Seizures

Table of Contents

(Adapted from an evidence-based guideline created using the National Prehospital Evidence-Based Guideline Model Process)

Aliases

Status epilepticus, febrile seizure, convulsions, eclampsia

Patient Care Goals

  1. Prompt cessation of seizures in the prehospital setting
  2. Minimizing adverse events in the treatment of seizures in the prehospital setting
  3. Minimizing seizure recurrence during transport

Patient Presentation

Seizures due to trauma, pregnancy, hyperthermia, or toxic exposure should be managed according to those condition-specific guidelines

Inclusion Criteria

Seizure activity upon arrival of prehospital personnel or new/recurrent seizure activity lasting greater than 5 minutes

Exclusion Criteria

None

Patient Management

Assessment

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

Treatment and Interventions

  1. If signs of airway obstruction are present and a chin-lift, jaw thrust, positioning, and/or suctioning does not alleviate it, place oropharyngeal airway (if gag reflex is absent) or nasopharyngeal airway
  2. Place pulse oximeter and/or waveform capnography to monitor oxygenation/ventilation
  3. Administer oxygen as appropriate with a target of achieving 94-98% saturation. Use bag-valve-mask ventilation if oxygenation/ventilation are compromised
  4. Assess perfusion
  5. Assess neurologic status
  6. Anticonvulsant Treatment
    1. Active seizure > 5 mins or recurrent seizures without resolution of postictal phase
      1. If vascular access is absent: midazolam 0.2 mg/kg (maximum dose 10 mg), IM preferred, or IN
      2. If vascular access (IV or IO) is present:
        1. Midazolam 0.1 mg/kg IV or IO, maximum 5 mg
          1. Repeat every 5 minutes as needed until seizure cessation
  7.  Glucometry
    1. Check blood glucose level
    2. Treat per the Hypoglycemia guideline
  8. Consider magnesium sulfate in the presence of seizure in the third trimester of pregnancy or post-partum [see the Eclampsia/Pre-eclampsia guideline]
  9. For febrile seizures, consider the following interventions after stopping the seizure, since the following interventions provide symptomatic relief for fevers but do not stop the seizure:
    1. Removing excessive layers of clothing
      AND/OR
    2. Applying cool compresses to the body
  10. Consider acquiring a 12-lead EKG following cessation of seizure in patients without a history of seizure to determine possible cardiac cause

Notes – Seizures