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F02: Seizures
Mike Sugimoto
Updated:
Reviewed:
Introduction
A seizure is the result of abnormal and sudden electrical activity in the brain, and can be caused by a wide range of conditions. Seizures can be a symptom of an underlying acute medical or neurological condition, or they can lack a clear etiology (as in the case of epilepsy). The main goals of seizure management are to stop the seizure, protect the patient from secondary injury such as aspiration or trauma, evaluate for and treat potentially reversible causes, and provide safe, expeditious transport to hospital.
Essentials
- Seizures can be traumatizing for bystanders and family. First-time seizures are particularly disturbing.
- Benzodiazepines are the first line therapy for active seizures
- Consider important causes of seizures:
- Hypoglycemia
- Hypoxia
- Traumatic head injury
- Drug overdose, intoxication, or withdrawal
- Exposure to toxic substances
- Electrolyte disturbances
- Cerebrovascular accidents
- Infections and fevers, including infectious of the central nervous system
- Care more specifically for the patient than the patient’s seizures
- For women who are, or who may be pregnant, consider the role of eclampsia:
- For children, see CPG M04 or M12
Additional Treatment Information
- Protection of the airway, and maintenance of effective oxygenation and ventilation is of critical importance. Profound hypoxia can develop in patients with prolonged seizure activity.
- As a general rule, paramedics should consider controlling seizures in patients who continue to seize after their arrival on-scene: taking travel time into consideration, these patients are often seizing for upwards of ten minutes by the time an ambulance crew makes contact.
- Patients with known seizure disorders are often prescribed benzodiazepines to be administered by family or caregivers. Paramedics must be aware of this possibility and adjust their dosing strategies accordingly.
- Do not provide “prophylactic” benzodiazepines to patients who are not currently seizing.
- The duration of the postictal phase is often variable. Patients may exhibit a wide range of behaviors, none of which are intentional, and none of which should prompt intervention from law enforcement. Wherever possible, paramedics should provide patients with a quiet, non-stimulating space to recover from their seizure, while protecting them from further harm.
Referral Information
Patients with well-established seizure disorders, who experience a single, self-limited seizure, may refuse transport to hospital in consultation with CliniCall.
Interventions
First Responder (FR) Interventions
- Protect the patient from physical harm
- Provide supplemental oxygen as required
- Attempt to place pharyngeal airway if required to maintain patency (do not force mouth open)
Emergency Medical Responder (EMR) & All License Levels Interventions
- Provide supplemental oxygen to maintain SpO2 ≥ 94%
- Consider use of nasopharyngeal airway.
- Consider and search for reversible causes
- Obtain capillary blood sample
Primary Care Paramedic (PCP) Interventions
- Consider supraglottic airway device in patients who are no longer seizing but remain profound obtunded and require airway management
Advanced Care Paramedic (ACP) Interventions
- When indicated, control seizures
- MIDAZOLam intramuscularly. May repeat once if seizures continue and if IV access is unsuccessful.
- Obtain vascular access
- If seizures continue: MIDAZOLam intravenously. May repeat every 2-5 minutes as required.
- Modify doses for smaller / elderly individuals
- Contact CliniCall for additional dosing instructions
- Consider intubation or advanced airway management for seizures refractory to treatment or continued profound unconsciousness
Critical Care Paramedic (CCP) Interventions
- Attempt to arrest seizures with anticonvulsants. Consider:
- In unstable patients refractory to conventional treatments, consider the use of neuromuscular blockade and intubation to maintain physiologic norms.
- EPOS consultation is required prior to paralysis.
- Consider evaluating serum electrolytes in searching for underlying (and potentially treatable) causes.
- Secure airway if required.
Evidence Based Practice