The question of whether a seizure-like event is a true epileptic seizure or some type of pseudoseizure is often very hard to sort out. Oftentimes (in fact, most of the time) these events do not happen in front of us. We just hear reports from the deputies of “something happening–looked like a seizure.” Or perhaps the patient himself will tell us that he had an seizure, like the patient I saw recently who told me “I’ve had four seizures this week.” Of course all of them were un-witnessed by anyone else.
Even though you might suspect that these un-witnessed seizure-like events are pseudoseizures, you should be very cautious about labeling such events “fake.” The absolute worst mistake that you as a medical provider can make in these cases is to declare an event “fake”—and be wrong. Until you are very sure, it is better to assume that un-witnessed events are real–or at least keep that possibility in the forefront of your mind. Until you have more evidence, you just don’t know for sure.
That is why it is so valuable when a patient has one of these seizure-like events right in front of you. This is the one opportunity to use objective findings to distinguish a true epileptic seizure from a pseudoseizure. I discussed in my last post the various differences in presentation between epileptic seizures and pseudoseizures, such as the nature of the shaking, eye deviation and a post-ictal period. Unfortunately, however, none of these findings are perfect.
To this end, remember that the single most important difference between a grand mal epileptic seizure and one of the various types of pseudoseizures is this: patients having grand mal seizures are unconscious. Patients having a pseudoseizure are not. And that is where ammonia capsules come in. In my opinion, ammonia capsules are the single best method for determining whether a patient is conscious or not. Ammonia is much more reliable and effective than, say, the sternal rub and other painful procedures that are commonly taught.
The reason that ammonia is so effective at differentiating conscious from unconscious is that the reaction of a conscious person to inhaling ammonia is reflexive. Conscious people cannot blithely tolerate ammonia. They will always turn away from the capsule in a dramatic fashion. So all we need to do is make sure that the patient in question takes one good inhalation of the ammonia. That’s all it takes! If they don’t react in any way, they are unconscious. Otherwise, they will turn away, cough, tear and sputter.
The problem is that many medical practitioners do not know how to use ammonia capsules properly. And if improperly used, they can be ineffective, misleading and even worthless.
The most common mistake made with ammonia (that I have seen, anyway) is when the patient never breathes it. Often, patients will just hold their breath. If you dangle the ammonia in front of the patient’s face for 30 seconds and the patient held his breath the whole time, it won’t work. You must outwait the breath-holding.
The second most common mistake is to hold the ammonia in such a position that the patient can surreptitiously breathe through the corner of their mouth furthest from the capsule. Here are two pictures of ammonia being used incorrectly. In the first, the ammonia is just being waved in the patient’s general direction.
In the second, the ammonia has been placed beneath the patient’s nose, allowing the patient to avoid it by breathing through the corner of her mouth.
You can also place the ammonia capsule into a mask and hold this gently over the patient’s face. If the patient holds his breath, you may need to wait—sometimes for over a minute. Of course, you should be observing carefully so you know when the breath occurs.
If the patient is unconscious, she will take a breath and have no reaction.
However, if the patient is not unconscious, when she takes a breath, she will immediately turn away from the ammonia and cough. At this point, the ammonia has done its job and you should withdraw your hand.
What comes next is equally important though. When the patient turns away, help them to sit up while saying something like, “Great! I’m glad this event is over. Sit up so we can talk.” I usually will have the patient actually stand up and walk somewhere else, like a nearby chair, to cement in their mind that this episode is over.
I have found this technique to be very effective. However, it is a mistake at this point to just walk away. What you say next when you discuss the event with the patient is at least as important as the ammonia capsule itself. Your overall goal here is for the patient not to have any more of these events.
First, do not say or even remotely imply that you think the patient has been faking. Get rid of this notion. It is almost always counterproductive. There are two reasons for this. First, even if this was a pseudoseizure, the patient may not have been faking (as I discussed in my first post on pseudoseizures). Second, your goal is to stop these events from happening. If you accuse the patient of faking (often with a contemptuous sneer), they will feel humiliated and often want to prove that these events are real—by having more of them. Instead, the more effective course is to allow the patient to save face by saying “I’m glad this event is over. Let’s talk.”
When I give the post pseudoseizure talk, I try to emphasize a couple of important points. First, although this event was real, it evidently was not an epileptic seizure. And that is good news, because epileptic seizures can be dangerous and because I don’t have to prescribe potentially dangerous drugs. Second, I emphasize that (great news!) we have discovered a medication that can stop these events from happening—ammonia!
I have found that allowing the patient to save face plus the knowledge that any more events will result in another unpleasant encounter with ammonia does wonders to slow down the incidence of pseudoseizures.
This is very important to remember: Up to a third of patients who have pseudoseizures have real epileptic seizures as well. Do not make the mistake of thinking that since this one event was proven to be a pseudoseizure, the patient cannot have a real seizure.
Step-by-Step Summary: Ammonia Capsule Use:
1. Break the ammonia capsule.
2. Grasp the ammonia capsule in your palm, between your thumb and index finger (or alternatively, place the ammonia capsule in a mask).
3. Place your hand loosely over the patient’s mouth and nose.
4. Wait for the patient to take a breath. Observe closely!
5. If the patient turns away, coughs and sputters, withdraw the ammonia and help the patient to sit up while saying something like “I’m glad you are back with us! Let’s sit you up so we can talk.”
6. Move the patient to a chair.
7. Talk to the patient about what just happened. Do not humiliate them. Emphasize that what they experienced is not an epileptic seizure, but something else. We know now how to make it stop, using ammonia.
Mandatory Disclaimer: Once again, what I have written here is my own opinion based on my training and my experience. This approach has worked well for me, but is certainly not the only way to approach seizures and pseudoseizures. Feel free to disagree with me! I could be wrong. If you do disagree, or if you have an alternative approach to these difficult patients that works for you, please tell us about it, in comments!