There is nothing quite like the adrenaline spike of a dispatch call for a “seizing patient.” You arrive on scene to find chaos, family members panicked, and a patient in the throes of convulsions. But here is the truth about seizure treatment EMTs must master: the real medical work often happens after the shaking stops.
This guide breaks down the entire protocol, from scene safety to the critical postictal assessment, so you can manage these calls with confidence and clinical precision.
Scene Size-Up and Safety First
Before you even touch the patient, you need to secure the environment. Seizure patients don’t follow the rules of physics, and furniture becomes a weapon.
- BSI and Scene Safety: Gloves and eye protection are non-negotiable. Saliva and possibly blood are often present.
- Scan for Hazards: Look for sharp corners, glass, or water (especially if a seizure occurred in the bathroom).
- Make Space: Move furniture away from the patient. You don’t want them flailing their arm into a glass coffee table.
Pro Tip: If the patient is on a bed or couch, do not leave them unattended unless you can safely lower them to the floor. The risk of a fall injury during a seizure is high and often overlooked.
Managing the Active Seizure Phase
It is easy to feel helpless watching someone seize. Your instinct might be to stop it, but you cannot. Your job here is protection and documentation.
Stay Calm and Time It This is your most critical task. Look at your watch or your truck clock. Knowing the exact onset time is vital for the hospital and ALS to determine if the patient is in Status Epilepticus.
Protect, Don’t Restrain Let’s be honest: trying to hold down a seizing patient is a losing game. It usually results in injury to you or the patient, and it does not stop the seizure. Instead, pad the area around their head with a pillow or a folded jacket.
Clinical Pearl: Status Epilepticus is traditionally defined as a seizure lasting longer than 5 minutes, or recurrent seizures without a return to consciousness between them. If you hit that 5-minute mark, consider an ALS intercept immediately if available.
The Postictal Phase: The “Postictal Paradox”
The shaking stops. Silence falls. This is the Postictal Paradox: the patient looks “restful,” but this is often the most dangerous time for their airway and the most challenging for your assessment.
The patient is often confused, agitated, or combative (postictal state). Their airway is at risk due to relaxed tongue muscles and possible vomiting.
Airway Management Steps:
- Position the patient in the recovery position (lateral recumbent) to allow secretions to drain.
- High-flow oxygen via non-rebreather mask is standard protocol.
- Have suction ready. Vomiting during the postictal phase is common and can lead to aspiration.
Common Mistake: Shaking a postictal patient and yelling, “Can you hear me?” to wake them up. This often triggers a “fight or flight” response, making an already confused patient combative. Speak softly and minimize stimulation.
Focused History: SAMPLE & OPQRST
You need to figure out why this happened. Is this epilepsy, or is something new killing brain cells? Witnesses are your best source of information here because the patient usually won’t remember.
Key History Questions to Ask:
- Does the patient have a history of epilepsy?
- Have they missed any medications?
- Was there a “warning” or aura before the seizure?
- Did the patient lose bladder or bowel control? (Common in tonic-clonic seizures but less common in fainting)
The “Mimic” Check Always keep “The Deadly Dozen” in mind. Seizures are often symptoms of other underlying issues.
- Hypoglycemia: Always check a blood glucose level. A brain without sugar acts like a seizing brain.
- Head Trauma: Did they fall and seize, or seize and fall?
- Toxicological Ingestion: Alcohol withdrawal, stimulants, or recreational drugs.
Scenario: Imagine you walk into a party. A 21-year-old male is seizing. Everyone says he’s “drunk.” Don’t assume. Check the glucose. He could be a diabetic suffering from severe hypoglycemia. Treat the patient, not the reputation.
Assessment Checklist: Trauma and Vitals
Seizures are violent. Muscles contract at maximum force. This causes trauma that you might miss if you aren’t looking closely.
Rapid Trauma Assessment:
- Check the tongue. Lacerations are common.
- Look for shoulder dislocations or posterior hip dislocations.
- Check for compression fractures in the spine if they fell from a height or onto a hard surface.
Vital Signs:
- Blood pressure is often transiently elevated post-seizure (Cushing’s reflex).
- Pulse rate is usually tachycardic.
- SpO2 is critical—watch for desaturation during the postictal phase.
Common Myths vs. Reality
We have all heard the “old wives’ tales” about seizure care. Unfortunately, some of them persist even among newer providers. Let’s set the record straight.
| Myth | Reality | Why It Matters |
|---|---|---|
| Put a spoon/wallet in their mouth | NEVER put anything in the mouth. | This causes broken teeth, oral trauma, and airway obstructions. It is physically impossible to “swallow the tongue.” |
| Hold them down to stop it | Never restrain. | Restraining muscles in full contraction can tear muscle fibers or break bones. It also increases agitation. |
| They need water immediately | Nothing by mouth (NPO) initially. | The gag reflex is often suppressed. Giving water too early is a choking hazard. |
Winner: Follow the protocol of Time, Protect, and Position. It is the safest and most evidence-based approach.
Determining Transport Priority and Necessity
The decision to transport isn’t always automatic, though it rarely goes wrong if you choose to transport.
High Priority (Emergency Transport/ALS):
- First-time seizure.
- Seizure lasting > 5 minutes (Status Epilepticus).
- History of head trauma or stroke.
- Persistent altered mental status (AMS) or low SpO2.
- Diabetic patient with unknown blood sugar (treat hypoglycemia protocol if indicated).
Low Priority / Potential Refusal:
- Known epileptic with a “typical” seizure for them.
- Fully returned to normal baseline mental status.
- Checked blood glucose (normal).
- No injuries sustained.
Key Takeaway: Even if the patient feels fine, strongly advise transport after a first-time event. A seizure is a symptom, not a diagnosis. They need a CT scan and an EEG to find the root cause.
Conclusion
Seizure calls test your ability to remain calm amidst chaos. Remember to prioritize your safety, accurately time the event, and aggressively manage the airway during the postictal phase. By treating the patient—not just the shaking—and checking for mimics like hypoglycemia, you ensure the best possible outcome. You’ve got this.
Have you encountered a seizure mimic that caught you off guard? Share your story in the comments below—let’s learn from each other’s close calls!
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