Seizure Medical Directive and PNES
Question# 899
My question is in regard to treatment expectation when faced with Psychogenic Nonepileptic Seizures(PNES).
We have a "frequent flyer" in our service area that is diagnosed with PNES. Sometimes the c/c is seizure but some times it could be other things.
Their seizures appear as full body posturing/convulsions, usually last 1-2 minutes during which her SpO2/ETCO2 values are unremarkable. When the seizure is over within +/- 30 seconds they are GCS 15.
I'm not convinced that this clinical situation was intended to fall under the seizure medical directive with midazolam treatment but am curious to know the RPPEO team opinion.
We have a "frequent flyer" in our service area that is diagnosed with PNES. Sometimes the c/c is seizure but some times it could be other things.
Their seizures appear as full body posturing/convulsions, usually last 1-2 minutes during which her SpO2/ETCO2 values are unremarkable. When the seizure is over within +/- 30 seconds they are GCS 15.
I'm not convinced that this clinical situation was intended to fall under the seizure medical directive with midazolam treatment but am curious to know the RPPEO team opinion.
Answer:
Clinically differentiating between PNES and epileptic seizures can often be very challenging, especially in the prehospital environment!
Psychogenic nonepileptic seizures (PNES), formerly called “pseudoseizures,” are not caused by abnormal brain activity. However, distinguishing PNES from epileptic seizures is extremely difficult in the prehospital setting, as electroencephalogram (EEG), which is the gold standard for diagnosis, is currently not available in the prehospital setting.
Since epilepsy and PNES can coexist, paramedics should use sound clinical judgment. If the patient meets the criteria outlined in the seizure medical directive, treatment with midazolam is appropriate to ensure safety and reduce the risk of complications. Also, the longer a true epileptic seizure goes untreated, the more resistant it becomes to anticonvulsant therapy and the more difficult it becomes to terminate, which reinforces the importance of treating it as a seizure when in doubt.
While the medical directive is not intended for patients experiencing a truly functional seizure, in general we must err on the side treating the seizure as an epileptic one since the implications of unmanaged status epilepticus can be catastrophic for the patient.
There was an article published in the July 2023 edition of Medic News by James Bowen that you can find here.
If you like Podcasts EM Cases also had a quite useful episode discussing resolved seizures which involved a discussion around PNES.
EM Cases: Emergency Approach to Resolved Seizures - emDocs
Psychogenic nonepileptic seizures (PNES), formerly called “pseudoseizures,” are not caused by abnormal brain activity. However, distinguishing PNES from epileptic seizures is extremely difficult in the prehospital setting, as electroencephalogram (EEG), which is the gold standard for diagnosis, is currently not available in the prehospital setting.
Since epilepsy and PNES can coexist, paramedics should use sound clinical judgment. If the patient meets the criteria outlined in the seizure medical directive, treatment with midazolam is appropriate to ensure safety and reduce the risk of complications. Also, the longer a true epileptic seizure goes untreated, the more resistant it becomes to anticonvulsant therapy and the more difficult it becomes to terminate, which reinforces the importance of treating it as a seizure when in doubt.
While the medical directive is not intended for patients experiencing a truly functional seizure, in general we must err on the side treating the seizure as an epileptic one since the implications of unmanaged status epilepticus can be catastrophic for the patient.
There was an article published in the July 2023 edition of Medic News by James Bowen that you can find here.
If you like Podcasts EM Cases also had a quite useful episode discussing resolved seizures which involved a discussion around PNES.
EM Cases: Emergency Approach to Resolved Seizures - emDocs