Exclusives, Patient Care

Prehospital Treatment of the Adult Patient Whose Seizure Has Stopped

Photo/National Highway Traffic Safety Administration

Seizures are a very common disease process and it is estimated that approximately 10% of the population in the United States will experience a seizure during their lifetime.1  There are approximately 200,00 new cases of seizures in the US each year and these make up approximately 5-8% of all emergency medical services (EMS) calls.2 Most paramedics take care of many seizure patients each year.3 

Seizures Make Up 5-8% of All EMS Calls 

There is ample literature on the optimal treatment of status epilepticus (a seizure that last longer than 10-20 minutes) for both in-hospital and prehospital care.4,5 The majority of seizures (over 90%) do not actually develop into status epilepticus, but are instead brief and self-limited.6 There is limited information on the best way to manage the seizure patient who has subsequently stopped seizing. This paper attempts to systematically discuss the elements of ideal care for these patients.  

Over 90% of Seizures Stop Within Several Minutes

As with all patients, managing the patient’s airway, breathing and circulation, or “ABCs,” is crucial. During a seizure, a patient may have transient hypoventilation with associated hypoxia. The most important goal is to keep the patient’s airway patent and maintain oxygenation. This will include keeping the patient supine, clear away surrounding objects, suctioning, supplemental oxygen, and occasionally a jaw thrust, nasopharyngeal airway, or ventilation assistance with a bag-valve mask. 

Related

Data from Alameda County (CA) EMS from 2013 to 2018 revealed that among patients with self-limited seizures, 6.5% received high flow oxygenation and 9.2% received any airway support (BVM, CPAP, intubation, or supraglottic airway). It is important to continuously monitor the patient’s airway, their oxygen saturation and possibly their end tidal CO2. 

A blood glucose test should be obtained to assess for hypoglycemia. While only 1% of seizures are the result of hypoglycemia, it is a quick and easy test to perform and hypoglycemia is an easily reversible etiology.7-9 In two studies, only 64-70% of seizure patients had a blood glucose measured during their clinical care.7,10 

A secondary survey should be done looking for signs of head trauma, either as a cause or a result of the seizure. The rate of cervical spine injury is rare in these patients.11 

The paramedic or EMT should attempt to obtain any history of a known seizure disorder or taking any antiepileptic medications.  


Treatment of the Adult Patient Who Has Stopped Seizing

  • Airway management (including opening the airway and suctioning) 
  • Pulse oximeter, supplemental oxygen for those with hypoxia 
  • Glucose measurement 
  • Secondary survey for signs of trauma 
  • Obtain history of epilepsy, seizure medication history as possible 
  • IM route of midazolam for recurrent seizure  

The frequency of a patient with a resolved seizure having another seizure episode in the field, as well as options for other routes of drug administration, can help inform the decision to place intravenous (IV) access in these patients. The incidence of patients having a second seizure have ranged from 6 to 12%.2,6,10,12 These numbers suggest that fewer than one in ten or one in twenty IV’s would be used to administer benzodiazepines.  

The RAMPART trial demonstrated the efficacy and time to seizure cessation was equal for both intravenous (IV) lorezapam and intramuscular (IM) midazolam.5 Recent studies also demonstrated midazolam is stable in an ambulance and doesn’t require refrigeration.13 Because of this, midazolam has become the benzodiazepine of choice in more EMS systems.14 The rate of IV placement in inactive seizure patients was 63% in a study from 2009 and was 34% in our more recent Alameda data.10 This new information has decreased the need to place an IV in the prehospital patient who has stopped seizing.

The IM Midazolam Option for the Infrequent Recurrent Seizure Makes It Less Necessary to Place an IV in These Patients.  

One recent study of a cohort of prehospital seizure patients noted that among these patients, 3.3% had a partially occluded airway, 6.8% had ongoing seizures and 59% had additional clinical problems.6 Approximately 29% of these patients had minor injuries requiring further evaluation.  


Rate of Medical Emergencies Among Seizure Patients 

  • Partially occluded airway – 3.3% 
  • Ongoing seizure – 6.8% 
  • Bruises, lacerations – 29% 

Not all patients who have experienced a seizure and recover are transported to an emergency department. The published non transport rate has ranged from 19-40%.15-18  

This is an area of limited research and consensus. These complex decisions require a combination of a good clinical assessment, review of the social situation, as well as consultation with the patient’s desires. Many EMS systems require base hospital contact for these types of patients. There have been two studies that performed follow up on non-transported seizure patients and found the rate of subsequent seizures to be 6-10%.12,16 About half of these patients with subsequent seizures required hospital admission.16

Non-transport Rates of Seizure Patients Range from 19-40%

The United Kingdom (UK) has the most experience in trying to define the optimal protocol in making these decisions. Current UK guidelines state that “when persons who have had an epileptic seizure are fully recovered and not at risk, and in the care of a responsible adult, consideration may be given to not transferring patients routinely to a hospital unless they wish to travel.”16 After an initial assessment, they can be referred to an alternative destination rather than the emergency department.  

The national guidelines that are in place for prehospital providers set by the Joint Royal Colleges Ambulance Liaison Committee assist in these decisions. Indications that uniformly prompt transport include pre-eclamptic seizures, patients suffering from three or more seizures in an hour, those experiencing their first ever seizure, and those who don’t have clear plans to have their condition monitored.  


Contraindication to Non Transport of a Prehospital Seizure Patient

  • First time seizure 
  • Fails to fully regain a normal or baseline mental status 
  • Pre-eclamptic seizures, pregnancy 
  • Not in alcohol or benzodiazepine withdrawal
  • More than one seizure in the past hour 
  • No clear plan for monitoring 

The protocols do allow patients to decline transport if they have a known epilepsy disorder, and can be supervised by someone to ensure no worsening of their condition. It is recommended that the paramedics measure vital signs, ensure the patient will contact their primary care provider, document the interaction, and have the patient sign documentation related to the decision to not be transported.  


Conditions Needed for Considering Non Transport of a Seizure Patient

  • Known history of epilepsy 
  • Full recovery of mental status 
  • No other injuries requiring attention 
  • Adequate plan for supervision 

Currently, paramedic education does not overtly teach about treating and releasing patients even though it is consistently done in a small group of seizure patients. Several recent qualitative studies of practicing paramedics demonstrated consistent concerns about non transport decisions and a desire for more training.3,16,17,19  

The prehospital treatment of the patient who has had a seizure and stopped seizing is less clear than those experiencing status epilepticus. As with all patients, the ABCs should rapidly be evaluated and managed. Paramedics may choose to forego IV placement in these patients when IM midazolam is an option in the local treatment protocol. In terms of disposition, non-transport after seizure is not uncommon. This practice may be considered safe with standard non-transport protocols if the patient has a known seizure disorder, has returned to their baseline mental state and has an alternative plan for their own treatment and monitoring. Alternatively, those with a first time seizure should strongly be urged to be transported.  

References

1. Pellock JM. Overview: definitions and classifications of seizure emergencies. J Child Neurol 2007;22:9S-13S. 

2. Michael GE, O’Connor RE. The diagnosis and management of seizures and status epilepticus in the prehospital setting. Emerg Med Clin North Am 2011;29:29-39. 

3. Kinney MO, Hunt SJ, McKenna C. A self-completed questionnaire study of attitudes and perceptions of paramedic and prehospital practitioners towards acute seizure care in Northern Ireland. Epilepsy Behav 2018;81:115-8. 

4. Alldredge BK, Gelb AM, Isaacs SM, et al. A comparison of lorazepam, diazepam, and placebo for the treatment of out-of-hospital status epilepticus. N Engl J Med 2001;345:631-7. 

5. Silbergleit R, Durkalski V, Lowenstein D, et al. Intramuscular versus intravenous therapy for prehospital status epilepticus. N Engl J Med 2012;366:591-600. 

6. Dickson JM, Taylor LH, Shewan J, Baldwin T, Grunewald RA, Reuber M. Cross-sectional study of the prehospital management of adult patients with a suspected seizure (EPIC1). BMJ Open 2016;6:e010573. 

7. Beskind DL, Rhodes SM, Stolz U, et al. When should you test for and treat hypoglycemia in prehospital seizure patients? Prehosp Emerg Care 2014;18:433-41. 

8. Shah MI, Carey JM, Rapp SE, et al. Impact of High-Fidelity Pediatric Simulation on Paramedic Seizure Management. Prehosp Emerg Care 2016;20:499-507. 

9. Remick K, Redgate C, Ostermayer D, Kaji AH, Gausche-Hill M. Prehospital Glucose Testing for Children with Seizures: A Proposed Change in Management. Prehosp Emerg Care 2017;21:216-21. 

10. Martin-Gill C, Hostler D, Callaway CW, Prunty H, Roth RN. Management of prehospital seizure patients by paramedics. Prehosp Emerg Care 2009;13:179-84. 

11. McArthur CL, 3rd, Rooke CT. Are spinal precautions necessary in all seizure patients? Am J Emerg Med 1995;13:512-3. 

12. Mechem CC, Barger J, Shofer FS, Dickinson ET. Short-term outcome of seizure patients who refuse transport after out-of-hospital evaluation. Acad Emerg Med 2001;8:231-6. 

13. McMullan JT, Jones E, Barnhart B, et al. Degradation of benzodiazepines after 120 days of EMS deployment. Prehosp Emerg Care 2014;18:368-74. 

14. Shtull-Leber E, Silbergleit R, Meurer WJ. Pre-hospital midazolam for benzodiazepine-treated seizures before and after the Rapid Anticonvulsant Medication Prior to Arrival Trial: A national observational cohort study. PLoS One 2017;12:e0173539. 

15. Galustyan SG, Walsh-Kelly CM, Szewczuga D, Bergholte J, Hennes H. The short-term outcome of seizure management by prehospital personnel: a comparison of two protocols. Pediatr Emerg Care 2003;19:221-5. 

16. Burrell L, Noble A, Ridsdale L. Decision-making by ambulance clinicians in London when managing patients with epilepsy: a qualitative study. Emerg Med J 2013;30:236-40. 

17. Sherratt FC, Snape D, Goodacre S, et al. Paramedics’ views on their seizure management learning needs: a qualitative study in England. BMJ Open 2017;7:e014024. 

18. Dickson JM, Asghar ZB, Siriwardena AN. Pre-hospital ambulance care of patients following a suspected seizure: A cross sectional study. Seizure 2018;57:38-44. 

19. Noble AJ, Snape D, Goodacre S, et al. Qualitative study of paramedics’ experiences of managing seizures: a national perspective from England. BMJ Open 2016;6:e014022.