Skip to content

Seizure

Category: Medical Sources: raw/protocols/nm-sop-guidelines-treatment-2022.pdf Last updated: 2026-04-03

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

Sources

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