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Seizure

Category: Medical Sources: raw/protocols/nm-sop-guidelines-treatment-2022.pdf; UCLA EMT Ultimate Study Guide (2026) Last updated: 2026-05-06

Overview

A seizure is abnormal, excessive, synchronous neuronal discharge in the brain resulting in transient involuntary motor, sensory, or behavioral events. Most seizures self-terminate within 1–3 minutes and are followed by a postictal period of altered consciousness, confusion, or lethargy. Status epilepticus — seizure activity lasting >10 minutes or multiple seizures without return to baseline — is a medical emergency requiring ALS intervention.

EMT-B priorities: protect the patient from injury during the seizure, manage the airway in the postictal phase, check blood glucose, obtain thorough history, and transport.

Key Points

  • Never restrain a seizing patient — injury from forceful restraint; you cannot stop a generalized seizure
  • Do not put anything in the mouth — the "swallowing tongue" myth is false; a tongue cannot block the airway; bite sticks cause injury
  • Position lateral (recovery position) after seizure stops — airway protection, secretion drainage
  • Distinguish: generalized tonic-clonic (classic grand mal) vs. focal/partial vs. absence seizures
  • The postictal phase mimics other emergencies — always perform glucometry
  • Status epilepticus (>10 min or multiple seizures without recovery) requires ALS intervention — benzodiazepines are the first-line treatment, which is ALS/EMT-I/P scope
  • Common causes: known epilepsy, hypoglycemia, head trauma, hypoxia, stroke, fever (pediatric), alcohol withdrawal, eclampsia (pregnant)
  • New-onset seizure in a non-epileptic patient has a serious underlying cause until proven otherwise

Assessment Relevance

History (history-taking): - SAMPLE: Known seizure disorder? Current medications and compliance (skipped doses)? Prior seizures (frequency, type, duration)? Events before seizure (aura, fall, trauma)? Drug or alcohol use? - Specific key questions: - "Did the patient have a seizure or is this the patient's baseline?" — family/bystanders are essential - Pregnant? (eclampsia) - Recent fever? (febrile seizure in child, CNS infection in adult) - History of head injury? - Last BGL? - Duration of seizure — this determines status epilepticus and ALS need

Physical exam (secondary-assessment): - LOC (AVPU): postictal patients are typically V or P initially, recovering over minutes - Airway: saliva, blood (tongue bite), secretions - Pupils: may be temporarily dilated or sluggish post-seizure - Injuries from the seizure: tongue laceration, head trauma from fall, shoulder dislocation - Glucometry: mandatory — hypoglycemia causes seizures - Fever? (consider febrile seizure in pediatric patients) - Incontinence: suggests generalized seizure

Procedures

During an active seizure: 1. Protect from injury: clear hard objects, cushion head, do not restrain 2. Note start time — duration determines status epilepticus and ALS need 3. Position: laterally if possible for secretion drainage 4. Do NOT put anything in mouth 5. Apply supplemental oxygen via face mask or NRB mask if available

Post-ictal phase: 1. Primary assessment (primary-assessment): airway (suction if needed), breathing, circulation 2. Position lateral (recovery position) if LOC impaired 3. Check blood glucose — treat if <60 mg/dL per diabetic-emergencies 4. Obtain history from patient/bystanders 5. Transport to appropriate facility 6. Request ALS intercept if status epilepticus or multiple seizures

If status epilepticus (>5 min, or >2 seizures without lucid interval) — NM Protocol directs anticonvulsants: - This is ALS scope — request intercept; transport immediately - EMT-B: large bore IV/IO isotonic fluid at TKO rate in preparation for ALS medications

NM Protocol Notes

From NM EMS Treatment Guidelines (2022):

EMT-B scope: - Airway management as indicated - Oxygen via face mask or NRB mask; BVM if oxygenation/ventilation compromised - Initiate transport; consider ILS/ALS intercept - Check blood glucose; if <60 mg/dL, treat per Diabetic Emergencies guideline - Initiate large bore IV/IO isotonic at TKO rate if IV medications are needed - Cardiac monitoring

Anticonvulsant medications (for seizure >5 min or >2 seizures without lucid interval — primarily ALS/EMT-I/P scope): - MIDAZOLAM (preferred route: buccal/intranasal/IM first, then IV) - Adult: 5–10 mg IN/IM (max single dose 10 mg; may repeat once after 10 min); OR 2–5 mg SIVP/IO (repeat every 5 min up to 10 mg total) - Pediatric: 0.2 mg/kg IN/IM (max 5 mg; may repeat once after 10 min); OR 0.1 mg/kg SIVP/IO (repeat every 5 min up to 10 mg total) - DIAZEPAM - Adult: 2–10 mg IV/IO/IM slow, with IV running open - Pediatric: 0.05–0.1 mg/kg IV/IO - Note: apnea in children after diazepam; rectal diazepam not recommended per NM protocol

NM protocol-specific notes: - Buccal, intranasal, or intramuscular routes preferred as first-line for anticonvulsants — IV should follow initial treatment, not precede it - Rectal anticonvulsant administration is NOT recommended - For febrile seizures (after stopping the seizure): remove excess clothing; Acetaminophen 15 mg/kg PO if able to swallow (max 650 mg) - If third trimester pregnant or recently postpartum and seizing: consider magnesium sulfate — refer to Childbirth Complications guideline - Cardiac monitoring throughout

NREMT Relevance

Common NREMT question angles: - Never restrain during seizure; never insert anything in mouth - Postictal state: patient appears unresponsive/confused — this is expected; airway management priority - Recovery position post-seizure for airway protection - Blood glucose check in all seizure patients - Status epilepticus definition: >10 minutes continuous OR multiple seizures without recovery - Benzodiazepines for status epilepticus — ALS scope; EMT-B role is airway management and ALS intercept - Febrile seizure in pediatric: cooling measures, transport

NREMT Differentiators

Seizure vs. Syncope

Feature Seizure Syncope (Fainting)
LOC duration Minutes (ictal phase) Seconds to <1 minute
Movement during event Tonic-clonic jerking, stiffening Limp, flaccid
Postictal confusion YES — hallmark NO — alert immediately on recovery
Incontinence Common Rare
Tongue bite Common Rare
Witnesses report Convulsions, rigid then jerking "Just fell over, woke up right away"
Recovery Gradual (minutes of confusion) Rapid (seconds)

KEY DIFFERENTIATOR — Postictal Confusion: If patient is confused/lethargic after LOC, it's a seizure until proven otherwise. A syncopal patient wakes up quickly and is oriented. Postictal confusion is THE distinguishing feature on the NREMT.

NREMT TRAP: Patient found unresponsive, then confused — could look like stroke. Check BGL immediately (hypoglycemia mimics seizure and stroke). Differentiate with history from bystanders — did they witness jerking?

Seizure Types

Type Description EMT Recognition
Generalized Tonic-Clonic (Grand Mal) Full-body stiffening (tonic) → rhythmic jerking (clonic) Classic seizure; incontinence, tongue bite, postictal
Absence (Petit Mal) Brief staring spell, no convulsions; 5–30 sec Patient appears to "blank out" momentarily; no postictal
Focal (Partial) One limb or side of body; may stay conscious Rhythmic jerking of one extremity
Febrile Pediatric; triggered by rapid fever rise Child with fever; brief, usually self-limiting
Status Epilepticus Seizure >10 min OR multiple without recovery ALS intercept immediately

Status Epilepticus

Definition: Seizure lasting >10 minutes continuously, OR two or more seizures without the patient returning to baseline between them.

  • Life-threatening — hypoxia, lactic acidosis, brain injury from prolonged neuronal firing
  • EMT-B action: airway management, O2, BVM if needed, ALS intercept, transport
  • First-line treatment: benzodiazepines (midazolam, diazepam) — ALS scope

KEY DIFFERENTIATOR — Status Epilepticus: Start timing the seizure immediately. If >5 minutes (NM protocol) or >10 minutes (general criterion) without stopping, request ALS intercept and treat as status epilepticus. Do not wait for it to stop on its own.

Postictal Phase Management

The postictal phase is a high-NREMT-yield scenario:

  1. Airway: patient is unconscious or drowsy — lateral recovery position, suction secretions
  2. Breathing: apply O2 via face mask; BVM if breathing inadequate
  3. Check BGL — hypoglycemia causes seizures; treat if <60 mg/dL
  4. Neuro: AVPU every 5 minutes; expect gradual improvement
  5. Assess for injuries: tongue laceration, head trauma (fall), shoulder dislocation (from violent jerking)
  6. History from bystanders: duration of seizure, number of episodes, known epileptic?

NREMT RULE: Postictal patient who doesn't improve within 10–15 minutes, or who has focal neuro deficits after the seizure → consider stroke or TBI. Treat as priority transport.

Common Seizure Causes (AEIOU-TIPS Subset)

Cause EMT Clue
Hypoglycemia Always check BGL — hypoglycemia is the most treatable cause
Hypoxia Check SpO2 — airway/breathing problem causes seizure
Head trauma History of fall or mechanism
Eclampsia Third-trimester pregnant patient — treat as OB emergency
Fever (pediatric) Child with fever — febrile seizure
Alcohol withdrawal Known alcoholic, stopped drinking
Epilepsy (med non-compliance) Known epileptic who skipped medications
Stroke New-onset seizure in older adult — consider cerebrovascular event

Sources

  • raw/protocols/nm-sop-guidelines-treatment-2022.pdf — Seizure protocol (p. 43–44)