⏱ Seizure Timer — Start Immediately on Arrival
00:00
Tap START when seizure activity is observed
1
Scene Size-Up & BSI ▼
- BSI: Gloves — fall injuries may involve blood
- Medication bottles: Anti-epileptics (Keppra, Dilantin, Depakote, Tegretol) — missed dose common trigger. Note any medications.
- Clues at scene: Alcohol containers, drug paraphernalia, medical alert bracelet
- Trauma: Note MOI — did the patient fall and hit head during seizure? C-spine consideration if trauma occurred.
- Bystanders: Ask "how long has it been going?" — critical for duration assessment
- Scene safety: Agitated post-ictal patients can be combative — position yourself accordingly
- Determine # of patients — carbon monoxide, toxic exposure can cause multiple victims seizing
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2
During Active Seizure — What to Do NOW
Do NOT restrain. Do NOT put anything in the mouth. Restraint worsens injury. Teeth clenching prevents airway access — you cannot place an oral airway during active seizure.
- ⏱ TIME THE SEIZURE — start timer above NOW. Duration drives every decision.
- Protect the head: Place jacket, blanket, or padding under the head
- Clear area: Move furniture, hard objects away from patient
- Position: Gently roll to lateral (side) position if possible — reduces aspiration risk
- Suction: Ready and available — use after seizure ends if secretions present
- Oxygen: Have ready — defer application until seizure activity stops
- Observe and document: Type of movements (focal vs. generalized?), eye deviation, incontinence, tongue biting, duration, any aura reported
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Seizure Duration > 5 Minutes?
Or: no recovery between back-to-back seizures?
Or: no recovery between back-to-back seizures?
YES — Status Epilepticus
ALS IMMEDIATELY. Prepare BVM. High-flow O2. Maintain airway. Do not delay transport. Benzodiazepines required (ALS).
NO — Continue Assessment
Allow seizure to terminate. Prepare for post-ictal care. Monitor duration and document. Maintain safe position.
4
Post-Ictal Assessment
Normal post-ictal state: confusion, fatigue, sleepiness lasting minutes to hours; headache; muscle soreness.
- AVPU: Track LOC — should progressively improve toward baseline
- Glucose: Check BGL ALWAYS — hypoglycemia causes seizures AND can masquerade as post-ictal state
- Pupils: Equality, reactivity, size
- Injury survey: Head trauma, tongue lacerations, shoulder dislocation, back/limb injuries from fall
Red Flags — Not routine post-ictal: Focal neuro deficit lasting >30 min (Todd's paralysis vs. stroke), not returning to baseline within expected time, first-time seizure in adult, fever + seizure, head trauma, pregnancy
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5
SAMPLE History ▼
- Known seizure disorder? What type? How frequent?
- Last seizure: When was the last episode? Same as usual?
- Anti-epileptic medications: Keppra, Dilantin, Depakote, Tegretol, Lamictal — missed doses? This is the most common cause of breakthrough seizure.
- Alcohol/drug use: Alcohol withdrawal seizures — last drink? Illicit drug use?
- Fever/infection: Febrile seizure in children; CNS infection in adults
- Head trauma: Recent or current — intracranial bleed?
- Pregnancy: Eclampsia — critical diagnosis. BP elevated?
- Prior stroke: Scar-related seizure focus
- Diabetes: Last BGL, last meal, insulin taken?
- Sleep deprivation: Common seizure trigger in epileptics
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⚡ Step 6 — Interactive Seizure Type Classifier
📋 Classify the Seizure Type
Select observed features (tap all that apply)
Select observed features above to classify seizure type
📖 Step 7 — Seizure Causes Reference
| Cause | Key Clues / Action |
|---|---|
| Epilepsy / Missed Meds Most Common | Known seizure disorder, anti-epileptic Rx present, missed dose history |
| Hypoglycemia | ⚠ Check BGL every patient — direct cause and mimic. Treat if < 60 |
| Stroke / ICH | Focal seizure, new onset, age >50, anticoagulants, headache "worst ever" |
| Febrile Seizure | Child 6 mo–5 yr with fever — usually brief and benign, but rule out meningitis |
| Toxic / Drug-Related | Cocaine, stimulants, alcohol withdrawal, drug paraphernalia at scene |
| Eclampsia | ⚠ Pregnant patient + seizure + hypertension = obstetric emergency |
| Trauma / Head Injury | Post-traumatic seizure — assume intracranial injury until proven otherwise |
| Hyponatremia / Metabolic | Marathon runners, psychiatric patients (water intoxication), dialysis patients |
| CNS Infection | Fever + headache + seizure + stiff neck = meningitis/encephalitis until ruled out |
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Management
Post-Seizure Care (All Patients)
BLS Position: Recovery (lateral) position — reduces aspiration risk. Do not leave patient supine if unresponsive.
BLS O2: 15L NRB after seizure stops. Titrate to SpO2 ≥ 94% once patient cooperative.
BLS Suction: Clear airway of secretions, blood, vomit. Have suction ready immediately.
BLS BGL check: Every seizure patient. Oral glucose if BGL < 60 and patient conscious and can swallow.
BLS Vitals: BP (eclampsia?), HR, RR, temp, SpO2, pupils.
BLS Febrile seizure — cooling: Remove excess clothing, cool environment. Reassure parents — usually brief and benign. Transport and evaluate for meningitis.
ALS Status epilepticus: Midazolam 10 mg IM or 5 mg IN / Diazepam 5–10 mg IV / Lorazepam 2–4 mg IV. IV access × 2. Continuous monitoring.
BLS Transport: First-time seizure — transport ALL. Known epileptic with typical seizure — strongly recommend transport, patient may refuse with proper refusal. Status epilepticus — immediate ALS and transport.
🚨 ALS Intercept Criteria
🔴 ALS Request — Any of the following:
- Status epilepticus — seizure > 5 minutes or no recovery between seizures
- First-time seizure with no clear cause
- Seizure + fever (possible meningitis/encephalitis)
- Seizure + pregnancy (eclampsia — obstetric emergency)
- Post-ictal LOC not improving after 30 minutes
- Focal neurological deficit persisting (stroke? Todd's paralysis?)
- Traumatic head injury + seizure (intracranial bleed)
- BGL < 60 not correcting with oral glucose (IV dextrose needed)
- Suspected alcohol withdrawal seizure (risk of recurrence and delirium tremens)
- Respiratory distress or SpO2 not improving with O2