Paramedics transporting a patient in the snow

Seizure Emergencies

Learn How EMTs & Paramedics Identify, Treat, and Care for Patients with Seizure Emergencies

Paramedics transporting a patient in the snow

A seizure is the eighth most common emergency that EMS professionals respond to, accounting for almost 5% of all EMS calls.

(Click here for our list of the most common EMS Emergencies for EMTs and Paramedics).

A seizure (formally called an epileptic seizure) is a period of uncontrolled electrical activity in the brain. It can result in a number of outward symptoms, which may include: convulsion, minor physical signs, thought disturbances, or a combination of symptoms.

The type of symptoms and seizures depend on where in the brain the abnormal electrical activity is located, what caused the electrical disturbance, and other factors such as the patient’s age and general state of health.

A seizure can be caused by a wide range of conditions, including:

  • Head injuries
  • Brain tumors
  • Poisoning
  • Brain development problems before birth
  • Genetic and infectious illnesses
  • Fevers

In 70% of seizure cases, no cause for epilepsy can be found, though genetic factors likely play a role.

Seizure Definition

What Is a Seizure?

A seizure is a period of abnormally excessive brain activity. Visible symptoms can range from uncontrolled shaking movements involving much of the body with loss of consciousness (called tonic-clonic seizure) to shaking movements involving only part of the body with variable levels of consciousness (focal seizure) to a slight momentary loss of awareness (absence seizure). In most cases, a seizure will last less than 2 minutes, and the afflicted person will need some time to return to normal—generally 3 to 15 minutes, but it may take hours.

Seizures may be provoked or unprovoked. A provoked seizure is the result of a temporary event, such as low blood sugar, alcohol withdrawal, abusing alcohol together with prescription medications, low blood sodium, fever, brain infection, or concussion.

Unprovoked seizures can occur without a known or identifiable cause and will likely be recurring. This type of seizure may be triggered by stress or sleep deprivation. Diseases of the brain, where there has been at least one seizure and an ongoing risk of recurring seizures, are collectively known as epilepsy.

Any seizure that lasts for more than a brief period is a medical emergency. Any seizure lasting longer than 5 minutes should be treated as status epilepticus, leading to permanent brain damage or death.

The first seizure someone experiences generally does not require long-term treatment with anti-seizure medications unless a specific problem is found on an electroencephalogram (EEG) or brain imaging machine. Typically, it is safe to complete the work-up for a single, first-time seizure as an outpatient treatment. However, in many cases, what appears to be the first seizure was actually preceded by other smaller seizures that went unrecognized.

Here are some other quick facts about seizures:

  • Seizures are a common medical condition, with 10% of Americans experiencing at least one epileptic seizure in their lifetime.
  • Epilepsy will develop in 3% of Americans by age 75.
  • Provoked seizures occur in about 3.5 per 10,000 people a year
  • Unprovoked seizures occur in about 4.2 per 10,000 people a year.
  • After one seizure, the chance of experiencing a second is about 50%.
  • Nearly 80% of people who have epilepsy live in developing or lower-income countries.
  • Many places require people to stop driving until they have not had a seizure for a specific period.
  • About 71% of EMS calls for seizure will result in transport.
  • Prehospital interventions, such as airway management, IV access, benzodiazepine administration, and blood glucose testing are common
  • While advanced life support (ALS) care is standard in prehospital seizure management, there is a broad range of interventions employed.

Signs and Symptoms of Seizures

Close up of a patient's hand

The signs and symptoms of seizures vary depending on the type of seizure. The most common type of seizure is convulsive (60%). Two-thirds of this type of seizure begin as focal seizures and become generalized, while one-third begin as generalized seizures. The remaining 40% of seizures are non-convulsive.

Focal seizures

Focal seizures often begin with certain experiences, known as an aura. These may include sensory, visual, psychic, autonomic, smell, or motor phenomena.

A person may appear confused or dazed in a complex partial seizure and cannot respond to questions or directions.

Jerking activity may start in a specific muscle group and spread to surrounding muscle groups, known as a Jacksonian march. Unusual activities that are not consciously created may occur as well—these are known as automatisms and include simple activities like smacking of the lips or more complex activities such as attempts to pick something up.

What Are the Different Types of Seizures?

All of the generalized seizures involve a loss of consciousness and typically happen without warning. There are six main types of generalized seizures:

  • Tonic-clonic seizures present with a contraction of the limbs followed by their extension and arching of the back for 10–30 seconds. A cry may be heard due to the contraction of the chest muscles. The limbs then begin to shake in unison. After the shaking has stopped, it may take 10–30 minutes for the person to return to normal.
  • Tonic seizures produce constant contractions of the muscles. The person may turn blue if breathing is impaired.
  • Clonic seizures involve shaking of the limbs in unison.
  • Myoclonic seizures involve spasms of muscles in either a few areas or generalized through the body.
  • Absence seizures can be subtle, with only a slight turn of the head or eye blinking. The person often does not fall over and may return to normal immediately after the seizure ends, though there may also be a period of postictal disorientation.
  • Atonic seizures involve the loss of muscle activity for greater than one second. This typically occurs bilaterally (on both sides of the body).

How Long Do Seizures Last?

A seizure can last from a few seconds to more than five minutes, which is known as status epilepticus. Most tonic-clonic seizures last less than two or three minutes. Absence seizures are usually around 10 seconds in duration.

What Is the Postictal Period?

After the active portion of a seizure, there is typically a period of confusion called the postictal period before a normal level of consciousness returns. This usually lasts 3 to 15 minutes but may last for hours. Other common symptoms include: feeling tired, headache, difficulty speaking, and abnormal behavior.  Psychosis after a seizure is relatively common, occurring in between 6 and 10% of people. Often people do not remember what occurred during this time.

What Causes a Seizure?

Seizures have several causes. About 25% of people who experience seizures have epilepsy. Several conditions are associated with seizures but are not caused by epilepsy. These include most fever seizures and those that occur around an acute infection, stroke, or toxicity. These seizures are known as “acute symptomatic” or “provoked” seizures and are part of the seizure-related disorders. In many cases, the cause is unknown.

These are the different causes of seizures common in certain age groups:

  • Seizures in babies are most commonly caused by hypoxic-ischemic encephalopathy, central nervous system (CNS) infections, trauma, congenital CNS abnormalities, and metabolic disorders.
  • The most frequent cause of seizures in children is febrile seizures. These occur in 2–5% of children between six months and five years of age.
  • During childhood, well-defined epilepsy syndromes are generally seen.
  • In adolescence and young adulthood, non-compliance with the medication regimen and sleep deprivation are potential triggers.
  • Pregnancy and labor and childbirth and the post-partum or post-natal period (after birth) can be at-risk times, especially if certain complications like pre-eclampsia.
  • During adulthood, the likely causes are alcohol-related, strokes, trauma, CNS infections, and brain tumors.
  • In older adults, cerebrovascular disease is a very common cause. Other causes are CNS tumors, head trauma, and other common degenerative diseases in the older age group, such as dementia.

Metabolic Causes of Seizures

Dehydration can trigger epileptic seizures if it is severe enough. Several metabolic disorders can cause seizures, including:

  • Low blood sugar
  • Low blood sodium
  • Hyperosmolar nonketotic hyperglycemia
  • Low blood calcium
  • High blood urea levels
  • Hepatic encephalopathy
  • Porphyria

Structural Causes of Seizures

Cavernoma and arteriovenous malformation are treatable medical conditions that can cause seizures, headaches, and brain hemorrhages. Abscesses and tumors in the brain can cause seizures of varying frequency, depending on their location in the brain’s cortical region.

Medications

Close up of various medication and pills

Both medication and drug overdoses can result in seizures, as well as withdrawal from certain medications and drugs. Common drugs involved in causing seizures include:

  • Antidepressants
  • Antipsychotics
  • Cocaine
  • Insulin
  • Lidocaine

Withdrawal seizures, or delirium tremens, commonly occur after prolonged alcohol or sedative use.

Infections

Infections cause many cases of seizure and epilepsy, especially in Third World countries. These infections include:

  • Pork tapeworm infection. Pork tapeworm, which can cause neurocysticercosis, is the cause of up to half of epilepsy cases in countries where the parasite is common.
  • Parasitic infection. Parasitic infections, such as cerebral malaria, are a frequent cause of seizures in some countries. In Nigeria, parasitic infections are among the most common causes of seizures in children under five years of age.
  • Infection. Many infections, such as encephalitis or meningitis, can cause seizures.

Stress

Stress can cause seizures in people with epilepsy. It is also a risk factor in the development of epilepsy. Severity, duration, and time at which stress occurs during development contribute to the frequency and susceptibility to developing epilepsy. It is one of the most frequently self-reported triggers in patients with epilepsy. Stress triggers a release of hormones that mediate the effect of stress on the brain. These hormones act on both excitatory and inhibitory neural synapses, causing neurons in the brain to become hyper-excited.

Other Causes of Seizures

Seizures may occur as a result of a variety of conditions or triggers, including:

  • High blood pressure
  • Eclampsia (high blood pressure during pregnancy and organ dysfunction)
  • Very high body temperature, typically greater than 107.6ºF
  • Head injury may cause non-epileptic post-traumatic seizures
  • Celiac disease
  • Shunt failure
  • Hemorrhagic stroke
  • Cerebral venous sinus thrombosis (a rare type of stroke)
  • Multiple sclerosis
  • Electroconvulsive therapy (ECT) induces a seizure to treat major depression

When to Call 911 for Seizures

Seizures do not usually require emergency medical attention. Only call 911 if one or more of the following are true:

  • The person has never had a seizure before
  • The person has difficulty breathing or waking after the seizure
  • The seizure lasts longer than 5 minutes
  • The person has another seizure soon after the first one
  • The person is hurt during the seizure
  • The seizure happens in water
  • The person has a health condition like diabetes, heart disease, or is pregnant

How to Treat Seizures

General steps to help someone who is having any type of seizure:

  • Stay with the person until the seizure ends and they are fully awake. After it ends, help the person sit in a safe place. Once they are alert and able to communicate, tell them what happened in basic terms.
  • Comfort the person and speak calmly
  • Check to see if the person is wearing a medical bracelet or other emergency information
  • Keep yourself and other people calm
  • Offer to call a taxi or another person to make sure the person gets home safely

First aid for generalized tonic-clonic (grand mal) seizures

When most people think of a seizure, they think of a generalized tonic-clonic seizure called a grand mal seizure. In this type of seizure, the person may cry out, fall, shake, or jerk, and become unaware of what’s going on around them.

EMS team helping a patient on a stretcher

What you can do to help someone having a seizure:

  • Ease the person to the floor
  • Turn the person gently onto one side. This will help the person breathe.
    • (This position is not necessarily used by healthcare professionals, as they have access to more advanced airway management techniques, such as tracheal intubation.)
  • Clear the area around the person of anything hard, sharp, or potentially dangerous. This can prevent injury.
  • Put something soft and flat, like a folded jacket, under the person’s head.
  • Remove eyeglasses.
  • Loosen ties or anything around the neck that may make it hard to breathe.
  • Time the seizure. Call 911 if the seizure lasts longer than 5 minutes.

What NOT to do for someone having a seizure:

  • Do not hold the person down or try to stop his or her movements
  • Do not put anything in the person’s mouth. This can injure teeth or the jaw. A person having a seizure cannot swallow his or her tongue.
  • Do not try to give mouth-to-mouth breaths (like CPR). People usually start breathing again on their own after a seizure.
  • Do not offer the person water or food until he or she is fully alert

How Do EMTs & Paramedics Treat Seizures?

For all clinical emergencies, the first step is a rapid and systematic assessment of the patient. For this assessment, most EMS providers will use the ABCDE approach.

The ABCDE (Airway, Breathing, Circulation, Disability, Exposure) approach is applicable in all clinical emergencies for immediate assessment and treatment. It can be used in the street with or without any equipment. It can also be used in a more advanced form where emergency medical services are available, including emergency rooms, hospitals, or intensive care units.

Treatment Guidelines & Resources for Medical First Responders

Treatment guidelines for a seizure can be found on page 94 of the National Model EMS Clinical Guidelines by the National Association of State EMT Officials (NASEMSO). NASEMSO maintains these guidelines to facilitate the creation of state and local EMS system clinical guidelines, protocols, and operating procedures. These guidelines are either evidence-based or consensus-based and have been formatted for use by EMS professionals.

The guidelines include the following assessment:

  1. History
    • Duration of current seizure
    • Prior history of seizures, diabetes, or hypoglycemia
    • Typical appearance of seizures
    • Baseline seizure frequency and duration
    • Focality of onset, the direction of eye deviation
    • Concurrent symptoms of apnea, cyanosis, vomiting, bowel/bladder incontinence, or fever
    • Bystander administration of medications to stop the seizure
    • Current medications, including anticonvulsants
    • Recent dose changes or non-compliance with anticonvulsants
    • History of trauma, pregnancy, heat exposure, or toxin exposure
  2. Exam
    • Air entry/airway patency
    • Breath sounds, respiratory rate, and effectiveness of ventilation
    • Signs of perfusion (pulses, capillary refill, color)
    • Neurologic status (GCS, nystagmus, pupil size, focal neurologic deficit, or signs of stroke)

What Is the EMS Protocol for Seizure Emergencies?

Protocols for prehospital treatment of seizures vary by EMS provider and can also depend on the patient’s symptoms or medical history. Below are prehospital treatment protocols from the Epilepsy Foundation.

Prehospital Treatment: Convulsive Seizure in Progress

All Providers/BLS Response:

  • Assure scene safety, utilize BSI precautions, and advocate for patient respect, rights, and privacy.
  • Do not restrain movements.
  • Assess the level of consciousness (LOC).
  • Ask witnesses how long the seizure has been underway, precipitating factors, witnesses injury, and if they gave any medication or tried any treatments to stop the seizure prior to arrival. Determine if they witnessed any blank stare, cry, fall, loss of consciousness, shaking or shaking on one side of the body that progressed to full-blown seizure, staring, chewing movements of the mouth, followed by confusion and loss of awareness of environment.
  • Time the seizure from the beginning point supplied by bystanders. If the time extends beyond five minutes, transport actively convulsing patient to the hospital, with or without ALS, and notify receiving hospital.
  • If trauma is not suspected, turn the patient on one side into the recovery position to allow fluids in the mouth to drain and keep the airway clear.
  • Place something soft and flat under the head to protect against injury.
  • Protect patient’s privacy by removing nonessential bystanders.
  • Clear surrounding area of items that could injure the patient.
  • Institute active seizure management to protect life and safety until the seizure ends, as follows:

—    Make sure the mouth and airway are clear of any items that well-meaning but misguided bystanders may have inserted. Do not attempt to secure the tongue.

—    Loosen restraining garments around the neck and airway.

—    Determine the need for airway support (breathing may be arrested at the start of the seizure as muscles contract, resulting in a bluish tinge to tissues, and may be shallow during the postictal phase) if the airway is compromised by secretions, blood, or vomit, suction to remove.

—    Maintain an open airway and administer oxygen using an appropriate delivery device, such as a non-rebreather mask with 100% supplemental oxygen at 12- 15LPM. (If ventilations require assistance, consider inserting a nasopharyngeal airway (NPA) and maintain until the patient can control his or her airway.)

—    Assess the presence of a pulse and closely monitor pulse rate. This is critical in an actively seizing patient because of the risk of cardiac arrest due to low oxygen levels (hypoxia).

—    Initiate and monitor ventilatory and cardiac status. If available, utilize BP, EKG, pulse-oximetry, eTCO2, and other approved methods of monitoring the effectiveness of the cardiopulmonary systems.

—    Look for medical ID bracelet or necklace on patient or in patient’s wallet if authorized (“epilepsy”, “seizures”, “seizure disorder”, “diabetic”, etc.). Lack of medical history ID does not rule out epilepsy.

—    Check patient’s blood glucose level and treat as authorized.

—    Check patient’s temperature. Ensure hyperthermic patient (infant, child, and adult) experiencing seizure is not excessively dressed or bundled—cool using approved methods. Do not allow the patient to shiver, thus increasing metabolic rate and body temperature.

—    Obtain a focused history from witnesses, family, or accompanying individuals about any diagnosis of epilepsy and other precipitating events, history of pregnancy, diabetes, alcohol/drug use, history of abnormal ingestion, or known head injury.

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