Understanding Seizures
A seizure is an episode of abnormal, excessive electrical activity in the brain that produces involuntary changes in movement, sensation, behavior, or consciousness. Seizures are one of the most common neurological emergencies in EMS, affecting approximately 3.4 million Americans with epilepsy and occurring in many other conditions. While most seizures are self-limiting and resolve within 1 to 2 minutes, prolonged seizures (status epilepticus) are a medical emergency that can cause permanent brain damage or death.
Seizures have many causes beyond epilepsy: hypoglycemia, head trauma, stroke, infection (meningitis, encephalitis), fever (febrile seizures in children), eclampsia in pregnancy, drug and alcohol withdrawal, electrolyte imbalances, and medication toxicity. Identifying and treating reversible causes is an important part of seizure management.
Seizure Classification
Seizures are classified as generalized (affecting both brain hemispheres) or focal (originating in one area of the brain):
- Generalized tonic-clonic (grand mal): The most dramatic seizure type. The tonic phase involves sudden stiffening of the body, often with a cry as air is forced past closed vocal cords. The clonic phase involves rhythmic jerking of the extremities. The patient is unconscious throughout and may bite their tongue, become incontinent, and develop cyanosis from diaphragmatic spasm.
- Absence (petit mal): Brief episodes of staring and unresponsiveness lasting 5 to 30 seconds, most common in children. The patient may have subtle eye blinking or lip smacking but no major motor activity.
- Focal seizures: Originate in one area of the brain and may cause localized twitching, sensory changes, or altered awareness without generalized motor activity. They can progress to generalized seizures (secondary generalization).
Seizure Management in the Field
During an active seizure, your priorities are protecting the patient from injury and maintaining the airway. Move objects away from the patient, place padding under their head if possible, and position the patient on their side (recovery position) to allow secretions to drain. Do not restrain the patient or place anything in their mouth. Time the seizure; duration is critical information for the receiving physician.
After the seizure ends, the patient enters the postictal phase, characterized by confusion, drowsiness, headache, and sometimes temporary focal neurological deficits (Todd's paralysis). The postictal phase can last minutes to hours. During this phase, manage the airway (suction secretions, provide supplemental oxygen), check blood glucose, and perform a thorough assessment looking for injuries sustained during the seizure and potential causes.
Status Epilepticus
Status epilepticus is defined as a seizure lasting more than 5 minutes or two or more seizures without return to baseline consciousness between them. This is a medical emergency because prolonged seizure activity causes neuronal damage, hyperthermia, rhabdomyolysis, and metabolic acidosis. Treatment involves benzodiazepine administration: midazolam (10 mg intramuscular or 5 mg intranasal for adults) or diazepam (5 to 10 mg IV) per protocol. Secure the airway, administer high-flow oxygen, establish IV access, check blood glucose, and transport immediately. If the initial benzodiazepine dose does not terminate the seizure within 5 minutes, repeat dosing per protocol. Be prepared for respiratory depression, a common side effect of benzodiazepines.