Status Epilepticus and Seizures: Seizure First Aid, Causes and Field Care

A seizure is a burst of abnormal, excessive electrical activity in the brain that changes how a person moves, behaves, feels or responds. Most seizures stop on their own within a couple of minutes. Status epilepticus is a seizure that does not stop, or seizures that keep coming without the person recovering between them, and it is an emergency because the longer it runs the harder it is to stop and the more harm it does. This guide covers recognizing seizures, the postictal state, status epilepticus, the causes to look for, first aid and field care.

Types of seizure, in plain terms

The ILAE (the international league of epilepsy specialists) classifies seizures by where they start in the brain. A generalized seizure involves both sides of the brain from the start. A focal seizure starts in one area and may stay there or spread. You do not need the full classification in the field, but you do need to describe what you see, because the description is what the receiving team works from.

Other types include myoclonic seizures (brief, shock-like jerks) and atonic seizures (a sudden loss of muscle tone, often causing a fall).

The postictal state

After a seizure, most people pass through a postictal period: drowsiness, confusion, headache, sore muscles and sometimes agitation. A bite to the side of the tongue and incontinence of urine are common after a tonic-clonic seizure. Most patients improve steadily over minutes to hours. Approach a confused postictal patient calmly, because they may resist or strike out without understanding where they are.

Some patients have a temporary weakness of one side of the body after a seizure, called Todd's paralysis. It usually resolves within hours, but in the field you cannot tell it from a stroke, and a stroke can cause a seizure. Treat a new one-sided weakness as a possible stroke and follow your stroke protocol.

Screen for stroke when a patient has a new weakness after a seizure

Status epilepticus

The ILAE's 2015 operational definition sets two time points for a generalized tonic-clonic seizure. At 5 minutes, the seizure is unlikely to stop on its own and treatment should start. At about 30 minutes, lasting harm to the brain becomes likely. The definition was deliberately shortened from older teaching, which used 30 minutes, so that treatment is not delayed.

In emergency care, status epilepticus is generally treated as either of these:

• A convulsive seizure lasting 5 minutes or more.
• Two or more seizures without the patient returning to their baseline level of consciousness in between.

If the seizure started before you arrived, start the clock from when it began, as best the witnesses can tell you. A seizure that bystanders say has been going on for several minutes is already near or past the 5-minute mark when you walk in.

Causes to look for

A seizure is a symptom. Some causes are found in the field, and a few can be treated there. Check a blood glucose in every seizing or postictal patient, even when the story fits epilepsy perfectly.

1. Hypoglycemia. It is common, quickly reversible, and a seizure from low glucose can be stopped by a drug while the brain stays starved of glucose. Check it first.
2. Hypoxia, from an airway problem, drowning, a breathing problem or cardiac arrest.
3. Head injury, recent or days old. Look for signs of trauma and ask about falls.
4. Missed or reduced anti-seizure medication in a patient with known epilepsy, one of the most common causes of a breakthrough seizure.
5. Withdrawal from alcohol or from sedative medication.
6. Drugs and poisons, including stimulants and overdoses of some prescription medications.
7. Eclampsia in pregnancy or after delivery.
8. Infection, including meningitis and encephalitis, and fever in a young child.
9. Stroke, a bleed in the brain or a brain tumor.
10. Low sodium and other metabolic problems, and heat stroke.

Seizure in pregnancy or after delivery: think eclampsia

A new seizure in a patient who is more than about 20 weeks pregnant, or who has recently delivered, including in the days to weeks after the birth, is eclampsia until proven otherwise. Eclampsia can occur in a patient with no known history of high blood pressure, and the blood pressure may only be found high after the seizure. Ask about the pregnancy and take a blood pressure. Magnesium sulfate, given per protocol, is the first-line anticonvulsant for an eclamptic seizure, and a benzodiazepine is commonly the protocol's backup, so the pregnancy is something your protocol needs to know before treatment, not after. In late pregnancy, position the patient on the left side or displace the uterus to the left once the convulsion allows.

Seizure first aid

Most people who search for seizure first aid are bystanders, and the advice is the same advice EMS gives a caller or coaches a caregiver to do.

1. Stay with the person and note the time the seizure started.
2. Move hard or sharp objects away and cushion the head. Do not hold the person down or try to stop the movements.
3. Put nothing in the mouth. A person cannot swallow their tongue, and an object can break teeth, block the airway or injure the helper.
4. Loosen anything tight around the neck.
5. When the jerking stops, roll the person onto their side to keep the airway clear, and stay with them until they are fully awake.
6. Speak calmly as they wake up. They may be confused and not know what happened.

Common first-aid guidance from epilepsy charities says to call 911 when a seizure lasts more than 5 minutes, when another seizure follows before the person wakes up, when it is the person's first seizure, when the person is injured, pregnant, diabetic or having trouble breathing, or when the seizure happened in water.

Field care

The principles below are taught across EMS curricula. Which medication, its dose and its route are set by your protocol.

• Scene and safety: protect the patient and the crew. Note the time of onset and how long it has been going on.
• Protect the patient from injury without restraining the limbs. Restraint causes fractures and dislocations and does not shorten the seizure.
• Put nothing in the mouth. An oral airway or a bite block in a clenched jaw breaks teeth and can obstruct the airway. A nasopharyngeal airway is often the adjunct that can be placed in a seizing or postictal patient, where your protocol allows it, with the caution about a suspected basilar skull fracture or major facial injury that the airway adjuncts guide describes.
• Airway and breathing: suction secretions, give oxygen, and assist ventilation if breathing stays inadequate. Once the convulsion stops, place the patient on the side unless a spinal injury is suspected.
• Check a blood glucose, every time.
• Treat status epilepticus without delay. Benzodiazepines are the first-line drug class for status epilepticus in EMS protocols. Many protocols allow an intramuscular or intranasal route so that the drug is not delayed while someone tries to start a line on a convulsing patient. The drug, dose and route are your protocol's. In pregnancy past about 20 weeks or after a recent delivery, magnesium sulfate is first-line per protocol (see eclampsia above).
• In a child, establish a weight, by length-based tape or scale where you have one, before any weight-based dose.
• Monitor closely after the seizure stops. The postictal state and a benzodiazepine both depress breathing, and the period after the seizure is when breathing problems appear. Pulse oximetry, capnography where you have it, and repeated checks of the airway and breathing.
• Consider spinal precautions per protocol if the patient fell or was injured during the seizure.
• Reassess the level of consciousness and trend it, and check for injuries, including the tongue.

Score and trend the level of consciousness as the patient recovers

The history

• What did it look like, and what happened first? A jerking hand before a full convulsion suggests a focal start.
• How long did it last, and has the patient woken between seizures?
• Has this happened before? Known epilepsy, the usual seizure pattern, and whether this one is different.
• Medications, including anti-seizure medication and whether doses have been missed or changed.
• Diabetes, recent illness or fever, a headache before the seizure, recent head injury.
• Alcohol, drugs, or stopping either recently.
• Pregnancy or recent delivery.

Things that look like seizures

• Fainting. A person who faints can have a few brief jerks, which is common and not a seizure; the quick return to normal and the absence of a long confused period are clues.
• Psychogenic nonepileptic seizures, which are real events but are not caused by abnormal electrical activity. They cannot be reliably told apart in the field, so treat the patient as seizing.
• An abnormal heart rhythm causing loss of consciousness, which can produce jerking movements.
• Hypoglycemia, stroke, and drug or alcohol effects.

Febrile seizures in children

A febrile seizure is a seizure in a young child with a fever, commonly between 6 months and 5 years of age, without an infection of the brain or another cause. They are frightening for parents and are among the most common seizures EMS sees in children. Most are brief and stop on their own, and the outlook for a simple febrile seizure is generally good.

A child who is still seizing at 5 minutes is treated as status epilepticus, whatever the fever. Complex features raise concern for meningitis, encephalitis or another cause, and so does a child who does not return to normal, who has a stiff neck, a rash, a bulging soft spot in an infant, or who looks very unwell between seizures.

• Check a blood glucose even when the story fits a febrile seizure perfectly.
• Do not cool the child with cold water or ice. Remove excess clothing and let the fever come down passively.
• Keep the child with the caregiver where you can. Be calm and reassuring, and do not tell a family it is just a febrile seizure when it has complex features.
• Be ready for another seizure on the way.

Estimate a weight from age when nothing better is available

The short version

• A seizure is abnormal electrical activity in the brain. Describe what you see, including how it started.
• Status epilepticus: a convulsion lasting 5 minutes or more, or repeated seizures without recovery between them. The ILAE's 2015 definition puts the start of treatment at 5 minutes.
• Check a glucose every time. Think of hypoxia, head injury, missed medication, withdrawal, poisoning and infection.
• A seizure in pregnancy or after delivery is eclampsia until proven otherwise, and it changes the treatment.
• Protect without restraining, nothing in the mouth, on the side when it stops, airway and oxygen.
• Benzodiazepines are the first-line drug class, per protocol. Watch breathing closely afterward. In pregnancy past about 20 weeks or after a recent delivery, magnesium sulfate is first-line per protocol (see eclampsia above).
• Febrile seizures are common and usually harmless, but check the glucose, do not cool with ice, and look for the features that make one complex.