Emergency Management of

Seizures
Deb Funk, M.D., NREMT-P
Medical Director;
Albany MedFLIGHT
Saratoga EMS

Goals
Review

definitions, classifications and

pathophysiology
Discuss several patient scenarios
Assessment
Management

Discuss

current pharmacologic techniques

for management of ongoing seizures

Definitions
Seizure:

episodic abnormal neurologic functioning

caused by abnormally excessive activation of
neurons

Epilepsy:

a clinical condition characterized by

recurrent seizures

status

epilepticus: >30min seizure or >2 seizures

w/o recovery

Epidemiology
6-10%

of US population will have at least 1

afebrile seizure during their lifetime
1-2% have recurrent seizures
100,000 new cases in US annually
Adult first time seizures represent 1% of all ED

visits

incidence

highest <20 and >60yrs

Male > female

Classification
primary/secondary
Primary do not have obvious source
Secondary occur as a result of many types of

injuries/illnesses

generalized/focal
generalized involves abnl neuron activity in both cerebral

hemispheres
tonic/clonic, absence, myoclonic
focal involve 1 hemisphere
simple partial, complex partial, secondarily generalized

Generalized: Tonic-Clonic
Seizure
most

common
vague prodromal symptoms
tonic phase
trunk flexion-->extension, eyes deviate up,

mydriasis, vocalization
clonic

phase

tonic contractions alternate with muscle atonia

Generalized: Tonic-Clonic
contd
loss

of consciousness and autonomic alterations

during both phases
any focality noted during or after seizure may point
to the origin
hypocarbia (resp alkalosis/lactic acidosis), transient
hyperglycemia, CSF pleocytosis, elevated serum
prolactin
post ictal phase
coma-->confusional state-->lethargy, myalgia, headache

Pathophysiology of Seizures
in

general not well understood

neuronal recruitment is a common theory and has
been demonstrated in some studies
propagation of abnormal electrical impulse to adjacent

neurons along variable paths

the pathway involved usually determines the type of
seizure seen

generalized sz: focus deep and midline, involving the RAS

focal sz: more limited focus of activity/does not cross midline

Pathophysiology contd
typically

self limited

bursts of electrical discharges from the focus

terminate

reflex inhibition/neuronal exhaustion/alteration of

neurotransmitter balance.

Case 1
2

yr old previously healthy boy given

Tylenol for tactile temp by Mom. Twenty
min later had shaking episode.

What

more do you need to know?

What do you look for on exam?
What is your assessment and plan?

Febrile Seizure: Definitions

generalized

seizure occurring during a sudden rise

in temp in absence of intracranial infection or
other defined etiology
Simple: single event lasting less than 15 min
(90%)
Complex: exceed 15 min, occur more than once in
24hr period, or show focal motor manifestations
(higher rate of epilepsy)

Febrile Seizure: Statistics

2-5%

of children
most common pediatric seizure
30% will have a single recurrence (1/2 of
these will have multiple)
age of onset 6mos-5yrs (peak 18-24 mos)
family history conveys 2-3 times the general
population risk
2-9% develop afebrile seizures

Febrile Seizures: Assessment

History
PMH/AMPLE (immunization hx)
Recent illness
Details of event

Physical

Exam

MS/ABCs
Detailed neuro exam
Search for source of fever (in ED)

Febrile Seizure: management

ABCs

and monitor VS
Check blood glucose
abort seizure if ongoing (benzodiazepine)
IV/IM/PR administration

Cooling

measures
Transport to appropriate hospital

Reference REMO Protocol P-10 Pediatric Seizures

Case 2
42

y/o WM reportedly had a seizure at a

Phish concert. Friends think he takes
Dilantin.

What

more do you need to know?

What do you look for on exam?
What is your assessment and plan?

Epilepsy: Considerations
multiple

different epilepsy syndromes

breakthrough vs noncompliance
provoking factors

Epilepsy: statistics
Affects

1.5-2.5 million people in US

30-40% patients with epilepsy continue to
have breakthrough seizures despite
appropriate medical management

Epilepsy: assessment
History
determine:

intercurrent illness/trauma
Sleep deprivation
drug or etoh use
drug drug interactions
med compliance
recent change in dosing regimen
change in seizure pattern

Physical

Exam

Evidence of injury
Detailed neuro exam

Epilepsy: management
MS/ABCs
Monitor

VS and check blood glucose

Treat any injuries
Transport to appropriate hospital
IV and ALS monitor:
Multiple seizures
Single seizure without return to baseline state
Atypical seizure (type or pattern)
Reference REMO Protocols M-2 Active Seizures

Case 3
19

y/o female college student who fell out

at a party. Witnesses describe generalized
seizure activity. Confused/combative upon
EMS arrival.

What

more do you need to know?

What do you look for on exam?
What is your assessment and plan?

Differential Considerations

Syncope
Hyperventilation syndrome
Prolonged breathholdling
toxic and metabolic disorders
ETOH abuse/withdrawal
hypoglycemia
other CNS event (TIA, migraine, narcolepsy)
movement disorders (hemiballismus, tics)
Psychiatric disorders (fugue state, panic attacks)
Functional Disorders (pseudoseizure)

Characteristics of Seizure
abrupt

onset
brief duration (90-120 sec)
Altered mental status (except simple partial)
purposeless activity
unprovoked (except febrile)
postictal state (except simple partial and
absence)

First Time Seizure: Statistics

Rates

of recurrence 23-71%
Predictors of recurrence
Etiology of seizure
EEG findings

Historical Information

History vital in determining the appropriate ED approach

description of event
preceding aura
loss of bowel/bladder
duration of event
post ictal period
clinical context (precipitating factors?)
febrile illness
head trauma
sleep deprivation
other stressor
baseline seizure pattern

Initial Assessment
No

longer seizing: recovery position, IV, glucose,

medication history
preventative medications?

Is

seizing still:

Airway assessment (npa, suction, ETT prn)

protect patient from self injury
pulseox, monitor, IV access, blood glucose

(hypoglycemia is the most common metabolic cause of sz, but can

also be a result of prolonged szneeds to be treated aggressively
either way)

abortive therapies

Detailed Physical Exam

Done

after cessation of seizure activity

assess for injuries
posterior shoulder dislocation common

Temperature

assessment
Bedside glucose determination
Cardiac Monitor
Assess for presence of systemic disease, toxic exposure,
infection, focal neurologic event
serial neurologic exams
Todds paralysis: focal deficit following a seizure lasting less than

48 hours

Typical Physical Exam

Findings
HTN,

tachycardia, tachypnea during seizure

activity
incontinence, vomiting, tongue biting
low grade temp common after generalized
seizure

First Time Seizure:

Management
MS/ABCs
Monitor VS and check blood glucose
IV access (draw labs)
Cardiac monitor
Treat any injuries
Transport to appropriate hospital
No benzodiazepines unless seizure recurs or
continues

Reference REMO Protocols M-2 Active Seizures

Case 4
6

y/o WF presents s/p seizure. During

transport EMS witnesses a generalized
tonic-clonic event.
What more do you need to know?
What do you look for on exam?
What is your assessment and plan?

Status Epilepticus:
Considerations
continuous

clinical or electrical seizure activity or

repetitive seizures with incomplete neurological
recovery for >30 min
Continuous seizure activity for >10min should be
treated as if in SE (most seizures last 1-2 min)
impending SE if >3 tonic-clonic seizures within
24hrs
Generalized or Partial

Status Epilepticus:
Considerations
Generalized convulsive activity results in:
hypoxia
hyperpyrexia
BP instability and cerebral dysautoregulation
respiratory and metabolic acidosis
hyperazotemia/hypokalemia/hyponatremia
hyperglycemia followed by hypoglycemia
marked elevations of prolactin, glucagon, growth
hormone and corticotropin
rhabdomyolysis may produce myoglobinuria and renal
failure

Status Epilepticus: Statistics

195,000

episodes in US annually
42,000 deaths annually in US
50% due to acute CNS insults (anoxia, TBI, CVA,
neoplasm, infection)
peds: fever/infection
elderly: cerebrovascular disease

20%

in epileptic patients during med adjustment

or due to noncompliance
30% undetermined etiology

Status Epilepticus:
Assessment
HPI/AMPLE
Detailed

exam and history taking done once

seizure has been stopped and patient has
been stabilized

 Rapid

Status Epilepticus:
Management

Seizure control

Patients do better when seizure treated by EMS

Step

1:

ABCs

NPA, OPA, ETT

If RSI needed use only short acting paralytics

blood glucose
Cardiac Monitor
IV access
HPI/PE

Further specific treatment based upon circumstance

Status Epilepticus:
Management
Step

2: 1st line drugs

Step 3: 2nd line drugs
Step 4: 3rd line drugs
The

longer the seizure continues;

The more difficult it is to stop

The more likely permanent CNS injury will

occur

Medication Options
First

line

diazepam (Valium) IV/ET/IO/PR

lorazepam (Ativan)IV/IN
midazolam (Versed)IV/IM/IN

Second

line

phenytoin/fosphenytoin
phenobarbital

Lastly

induction of anesthesia w. cont. EEG

Infusions of midazolam, diprivan, valproic acid, pentobarbital

Inhaled isoflurane

Rectal Route of
Administration

Surface area=200-400 cm2 (1/10,000 absorptive area of small

intestine)
Highly vascularized
Passive diffusion

Rates of Diazepam
Absorption by Various
Routes

Moolenaar F. Int J Pharma. 1980.

First Line Anticonvulsants

DRUG

ADULT DOSE

PEDS DOSE

Diazepam

.2mg/kg up to
20mg at 2mg/min

.2-.5mg/kg IV/IO CNS/CV/Resp

or .5-1.0mg/kg PR depression
up to 20mg
Onset 1min
Lasts 20-30min
(longer PR)

Lorazepam

.1mg/kg IV max
10mg at 2mg/min
**Intranasal use
promising

.05-.1mg/kg IV

.1mg/kg IV up to
10mg at 1mg/min
or .2mg/kg IM
**Intranasal use
promising

.15mg/kg IV
.2mg/kg IM

Midazolam

**Intranasal use
promising

**Intranasal use
promising

OTHER INFO

CNS/CV/Resp
depression
Onset 2min
Lasts >12hrs
Less depression
Onset 1min
Short duration

Second Line Anticonvulsants

DRUG

ADULT DOSE

PEDS DOSE

OTHER INFO

Phenytoin

20mg/kg IV at
50mg/min

20mg/kg IV at
1mg/kg/min

Hypotension,
arrhythmias
Onset 10-30min
Long acting

Fosphenytoin

15-20PE/kg IV
10-20PE/kg IV
at 150mg/min or at 3mg/kg/min
20PE/kg IM
or 20PE/kg IM

Can be given
faster
Expensive
Same times once
given

Phenobarbital

10-20mg/kg IV
at 30mg/min or
20mg/kg IM
May rpt to
40mg/kg total

Resp/CV
depression
Rapid onset,
long acting

Same as adult

Third Line Anticonvulsants

DRUG

ADULT

PEDS

OTHER

Midazolam

.15mg/kg IVthen As adult

1mcg/kg/min
up 1mcg/kg/min
q15

Propofol

1-3mg/kg IV
then 210mg/kg/h

Caution in
CNS/Resp/CV
<12yrs (reports depression
of met. Acidosis)

Valproic Acid

20-40mg/kg IV
over 5min then
5mg/kg/h

As adult

hypotension

Pentobarbital

5mg/kg IV at
25mg/min

As adult

Titr.to EEG
ETT/CV support

Isoflurane

Via genl ETT

anesthesia

As adult

Titr. to EEG
ETT/CV support

CNS/Resp/CV
depression

Conclusions
Seizures

are common presenting problems

to EMS.
Status epilepticus must be treated rapidly to
avoid significant morbidity.
Familiarity with protocols and medication
options is crucial.

Questions?

References

American College of Emergency Physicians: Clinical policy

for the initial approach to patients presenting with a chief
complaint of seizure who are not in status epilepticus. Ann
Emerg Med. May 1997;29:706-724.
ACEP, AAN, AANS, ASN: Practice parameter: Neuroimaging
in the emergency patient presenting with seizure (summary
statement). Ann Emerg Med. 1996;28:114-118.
Smith, BJ. Treatment of Status epilepticus. Neurologic Clinics.
May 2001;19:2
Bradford JC, Kyriakedes CG. Evaluation of the patient with
seizures: an evidence based approach. Emergency Medicine
Clinics of North America. Feb 1999;17:1

References contd

Goetz. Epileptic Seizures. Textbook of Clinical Neurology, 1st ed.

WB Saunders 1999. pp1062-1079
Pollack CV. Seizures. Rosens Emergency Medicine: Concepts
and Clinical Practice, 5th Ed. Mosby 2002. Pp145-149
Hanhan UA, Fiallos MR, Orlowski JP. Status Epilepticus.
Pediatric Clinics of North America. Jun 2001;48:3
Lahat E, Goldman M, Barr J, et al. Comparison of intranasal
midazolam with intravenous diazepam for treating febrile
seizures in children: prospective randomised study. BMJ. July
200;321:83-86
Hirtz D, Ashwal S, Berg A, et al. Practice parameter: evaluating
a first nonfebrile seizure in children. Neurology. Sept 2000;55:5