EMS Neurological Emergencies - Seizure Disorder Treatments

The treatment for seizures depends on several factors, including the type of seizure, underlying cause, and individual patient characteristics. 

Here are some common treatments for seizures:

Antiepileptic Medications (AEDs): Antiepileptic drugs (AEDs) are the mainstay of treatment for epilepsy and other seizure disorders. These medications work by stabilizing electrical activity in the brain and reducing the likelihood of seizures. 

There are many different types of AEDs available, and the choice of medication depends on factors such as the type of seizure, patient age, comorbidities, and potential side effects. Examples of AEDs include carbamazepine, valproate, levetiracetam, lamotrigine, and phenytoin.

Lifestyle Modifications: Certain lifestyle modifications can help reduce the frequency and severity of seizures in some individuals. These may include:

Getting an adequate amount of sleep and maintaining a regular sleep schedule.

Avoiding triggers that may provoke seizures, such as stress, flashing lights, or certain medications.

Following a healthy diet, such as the ketogenic diet, which is high in fat and low in carbohydrates and has been shown to be beneficial for some people with epilepsy.

Limiting alcohol consumption and avoiding recreational drugs.

Surgery: For some individuals with epilepsy that is not well-controlled with medications, surgery may be an option. Surgical procedures such as resective surgery (removing the part of the brain responsible for seizures), laser ablation, or implantation of devices like vagus nerve stimulators or responsive neurostimulation systems can significantly reduce or eliminate seizures in certain cases.

Vagus Nerve Stimulation (VNS): Vagus nerve stimulation (VNS) is a surgical procedure in which a device is implanted under the skin of the chest and connected to the vagus nerve in the neck. 

The device delivers electrical impulses to the vagus nerve at regular intervals, which can help reduce seizure frequency and severity in some individuals with epilepsy.

Responsive Neurostimulation (RNS): Responsive neurostimulation (RNS) is a newer treatment option for epilepsy that involves the implantation of a device in the brain that detects abnormal electrical activity and delivers electrical stimulation to prevent seizures from occurring.

Ketogenic Diet: The ketogenic diet is a high-fat, low-carbohydrate diet that has been shown to be effective in reducing seizures in some individuals with epilepsy, particularly children with certain types of epilepsy syndromes.

Biofeedback & Relaxation Techniques: Some individuals with seizures may benefit from biofeedback training or relaxation techniques, which can help reduce stress and improve overall well-being.

Medication Adjustments: For individuals already taking antiepileptic medications, adjusting the dosage or switching to a different medication may be necessary if seizures are not adequately controlled or if side effects are problematic.

It's important for individuals with seizures to work closely with their healthcare providers to develop a comprehensive treatment plan tailored to their specific needs and circumstances. 

Regular monitoring and adjustments to treatment may be necessary to achieve optimal seizure control and improve quality of life.

Further Reading:

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, Massachusetts: Pearson

Huff, J.S. & Murr, N (2023) Seizure. Treasure Island, Florida: StatPearls Publishing https://www.ncbi.nlm.nih.gov/books/NBK430765/ Accessed April 24, 2024

Peate, I. & Sawyer, S (2024) Fundamentals of Applied Pathophysiology for Paramedics. Hoboken, New Jersey:  Wiley Blackwell

EMS Neurological Emergencies - Seizure Disorder Pathophysiology

The pathophysiology of seizures involves complex changes in the electrical activity of the brain, leading to abnormal synchronization of neuronal firing and the generation of seizure activity. 

While the precise mechanisms underlying seizures can vary depending on the type of seizure and the underlying cause, there are several key components involved in the pathophysiology of seizures:

Neuronal Hyperexcitability: Seizures are characterized by abnormal, excessive, and synchronous neuronal activity in the brain. 

This hyperexcitability can arise from various factors, including changes in ion channel function, neurotransmitter imbalance, or alterations in neuronal connectivity.

Ion Channel Dysfunction: Ion channels play a crucial role in regulating the flow of ions (such as sodium, potassium, calcium, and chloride) across neuronal cell membranes, which is essential for maintaining normal neuronal excitability and function. 

Dysfunction of ion channels, either through genetic mutations or acquired alterations, can lead to abnormalities in neuronal excitability and contribute to seizure generation.

Imbalance of Excitatory & Inhibitory Neurotransmission: Normal brain function relies on a delicate balance between excitatory and inhibitory neurotransmission. 

Excitatory neurotransmitters, such as glutamate, promote neuronal activation, while inhibitory neurotransmitters, such as gamma-aminobutyric acid (GABA), dampen neuronal activity. 

Imbalances in the relative levels or function of these neurotransmitters can disrupt the normal inhibitory control of neuronal firing and contribute to seizure generation.

Aberrant Synchronization of Neuronal Firing: Seizures result from the abnormal synchronization of neuronal firing, leading to hypersynchronous activity within neuronal networks. This synchronized firing can spread rapidly throughout the brain, resulting in the characteristic clinical manifestations of seizures.

Network Dysfunction: Seizure activity often involves multiple brain regions and networks. 

Abnormalities in the connectivity and communication between different brain regions can facilitate the propagation of seizure activity and contribute to the generation of seizures.

Excitotoxicity & Neuroinflammation: Prolonged or recurrent seizure activity can lead to excitotoxicity, a process in which excessive release of excitatory neurotransmitters, such as glutamate, results in neuronal damage and cell death. 

Additionally, seizures can trigger neuroinflammatory processes, further exacerbating neuronal dysfunction and contributing to seizure generation.

Structural & Metabolic Factors: Structural abnormalities in the brain, such as tumors, vascular malformations, or cortical dysplasia, can disrupt normal neuronal circuitry and increase the likelihood of seizure activity. 

Metabolic disturbances, such as hypoglycemia, electrolyte imbalances, or mitochondrial disorders, can also trigger seizures by affecting neuronal function.

Overall, the pathophysiology of seizures involves a complex interplay of genetic, molecular, cellular, and network-level processes that lead to abnormal neuronal excitability and synchronization. 

Understanding these mechanisms is essential for developing targeted therapies aimed at preventing or controlling seizure activity.

Further Reading:

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, Massachusetts: Pearson

Huff, J.S. & Murr, N (2023) Seizure. Treasure Island, Florida: StatPearls Publishing https://www.ncbi.nlm.nih.gov/books/NBK430765/ Accessed April 24, 2024

Peate, I. & Sawyer, S (2024) Fundamentals of Applied Pathophysiology for Paramedics. Hoboken, New Jersey:  Wiley Blackwell

EMS Neurological Emergencies - Seizure Disorder Causes

The causes of seizures can vary widely and may depend on factors such as age, medical history, genetics, and environmental influences. 

Here are some common causes and risk factors associated with seizures:

Epilepsy: Epilepsy is a neurological disorder characterized by recurrent seizures. It can have various causes, including genetic factors, brain injury, infections, developmental disorders, and structural abnormalities in the brain.

Traumatic Brain Injury: Head injuries, such as those sustained in motor vehicle accidents, falls, or sports-related injuries, can lead to seizures. Traumatic brain injury (TBI) can disrupt normal brain function and increase the risk of seizures.

Brain Tumors: Tumors in the brain can cause seizures by interfering with normal brain activity or increasing intracranial pressure. Seizures may be a presenting symptom of a brain tumor.

Strokes: A stroke, which occurs when blood flow to the brain is disrupted, can lead to seizures, especially if the stroke affects certain areas of the brain responsible for regulating electrical activity.

Infections: Infections of the central nervous system, such as meningitis, encephalitis, or brain abscesses, can trigger seizures. These infections can cause inflammation and damage to brain tissue, leading to abnormal electrical activity.

Genetic Factors: Some seizure disorders have a genetic component, meaning they run in families. Mutations in certain genes can predispose individuals to develop epilepsy or other seizure disorders.

Metabolic Disorders: Metabolic imbalances, such as low blood sugar (hypoglycemia), electrolyte abnormalities, or kidney or liver failure, can provoke seizures by disrupting normal brain function.

Drug or Alcohol Withdrawal: Abrupt discontinuation of certain medications, especially anti-epileptic drugs or benzodiazepines, can trigger seizures. Similarly, alcohol withdrawal syndrome can lead to seizures in chronic alcoholics.

Toxic Exposure: Exposure to certain toxins, such as lead, carbon monoxide, or certain chemicals, can impair brain function and induce seizures.

Developmental Disorders: Some developmental disorders, such as autism spectrum disorder or cerebral palsy, are associated with an increased risk of seizures.

It's important to note that not all seizures have a clear identifiable cause, and in some cases, the cause may remain unknown (idiopathic). 

Proper evaluation and diagnosis by a healthcare professional are necessary to determine the underlying cause of seizures and guide appropriate treatment and management strategies.

Further Reading:

Alexander, M. & Belle, R. (2017) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). Hoboken, New Jersey: Pearson Education

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice Volume 2 (6th Ed) Pearson.

Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care (11th Ed). Hoboken, New Jersey: Pearson Education

Online Resources:

EpilepsyU

EMS Neurological Emergencies - Seizure Disorder Classification

Seizure disorders can be classified into several types based on their characteristics and underlying causes. 

Here are some common types of seizure disorders:

Generalized Seizures:

Tonic-Clonic Seizures: These seizures involve loss of consciousness, muscle stiffening (tonic phase), followed by rhythmic jerking of the limbs (clonic phase). They can be associated with convulsions and may result in injuries. Formerly known as Grand Mal Seizures.

Absence Seizures: Absence seizures typically occur in children and involve brief periods of staring or "spacing out." The person may appear to be unaware of their surroundings and may not remember the seizure afterward. Formerly known as Petit Mal Seizures.

Myoclonic Seizures: These seizures involve sudden, brief muscle jerks or twitches, often affecting the arms and legs. They can occur in various epilepsy syndromes.

Atonic Seizures: Atonic seizures cause sudden loss of muscle tone, leading to the person collapsing or falling ("drop attacks"). These seizures can result in injuries due to falls. Also known as Drop Attacks.

Partial (Focal) Seizures:

Simple Partial Seizures: These seizures affect a specific area of the brain and may cause twitching, sensory changes, or other symptoms without loss of consciousness.

Complex Partial Seizures: Complex partial seizures involve altered consciousness or awareness, with or without automatisms (repetitive, purposeless movements) and other behavioral changes. They may start as simple partial seizures and progress to affect larger areas of the brain.

Focal to Bilateral Tonic-Clonic Seizures: Focal seizures that spread to involve both hemispheres of the brain, resulting in generalized tonic-clonic activity.

Other Types:

Febrile Seizures: These seizures occur in young children as a result of fever, typically between the ages of 6 months and 5 years. They are usually brief and do not cause long-term harm.

Psychogenic Non-Epileptic Seizures: Some seizures may mimic epileptic seizures but are not caused by abnormal electrical activity in the brain. These may be due to psychological factors or other medical conditions.

It's important to note that within each type of seizure, there can be variations in presentation and severity. Proper diagnosis and classification of seizures are essential for determining appropriate treatment and management strategies. 

Further Reading:

Alexander, M. & Belle, R. (2017) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). Hoboken, New Jersey: Pearson Education

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice Volume 2 (6th Ed) Pearson.

Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care (11th Ed). Hoboken, New Jersey: Pearson Education

Online Resources:

EpilepsyU

EMS Neurological Emergencies - Seizure Disorders

EMS Providers play a crucial role in managing seizure disorders in prehospital settings. Here are key points they need to know:

Understanding Seizure Disorders: EMS providers should have a basic understanding of seizure disorders, including their causes, types, and manifestations. 

Seizures can vary widely in presentation, from generalized tonic-clonic seizures (formerly known as grand mal seizures) to focal seizures with or without impaired awareness.

Assessment & Initial Management: Upon arrival at the scene, EMS providers should assess the patient's airway, breathing, and circulation (ABCs) to ensure immediate life-saving interventions if necessary. They should also assess the patient's level of consciousness, vital signs, and any signs of injury.

Patient Safety: Ensuring patient safety is paramount during a seizure. EMS providers should protect the patient from injury by removing any nearby objects that could cause harm and placing them in a safe position, such as lying on their side to prevent aspiration.

Duration of Seizure: EMS providers should note the duration of the seizure. If a seizure lasts longer than 5 minutes (or according to local protocols), it is considered a medical emergency known as status epilepticus and requires prompt intervention.

Medication & Intervention: EMS providers may administer medications such as benzodiazepines (e.g., Midazolam, Lorazepam) to terminate prolonged seizures. Intravenous access should be established if possible to administer medications effectively.

Continuous Monitoring: EMS providers should continuously monitor the patient's vital signs and level of consciousness throughout the seizure and during transport to the hospital. They should also be prepared to manage any complications that may arise, such as respiratory compromise or injury.

Documentation & Communication: Accurate documentation of the seizure event, including its onset, duration, and any interventions performed, is essential for continuity of care. EMS providers should also communicate effectively with receiving healthcare providers to ensure seamless transition of care.

Patient Education & Follow-up: After the seizure episode, EMS providers may provide education to the patient and their caregivers on seizure management, including medication adherence and seizure precautions. They should also ensure appropriate follow-up care with a healthcare provider.

By understanding seizure disorders and following appropriate protocols and guidelines, EMS providers can effectively manage seizures in prehospital settings and improve patient outcomes. 

Ongoing training and education in the management of neurological emergencies are essential for EMS personnel.

Further Reading:

Alexander, M. & Belle, R. (2017) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). Hoboken, New Jersey: Pearson Education

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice Volume 2 (6th Ed) Pearson.

Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care (11th Ed). Hoboken, New Jersey: Pearson Education

Online Resources:

EpilepsyU

EMS Neurological Emergencies - The Monro-Kellie Doctrine

The Monro-Kellie Doctrine is a fundamental concept in neurology and emergency medicine that EMS providers should be familiar with.

Essentially, it states that the skull is a rigid container that houses the brain, blood, and cerebrospinal fluid (CSF), and that the total volume inside the skull must remain relatively constant to maintain normal intracranial pressure (ICP).

Here are some key points that EMS providers should know about the Monro-Kellie Doctrine:

Components of Intracranial Contents: The doctrine describes the three main components inside the skull - brain tissue, blood, and cerebrospinal fluid.

Any increase in the volume of one of these components must be compensated by a decrease in the volume of another to maintain a relatively constant intracranial pressure.

Implications for Traumatic Brain Injury (TBI): In cases of TBI, such as intracranial hemorrhage or cerebral edema (swelling of the brain tissue), the Monro-Kellie Doctrine helps EMS providers understand the potential consequences.

An increase in the volume of blood or swelling of the brain tissue can lead to increased intracranial pressure, which can compromise cerebral perfusion and cause further damage.

Clinical Assessment: EMS providers should be vigilant for signs and symptoms of increased intracranial pressure in patients with head injuries, such as altered level of consciousness, headache, vomiting, pupillary changes, and changes in vital signs.

These indicators may prompt the need for urgent intervention and transport to a higher level of care.

Treatment Implications: Understanding the Monro-Kellie Doctrine guides treatment strategies for patients with traumatic brain injury.

Interventions aimed at reducing intracranial pressure may include elevating the head of the bed, administering hyperosmolar therapy (such as mannitol or hypertonic saline) to reduce cerebral edema, ensuring adequate oxygenation and ventilation, and potentially performing interventions to control bleeding or relieve pressure, such as craniotomy or burr hole evacuation.

Importance of Monitoring: Continuously monitoring vital signs, neurologic status, and intracranial pressure in patients with head injuries is crucial for early detection of deteriorating conditions and timely intervention.

EMS providers should be trained in the use of appropriate monitoring devices and interpretation of data.

Overall, a solid understanding of the Monro-Kellie Doctrine is essential for EMS providers caring for patients with traumatic brain injury or other intracranial pathology.

It helps guide clinical assessment, treatment decisions, and ongoing management to optimize outcomes for these patients.

Further Reading:

Cowburn, R. & Cadogan, M (2020) Monro-Kellie Doctrine. Life in the Fast Lane https://litfl.com/monro-kellie-doctrine/ Accessed April 14, 2024

Mokri B (2001) The Monro-Kellie Hypothesis: Applications in CSF Volume Depletion. Neurology 56 (12): 1746-8

EMS Legal Matters - Medical Assistance in Dying (MAID

Medical Assistance in Dying (MAID) refers to a medical procedure where a competent adult patient, who meets specific eligibility criteria, may request assistance from a qualified healthcare provider to end their life peacefully and painlessly.

For EMS Providers, understanding MAID is crucial due to the potential for encountering patients who have undergone or are in the process of seeking MAID.

Here's what EMS providers should know about MAID:

Legal and Ethical Framework: MAID is a complex and highly regulated procedure that operates within legal and ethical frameworks established by national or regional legislation.

EMS providers must familiarize themselves with the laws and regulations governing MAID in their jurisdiction to understand the rights and responsibilities of both patients and healthcare providers.

Patient Eligibility Criteria: Patients seeking MAID must meet specific eligibility criteria, which typically include being mentally competent, having a grievous and irremediable medical condition, experiencing enduring suffering, and making a voluntary and informed request for assistance in dying.

EMS providers should be aware that not all patients requesting end-of-life care necessarily qualify for MAID, and eligibility assessments are typically conducted by specialized healthcare professionals.

Documentation and Communication: Patients who have undergone or are in the process of seeking MAID may have documentation, such as advance directives or medical orders, indicating their wishes and the circumstances under which MAID should be provided.

EMS providers should communicate effectively with other healthcare professionals involved in the patient's care to ensure they have accurate information regarding the patient's medical history, current condition, and end-of-life preferences.

Patient-Centered Care: EMS providers should approach patients who have undergone MAID or are considering it with empathy, compassion, and non-judgment. It's essential to respect patients' autonomy and dignity while providing appropriate medical care and support.

EMS providers may encounter family members, caregivers, or witnesses present during or after the MAID procedure. Sensitivity to their emotional needs and providing support and information as appropriate is essential.

Legal Obligations and Professional Conduct: EMS providers have legal and professional obligations to provide appropriate medical care and support to all patients, regardless of their choices regarding MAID.

In some jurisdictions, EMS providers may have specific responsibilities or protocols regarding responding to emergency situations involving patients who have undergone MAID or are in the process of seeking it.

Education and Training: EMS providers should receive education and training on end-of-life care, including MAID, as part of their professional development.

This training should include understanding the legal and ethical aspects, communication skills, and providing palliative care and support to patients and their families.

In summary, EMS providers should be knowledgeable about the legal, ethical, and clinical aspects of MAID to ensure they can provide compassionate and patient-centered care to individuals who have undergone or are considering this end-of-life option.

Effective communication, collaboration with other healthcare professionals, and ongoing education are essential components of delivering quality care in these challenging situations.

EMS Legal Matters - Emergency Medical Treatment and Labor Act (1986)

EMS Providers should be familiar with the Emergency Medical Treatment and Labor Act (EMTALA), as it impacts their responsibilities when transporting patients to hospitals. 

Here's what EMS providers need to know about EMTALA:

Purpose of EMTALA: EMTALA is a federal law that ensures public access to emergency services regardless of a patient's ability to pay.

The primary purpose of EMTALA is to prevent "patient dumping," where hospitals refuse to treat or transfer patients with emergency medical conditions because of their inability to pay or lack of insurance.

Key Provisions: EMTALA requires hospitals that participate in Medicare (virtually all hospitals) to provide a medical screening examination (MSE) to anyone who comes to the emergency department seeking treatment, regardless of their ability to pay.

If an emergency medical condition is identified during the MSE, the hospital must stabilize the patient's condition or transfer them to another facility that can provide appropriate treatment. The hospital must also provide necessary treatment within its capabilities to stabilize the patient before transfer.

Hospitals must accept transfers of patients in unstable conditions if they have the appropriate resources and capability to treat the patient's condition.

Impact on EMS Providers: EMS providers play a crucial role in the initial assessment and stabilization of patients before they arrive at the hospital.

EMS providers must perform an initial assessment and provide necessary interventions to stabilize a patient's condition to the best of their ability within their scope of practice.

EMS providers should transport patients to the nearest appropriate facility capable of providing the necessary level of care based on the patient's condition, even if the patient lacks insurance or ability to pay.

Documentation and Communication: Documentation of the patient's condition, interventions provided, and the decision-making process regarding transport destination is crucial.

EMS providers should communicate effectively with receiving facilities regarding the patient's condition, anticipated needs, and reason for transport to facilitate continuity of care.

Penalties for Non-Compliance: Hospitals found in violation of EMTALA may face civil monetary penalties, exclusion from the Medicare program, and potential lawsuits.

EMS providers may face liability if they knowingly transport a patient to a facility that does not have the capability to provide appropriate care for the patient's condition.

In summary, EMS providers must understand their role in EMTALA compliance, which includes providing appropriate medical care and transport to patients regardless of their ability to pay. 

Effective communication, documentation, and adherence to protocols are essential to ensure compliance with EMTALA regulations and provide quality emergency medical care.