Case summary:

An BLS crew was dispatched to a 60s man who had fallen.  When they arrived, he was found in the shower having generalized tonic-clonic movements consistent with a seizure.  Family on scene stated he was seizing for 5 minutes prior to arrival.  The crew immediately called for a backup ALS crew and moved the patient into the next room for more space to work.  The placed the patient on a nonrebreather at 15LPM and connected the patient to capnography to monitor ventilations.  Given that the patient had fallen in the shower, they placed the patient in a C collar as a precaution.  Vitals and a glucose level were obtained:

Vitals: BP 200/125, HR 140, RR 32, Sat 81% on RA, glucose 190

At this time the ALS crew arrived on scene and took over care.  Patient was still seizing so the crew immediately gave 5mg of midazolam intramuscular (IM).  They continued to assess and got additional history from family who was on scene.  After 5 minutes, the patient was still seizing so they gave a second dose of 5mg IM midazolam.  They then quickly extricated to the ambulance and placed an IV.  The patient continued to seize so the crew called online medical control for help given that the protocol allows for a maximum of 10mg IM midazolam to treat seizure per protocol but they knew that they still needed to control the seizures.  Online medical control gave the order for 1 mg/kg of ketamine IV.  The crew administered the ketamine and the seizures stopped.  The patient began to hypoventilate and required bag valve mask (BVM) support.  The crew knew that the patient needed intubation, but given how close they were to the hospital, they notified the ED of the need for intubation and proceeded to medically optimize the patient for intubation at the hospital.  The hospital team was able to mobilize resources and was ready to intubate the patient right upon arrival in the emergency department.  Vitals just prior to hand off at the hospital was:

Vitals: BP 183/113, HR 138, RR 20, Sat 99% on O2

Highlights of the case:

Call for back up early when more resources needed

A fall is a reasonable call for a BLS crew to be dispatched for.  However, once they arrived, they realized this was a seizure which requires ALS level of care.  Once they realized this, they immediately called for backup and then began treating the patient as much as they could within their scope of practice.  Given bystanders and patients often are in distress when they call 911, dispatchers often do not get the correct information to dispatch the correct resource.  This will sometimes lead to under triage.  When this crew arrived and realized the patient needed a higher level of care, they quickly mobilized back up.  This was great decision making by the crew.  

Treat active seizures as soon as possible.

Status epilepticus is defined as a seizure lasting longer than 5 minutes or back-to-back seizures where the patient never returns to baseline in between the episodes.  Given it takes >5 minutes for someone to find a patient seizing, to call 911, for a crew to be dispatched, and for a crew to arrive on scene, we should treat all patients that are seizing when we arrive as a patient in status epilepticus.  Status epilepticus is a true life-threatening emergency, and the goal is to get benzodiazepines board as soon as possible to abort the seizure.  The longer we delay treatment, the harder it is to treat the seizure.  This is due to the kindling effect where during seizures the brain down regulates the receptors that benzodiazepines bind to leading to them being less effective.  If a patient is seizing and there is no pre-established IV access, it is best to give the first benzodiazepine dose IM to get it on board quickly.  We can then work on an IV so that the second dose can be given IV if possible.  We also want to make sure that we give a true weight-based dose since underdosing benzodiazepines has also been associated with patient harm.  This crew was very quick to give a full midazolam dose which was key here.  While it did not end up working, it was great EMS care none the less.

Involve medical control when patients have needs that exceed the protocol.

Protocols provide standing orders that help EMS providers render care for the vast majority of patient encounters.  However, there are situations where patients do not fit the usual mold established by the protocols.  This might be that the patient has multiple disease processes that are simultaneously causing the acute problem, or it might be that the patient has a severe presentation of a disease process.  In either case, patients might need treatments that the protocol does not allow for.  When these situations are identified, we should not simply follow the protocol if we know the protocol is not meeting the need of the patient.  We also cannot deviate from the protocol on our own.  In these situations, we need to involve online medical control to get the order to provide treatments that are outside the protocol.  Once you have online medical control on the phone, EMS responders can do anything provided it is within his/her scope of practice and they have the online order to do so.  In the case of this patient, he was still seizing despite getting the correct maximum doses for midazolam.  The crew knew they needed to stop the seizure, do they called medical control to get the order for something that was beyond the protocol.  In this case, they were given the order for ketamine.  This is a drug our protocol allows for sedation of agitated patients, analgesia, and induction for rapid sequence intubation.  Ketamine can be used for seizures, but it is not in our protocol for that indication.  Given that the crew had an online order, it allowed them to treat the patient in a way that was outside the protocol.  In this case, the patient had been seizing for a long time prior to the first dose of midazolam.  As we discussed above, the longer the patient is seizing, the harder it is to abort the seizure since benzodiazepines like midazolam are often less effective.  Ketamine has activity on additional receptors in the brain (such as blocking NMDA receptors) that can help break seizures that benzodiazepines otherwise cannot break.  Ketamine was absolutely the correct treatment here and this crew was able to get the order to do this by calling for help as soon as they realized the protocol was not meeting the needs of the patient.

Mobilize hospital resources as soon as possible for sick patients.

This patient was no longer protecting his airway both because of being in status epilepticus and due to the large amount of sedatives needed to abort the seizure.   The crew correctly identified that this patient would need an advanced airway.  Given that they were in route to the receiving facility and would be arriving in a few minutes, they decided to medically optimize the patient for intubation while notifying the receiving facility of this need so they could prepare.  This allowed the EMS crew to optimize ventilation, oxygenation and hemodynamics so that the patient can be safely intubated immediately upon arrival at the receiving facility.  If they did not notify the hospital of this need, then there would be a delay in intubation since the preparation would not start until after arrival in at the hospital.  It takes time to mobilize respiratory therapy, bring a vent to the room, pull medications and set up an endotracheal tube.  We want this all to be done before we arrive if possible.  If the crew was further out or had not extricated, it would have been reasonable to perform rapid sequence intubation in the field.  However, given the proximity to the ED and ability to temporize the situation with BLS airway techniques, it was correct to defer this to the hospital.