establish vascular access as needed after administering initial IM/IN midazolam
• Check blood glucose

Question:

What findings on physical exam may be suggestive of non-convulsive status epilepticus?

1. Lack of vocal sounds
2. Bilateral gaze deviation to the left
3. Loose tone in the upper extremities
4. Respirations that are deep rapid breaths

Answer: 2. Bilateral gaze deviation is suggestive of non-convulsive status epilepticus in an otherwise unresponsive patient. The medic must elevate the eyelids to detect gaze deviation. Lack of vocal sounds may be normal for the immediate post-ictal period while a patient is recovering. Increased tone or clenched/rigid arms/legs, as opposed to decreased tone, is suggestive of ongoing seizure. Breathing during a seizure is often irregular. Rapid deep breaths are more suggestive of an underlying acidosis (Kussmaul breathing) such as occurs in Diabetic Ketoacidosis (DKA).

Identifying the cause of seizure is important to EMS because it may affect destination and ultimate care. Seizures occur for many different reasons and have a broad differential including:

• Severe hypoglycemia
• Subarachnoid intracranial hemorrhage
• Drug/Toxin overdose
• Hyponatremia
• Epilepsy (Seizure disorder)
• Infection (Meningitis/Encephalitis)
• Trauma
• Brain Mass/Tumor
• Eclampsia

EMS clinicians should also be aware of some seizure mimics that may be appear as seizure-like activity for which providers are called:

• Syncope
• Stroke/TIA
• Movement Disorders (e.g. dystonia)

The care for these conditions is covered in other L.A. County Protocols.

Eclampsia should be considered early in this seizure patient. The presence of a crying newborn baby in the home suggests that the patient is post-partum.

• Eclampsia should be suspected in patients who are ≥ 20 weeks gestational age or up to 6 weeks post-partum with blood pressure ≥ 140/90 with seizure or altered mental status.
• Research suggests that up to 1/5 of patients with eclampsia may have normal blood pressure at the time of evaluation, so clinical suspicion should stay high.
• History may rely heavily on family members who witnessed the seizure.
• In the absence of seizure, the same blood pressure criteria should be considered diagnostic for preeclampsia, especially in patients experiencing new lower extremity edema, changes in vision, headache, or right upper quadrant pain.
• Patients who are pregnant or post-partum with new-onset seizure should be treated according to TP 1231 – Seizure with rapid transport to a Perinatal Center.

Hypoglycemia is a common reason for a patient to experience seizures and should be checked early in the assessment for any patient with continued ALOC on EMS arrival. Providers should obtain a point of care glucose during all seizure evaluations after the administration of a first dose of IM/IN midazolam if the person is actively seizing.

• If glucose <60, treat according to TP 1203 – Diabetic Emergencies or TP-1203-P – Diabetic Emergencies with Dextrose 10% (250mL IV/IO for adults or children >24 kg; Per 1309 for pediatrics <24 kg) or Glucagon IM if unable to attain IV access.

Subarachnoid hemorrhage or other intracranial hemorrhage is a possible etiology for patient with reported headache prior seizure. Blood within the CSF is thought to exert both mass effect, release of glutamate (an excitatory neurotransmitter) and focal ischemia in the areas of bleeding, resulting in vasospasm and seizure. These patients should still be managed per TP 1231- Seizure or TP 1231-P.  However, you may consider base contact for destination guidance as these patients may be better served in a specialty center with neurosurgical capabilities.

Hyponatremia is a possible cause of seizure but unlikely in a young patient who is otherwise healthy and maintaining a normal diet after an uncomplicated delivery. However, patients who experienced significant post-partum hemorrhage during their delivery may suffer damage to the pituitary gland resulting in Sheehan’s Syndrome. Relative ischemia to the gland from post-partum hemorrhage may result in hypothyroidism, hyponatremia, hypoglycemia, and hypotension.

Meningitis/Encephalitis should be considered for new onset seizures. A post-partum infection of the uterine lining (called endometritis) can spread through the bloodstream to other areas of the body including the meninges and brain. These patients will present with fever or signs of sepsis and should be treated both for seizure and per TP 1204 – Fever/Sepsis, or TP 1204-P. In this patient who was previously well aside from headache prior to seizure, the diagnosis is less likely.

• The patient receives 10 mg Midazolam IM with a break in her seizure activity. She appears post-ictal with GCS 10 after treatment.
• An 18g IV is placed in her right AC and blood glucose is noted to be 126.
• You transport to the closest perinatal center given your concern for post-partum eclampsia.

Although the patient is post-partum, eclampsia remains an obstetric emergency and is best treated in a hospital that has rapidly accessible on-call Obstetricians, as are required in all perinatal centers in Los Angeles County.

• Her GCS steadily improves during the 20-minute transport.
• On arrival at the hospital, she is GCS 15 and able to provide history to the doctors but does not remember the seizures. The patient is taken to a resuscitation room where the doctor recommends additional treatments for management.

Within Los Angeles County, prehospital management of eclampsia consists of controlling seizures with benzodiazepines. However, in the hospital phase of care therapy for eclampsia-related seizures includes magnesium sulfate, with a loading dose of 4-6g IV followed by maintenance dosing of 1-2 g/hr. Additional benzodiazepines or antiepileptics may be necessary for control of ongoing seizures. Once the seizure has resolved, the blood pressure lowering medications such as labetalol or hydralazine may be used with a goal of < 130/80. Blood pressure control must be done carefully under continuous monitoring due to the risks associated with a sudden drop in blood pressure. These patients may receive a head CT to help rule out other pathologies and will require admission for ongoing monitoring and evaluation for liver and kidney injury.

Question:

A 22-year-old female calls 9-1-1 for mild abdominal cramping with nausea/vomiting. On evaluation she is visibly pregnant and found to have a blood pressure of 135/102 with a heart rate of 85. She denies any history of inciting trauma, vaginal bleeding. Her due date for the pregnancy is in two and a half months. To what destination should this patient be transported to?

1. Most Accessible Receiving
2. Pediatric Medical Center
3. Perinatal Center
4. Trauma Center

Answer: 3.  This patient is estimated to be at 30 weeks’ gestation (due date in 2.5 months) and presents with mildly elevated systolic and significantly elevated diastolic pressure. Medics should suspect preeclampsia. This patient should be managed at a perinatal center with ready access to obstetricians who can participate in her care.

Having a high suspicion for preeclampsia and eclampsia in both pregnant and post-partum patients is important to improving patient’s outcomes. According to a  resource document prepared for EMS clinicians by the American College of Obstetricians and Gynecologists (ACOG), over 80% of pregnancy-related deaths are preventable and up to 7% of maternal deaths result from hypertensive disorders of pregnancy. Identifying maternal hypertension is crucial as EMS clinicians are frequently the first level of contact for many pregnant patients. EMS has a significant role to play in managing these patients and delivering them to a facility with appropriate equipment and specialty resources. One key factor identified in hypertensive related deaths was the inability to transfer patients from one hospital to another with higher level of care. Rapid triage and transport to a perinatal center can prevent significant delays associated with interfacility transfers and may save a life.

• Blood pressure > 140/90 should be considered pre-eclampsia/eclampsia in a pregnant or post-partum patient.
• Eclampsia should be considered in any pregnant or post-partum patient with new onset seizure or ALOC.
• Witnessed seizure activity should be first treated with IM/IN midazolam, regardless of the cause.
• Recognition of maternal and post-partum hypertension is important in ensuring that treatments are initiated to protect patients from the undiagnosed danger of high blood pressure in and after pregnancy.