Patient Care, Special Topics

Epileptic Effect: The Aftermath of a Seizure isn’t Always What it Seems

Issue 5 and Volume 40.

You and your partner are dispatched to a 60ish-year-old female with signs and symptoms of a possible stroke. Upon arrival you find the patient lying on her right side with rapid respirations at about 26 per minute and unresponsive. Her airway is patent and her pupils are PEARRL (pupils equal and round, responsive to light). You notice she has a right-sided facial droop and her upper and lower extremities on the right side appear more flaccid than on the left.

Upon getting the patient ready to transport, the family advises you she was “walking around in a daze” and “had a seizure about an hour ago, then laid down.” You load the patient into the ambulance and get a set of vital signs, which are within normal limits. Blood glucose finger stick was 100 mg/dL. Differential diagnosis doesn’t allude to anything other than a possible stroke, or something neurologic at the very least.

Because you work in a rural area and the weather is good, you and your partner call air medical transport for this patient for possible stroke team intervention.

The flight crew’s first impression and differential diagnosis match yours, and they make the decision to utilize rapid sequence intubation on the patient. The flight crew paramedic gets the patient intubated and loaded on his litter system without a problem. The patient’s vital signs hold throughout transport, but the patient is combative during the 25-minute trip.

Diagnosis & Discussion

Upon arrival at the receiving facility, the patient’s cranial CT scan rules out any kind of stroke. She’s diagnosed with epilepsy and Todd’s Paralysis–a rare condition you and your partner have never heard of.

Todd’s Paralysis was found by clinician Robert Bentley Todd in the mid-1800s.1 It’s also known as epileptic hemiplegia and is a condition that affects epileptics. It follows an epileptic seizure in which the patient experiences total or partial paralysis of one side of the body.

“The paralysis may be partial or complete but usually occurs on just one side of the body. The paralysis can last from half an hour to 36 hours, with an average of 15 hours, at which point it resolves completely. Todd’s paralysis may also affect speech and vision.”2

This condition has baffled scientists. At this point they don’t know what causes this issue, but research is ongoing. Current theories accredit the condition to biological processes in the brain that involve a lower energy output of neurons or slower motor centers of the brain.2

The patient in question had the classic signs of a stroke: being dazed and confused prior to the event, going unresponsive, and having right-sided weakness. However, because both potential diagnoses require completely different forms of treatment, it’s important to distinguish between the two.2

If you have a patient with stable vitals but who’s a known epileptic and has just had a seizure and has paralysis on one side of the body, there’s a good chance they may be having a case of Todd’s Paralysis. However, it’s important to know their history before you suggest this to the doctors in the ED because the prognosis of patients affected by Todd’s Paralysis depends largely on their history, the effects of the seizure and the subsequent treatment of the epilepsy.

Todd’s Paralysis is a good indication the patient has had an epileptic seizure and managing their epilepsy is key to managing this strange condition. There’s no treatment for Todd’s Paralysis–patients must rest as comfortably as possible until the paralysis disappears.2

Conclusion

The National Institute for Neurological Disorders and Stroke within the National Institutes of Health are currently conducting studies about Todd’s Paralysis to further understand this rare condition. Research grants are also being provided to major medical institutions across the country.

As EMS professionals, it’s important we stay on top of our knowledge. EMS is a career in which a practitioner of the art never stops learning and seeks to further their knowledge in emergency medicine and prehospital care.  

 References

1. Binder DK. A history of Todd and his paralysis. Neurosurgery. 2003; 54(2):480–487.

2. NINDS Todd’s Paralysis information page. (Sept. 29, 2011.) National Institute for Neurological Disorders and Stroke. Retrieved Sept. 18, 2013, from www.ninds.nih.gov/disorders/toddsparalysis/toddsparalysis.htm#Clinical_trials.