DON’T CALL IT A SEIZURE…

Anecdote 1:Don’t call it a seizure, start CPR

Resident: Hey, remember that patient in room 7 with the heart attack? Now he’s having a seizure!

You: That is not a seizure, let’s start CPR!

(the patient survives, and receives emergent catheterization opening a blocked vessel)

 

Cardiac arrest is often accompanied by jerking movements. The cartoons of the 1940s understood this. Bugs Bunny would typically do a few good jerking leg kicks prior to faking death with Elmer Fudd, Yosemite Sam, etc. If the setting is more appropriate for cardiac arrest, check pulses first.

 

This is probably not substantially different from convulsive syncope but I will describe that separately:

 

Anecdote 2: Don’t call it a seizure, refer to cardiology

“we never figured out why the Brugada syndrome patient had a seizure” –someone who should know better

 

Blood bank studies show that about 10% of syncope events are accompanied by a convulsion. These can look like epileptic generalized tonic clonic seizures. The differences are:

Pre-ictal: what were the setting, the symptoms, and the signs, before the event. An aura suggests a seizure. Standing in church suggests syncope. Alcohol withdrawal suggests seizure, etc.

Ictal: convulsive syncope is less rhythmic, less symmetrical, and less sustained

Post-ictal: Convulsive syncope patients regain normal arousal within a minute, seizure patients take 10-15 minutes

 

It isn’t a seizure until you have a diagnosis. It is a convulsion. Apply an appropriate differential that includes convulsive syncope.

 

Ancedote 3: Don’t call it a seizure, check the temperature

A middle aged patient is waiting to be seen for generalized weakness. The triage RN rushes them out of the waiting room because of a “seizure.” He never lost consciousness and was awake the entire time. Temp is 103 oral. You ultimately diagnose sepsis from pyelonephritis.

 

Rigors can cause tremendous shaking and can make us worry about seizure. Obviously a seizure can raise the temperature so judgment is required. But don’t automatically assume that a convulsion from sepsis is a seizure. Rigors happen when the temperature is rising, so recheck the temperature.

 

Anecdote 4: Don’t call it a seizure, educate the family

A patient is here for opioids. The doctor said no. She has a history of developing “seizures” when she does not get narcotics. Now she is screaming loudly and, wait for it…. The RN runs to you announcing a seizure and asks if you will give Ativan. Okay, I admit it, I often give Ativan if I am not sure. One time I went to the patient and said “really, you are having a seizure? Can I see the tongue biting, show me the tongue” and she proceeded to show me her teeth, biting the tongue.

 

This is tough. Don’t expect the family to understand the difference between seizures and psychogenic convulsions (also known as pseudoseizure). Educate them on the potential for psychogenic causes (but don’t prematurely rule out epilepsy either, unless it is abundantly obvious)

 

TAKE HOME POINTS:

-Our terminology can box us in. Don’t call it a seizure unless you are committing to an epileptic etiology.

-Ask about circumstances before, during, and after the event to identify possible convulsive syncope

REAL TIME CHARTING IS REAL TIME THINKING

We speak of physical diagnosis as if the sign and the suggested diagnosis always match. Often they do, for example when we see acromial step off and suspect anterior shoulder dislocation.

 

But more often there is ambiguity. Most bedside information is non-specific. For example, tachycardia can mean a lot of different things. Later when we look at everything at once, there is the chance to “put it all together.”

 

But when will you do that? It is necessary at times to give uninterrupted concentrated thinking to a patient’s symptoms and signs. For example, how about the chronic headache patient who saw the chiropractor for neck pain? When you put it all together you might think of vertebral dissection.

 

Some call this a “cognitive pause,” others just call it medical decision-making, and others focus on the disruptive effect of interruptions.

 

Many ED groups routinely expect charting to be done at the end of the shift, after the patients are gone.

 

But charting is a chance to think critically, to put it all together. And sometimes when we do that early in the visit, it can prompt a “lightbulb” moment where we realize the need to check something else.

 

I advocate real time charting. The act of creating a chart requires thinking. Why not do that while the patient is still in the ED? I think at the end of the visit just before discharge is okay but even better would be right after seeing the patient. The recitation of the symptoms and signs are most accurate at that time and the “cognitive pause” of thinking through the whole presentation then can happen early, when it can change the workup.

 

It is simply impossible to do that on all patients on all shifts. But this is something we should try to do. The bottom line is that most historical and physical findings are ambiguous. There needs to be an explicit stage after information collection, which is information “integration.”

 

Take Home Points

-Complex patients require a “cognitive pause”

-It is hard to do that on a busy shift but real-time charting makes it more possible

 

References:

Check out Mark Jaben EP Monthly April 2013

To Reduce Medical Errors, Take a Cognitive Pause