First aid and medical intervention in epileptic seizures: convulsive emergencies
Epileptic seizures are the eighth most common emergency to which first aid professionals respond, accounting for almost 5% of all emergency calls
Epileptic seizures and convulsive emergencies: what they are and how to deal with them
An epileptic seizure is a period of uncontrolled electrical activity in the brain.
It can cause a range of outward symptoms, including: convulsions, minor physical signs, thought disturbances or a combination of symptoms.
The type of symptoms and seizure depends on the location in the brain of the abnormal electrical activity, the cause of the electrical disturbance and other factors such as the patient’s age and general health.
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Seizures can be caused by a wide range of conditions, including:
- Head trauma
- brain tumours
- poisoning
- Brain development problems before birth
- Genetic and infectious diseases
- Fever
In 70 per cent of seizure cases, it is not possible to find a cause for epilepsy, although genetic factors are likely to play a role.
What is an epileptic seizure?
An epileptic seizure is a period of excessive and abnormal brain activity.
Visible symptoms may vary from uncontrolled shaking movements involving a large part of the body with loss of consciousness (called a tonic-clonic seizure) to shaking movements involving only a part of the body with varying levels of consciousness (focal seizure) to a slight momentary loss of awareness (absence seizure).
In most cases, a seizure lasts less than 2 minutes and the affected person needs some time to return to normal: usually 3 to 15 minutes, but it can take hours.
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Seizures can be provoked or unprovoked
A provoked seizure is the result of a temporary event, such as low blood sugar, alcohol withdrawal, alcohol abuse along with prescription drugs, low blood sodium, fever, brain infection or concussion.
Unprovoked seizures may occur without a known or identifiable cause and are likely to be recurrent.
This type of seizure may be triggered by stress or sleep deprivation.
Diseases of the brain in which at least one seizure has occurred and the risk of recurrent seizures is known as epilepsy.
Any seizure lasting more than a short period is a medical emergency.
Any seizure lasting more than five minutes must be treated as an epileptic state, resulting in permanent brain damage or death.
The first seizure that occurs usually does not require long-term treatment with anti-epileptic drugs, unless a specific problem is found on an electroencephalogram (EEG) or brain imaging machine.
Generally, it is safe to complete the work-up for a single first-onset seizure as an outpatient treatment.
However, in many cases, what appears to be the first seizure was in reality preceded by other minor seizures that went unrecognised.
Here is more quick information on epileptic seizures:
- Epileptic seizures are a common medical condition: 10 per cent of people experience at least one seizure during their lifetime, in Western countries
- Epilepsy will develop in 3% of Americans by age 75.
- Provoked seizures occur in about 3.5 out of 10,000 people per year.
- Unprovoked seizures occur in about 4.2 out of every 10,000 people per year.
- After a seizure, the probability of having a second one is about 50 per cent.
- Almost 80% of people with epilepsy live in developing or low-income countries.
- In many places people are asked to stop driving until they have epileptic seizures for a specific period.
- Approximately 71% of emergency room calls for epileptic seizures result in transport.
- Pre-hospital interventions, such as airway management, IV access, benzodiazepine administration and blood glucose testing, are common.
- Although advanced life support (ALS) is standard in prehospital management of epileptic seizures, the range of interventions employed is wide.
Signs and symptoms of epileptic seizures
The signs and symptoms of epileptic seizures vary depending on the type of seizure. The most common type of seizure is the convulsive seizure (60 per cent).
Two-thirds of this type of seizure begin as focal seizures and become generalised, while one-third begin as generalised seizures. The remaining 40% of seizures are non-convulsive.
Focal crises
Focal seizures often begin with certain experiences, known as auras.
These may include sensory, visual, psychic, autonomic, olfactory or motor phenomena.
In a complex partial seizure, a person may appear confused or dazed and cannot respond to questions or directions.
Jerky activity may begin in a specific muscle group and spread to surrounding muscle groups, known as a Jacksonian march.
Unusual activities that are not consciously created can also occur: these are known as automatisms, which include simple activities such as smacking the lips or more complex ones such as trying to pick something up.
What are the different types of seizures?
All generalised seizures involve a loss of consciousness and usually occur without warning. There are six main types of generalised seizures:
Tonic-clonic seizures present with a contraction of the limbs followed by their extension and arching of the back for 10-30 seconds.
A cry may be heard due to the contraction of the chest muscles.
The limbs then begin to tremble in unison.
Once the shaking stops, it can take 10-30 minutes for the person to return to normal.
Tonic seizures produce constant contractions of the muscles.
The person may turn blue if breathing is impaired.
Clonic seizures involve shaking of the limbs in unison.
Myoclonic crises involve muscle spasms in a few areas or generalised throughout the body.
Absence seizures may be imperceptible, with only a slight head movement or blinking.
Often the person does not fall and can return to normal immediately after the end of the seizure, although a period of post-stroke disorientation may occur.
Atonic seizures involve the loss of muscle activity for more than one second. They usually occur bilaterally (on both sides of the body).
How long do seizures last?
A seizure can last from a few seconds to more than five minutes, which is known as status epilepticus.
Most tonic-clonic seizures last less than two to three minutes. Absence seizures usually last about 10 seconds.
What is the post-epileptic period?
After the active part of a seizure, there is usually a period of confusion called the post-ictal period, before a normal level of consciousness returns.
This period usually lasts three to 15 minutes, but can last for hours.
Other common symptoms are a feeling of tiredness, headaches, difficulty speaking and abnormal behaviour.
Psychosis after a seizure is relatively common and occurs in 6 to 10 per cent of people.
People often do not remember what happened during this period.
What are the causes of an epileptic seizure?
Epileptic seizures have several causes.
About 25 per cent of people who experience seizures have epilepsy.
Several conditions are associated with seizures, but are not caused by epilepsy.
These include most febrile seizures and those occurring in the vicinity of an acute infection, stroke or toxicity.
These seizures are known as ‘acute symptomatic’ or ‘provoked’ seizures and are part of seizure-related disorders.
In many cases, the cause is unknown.
These are the different causes of epileptic seizures common to certain age groups:
- Seizures in children are most commonly caused by hypoxic-ischemic encephalopathy, central nervous system (CNS) infections, trauma, congenital CNS abnormalities and metabolic disorders.
- The most frequent cause of epileptic seizures in children is febrile seizures. These occur in 2-5% of children between six months and five years of age.
- During childhood, well-defined epilepsy syndromes are generally observed.
- In adolescence and young adulthood, non-compliance with the drug regimen and sleep deprivation are potential triggering factors.
- Pregnancy, labour and delivery and the post-partum or post-natal period (after childbirth) can be risk moments, especially if certain complications such as pre-eclampsia occur.
- In adulthood, alcohol, strokes, trauma, central nervous system infections and brain tumours are the most likely causes.
- In older adults, cerebrovascular disease is a very common cause. Other causes are CNS tumours, head trauma and other degenerative diseases common in the older age group, such as dementia.
Metabolic causes of epileptic seizures
Dehydration can trigger seizures if it is severe enough.
Several metabolic disorders can cause seizures, including:
- Low blood sugar
- Low blood sodium
- Hyperosmolar non-ketotic hyperglycaemia
- Low blood calcium levels
- High blood urea levels
- Hepatic encephalopathy
- Porphyria
Structural causes of seizures
Cavernoma and arteriovenous malformation are treatable medical conditions that can cause seizures, headaches and bleeding in the brain.
Abscesses and brain tumours can cause seizures of varying frequency, depending on their location in the cortical region of the brain.
A) Medications
Both drug overdose and drug overdose can cause seizures, as can withdrawal from certain medications and drugs.
The most common drugs that cause seizures are:
- Antidepressants
- Antipsychotics
- Cocaine
- Insulin
- Lidocaine
Withdrawal crises, or delirium tremens, commonly occur after prolonged use of alcohol or sedatives.
B) Infections
Infections cause many cases of seizures and epilepsy, especially in Third World countries.
These infections include:
- Pig tapeworm infection. The pig tapeworm, which can cause neurocysticercosis, is the cause of up to half of all epilepsy cases in countries where the parasite is common.
- Parasitic infection. Parasitic infections, such as cerebral malaria, are a frequent cause of epileptic seizures in some countries. In Nigeria, parasitic infections are among the most common causes of seizures in children under five years of age.
- Infections. Many infections, such as encephalitis or meningitis, can cause seizures.
C) Stress
Stress can cause seizures in people with epilepsy.
It is also a risk factor for the development of epilepsy.
The severity, duration and timing of stress during development contribute to the frequency and susceptibility of developing epilepsy.
It is one of the most frequently reported triggering factors by patients with epilepsy.
Stress triggers a release of hormones that mediate the effect of stress on the brain.
These hormones act on both excitatory and inhibitory neural synapses, causing overexcitation of neurons in the brain.
Other causes of an epileptic seizure
Epileptic seizures can occur as a result of a number of conditions or triggers, including
- Elevated blood pressure
- Eclampsia (high blood pressure during pregnancy and organ dysfunction)
- Very high body temperature, typically above 107.6ºF
- Head trauma can cause non-epileptic post-traumatic seizures
- Celiac disease
- Shunt failure
- Haemorrhagic stroke
- Cerebral venous sinus thrombosis (a rare type of stroke)
- Multiple sclerosis
- Electroconvulsive therapy (ECT) induces an epileptic seizure to treat major depression.
When to call the Emergency Number in case of a seizure
Seizures usually do not require emergency medical attention.
Only call the Emergency Number if one or more of the following conditions are true
- the person has never had a seizure before
- the person has difficulty breathing or waking up after the seizure
- the seizure lasts more than 5 minutes
- the person has another seizure immediately after the first one
- The person is injured during the seizure
- The crisis occurs in water
- The person has a health condition such as diabetes, heart disease or is pregnant.
How to treat epileptic seizures
General steps to help a person who is having any kind of seizure
- Stay with the person until the seizure ends and they are fully awake. When finished, help the person sit up in a safe place. Once the person is alert and able to communicate, tell them what happened in elementary terms.
- Comfort the person and talk calmly
- Check if the person is wearing a medical bracelet or other emergency information.
- Keep calm for yourself and other people
- Offer to call a taxi or another person to make sure the person gets home safely.
First aid for generalised tonic-clonic (grand mal) seizures
When most people think of an epileptic seizure, they think of a generalised tonic-clonic seizure, called a grand mal seizure.
In this type of seizure, the person may scream, fall, tremble or shake and not be aware of what is happening around them.
What can be done to help a person who is having a seizure
- Slide the person to the ground
- Gently turn the person onto their side. This will help the person to breathe.
(This position is not necessarily used by health workers, who have access to more advanced airway management techniques, such as tracheal intubation).
- Clear the area around the person of any hard, sharp or potentially dangerous objects. This can prevent injuries.
- Place something soft and flat, such as a folded jacket, under the person’s head.
- Remove eyeglasses.
- Loosen ties or anything around the neck that may make breathing difficult.
- Time the crisis. Call the rescuers if the seizure lasts longer than 5 minutes.
What NOT to do in case of an epileptic seizure:
- Do not hold the person down or try to stop their movements.
- Do not put anything in the person’s mouth. This can injure the teeth or jaw. A person with epileptic seizures cannot swallow their tongue.
- Do not attempt mouth-to-mouth respiration (such as CPR). People usually resume breathing on their own after an epileptic seizure.
- Do not offer the person water or food until they are fully awake.
How do rescuers and paramedics treat epileptic seizures in the US?
For all clinical emergencies, the first step is a rapid and systematic assessment of the patient. For this assessment, most rescuers use the ABCDE approach.
The ABCDE approach (Airway, Breathing, Circulation, Disability, Exposure) is applicable in all clinical emergencies for immediate assessment and treatment. It can be used on the street with or without equipment.
It can also be used in a more advanced form where emergency medical services are available, including emergency rooms, hospitals or intensive care units.
Treatment guidelines and resources for first responders
Guidelines for the treatment of an epileptic seizure can be found on page 94 of the National Model EMS Clinical Guidelines of the National Association of EMT Officials (NASEMSO).
NASEMSO maintains these guidelines to facilitate the creation of clinical guidelines, protocols, and operating procedures for state and local EMS systems.
These guidelines are evidence-based or consensus-based and have been formatted for use by EMS professionals.
The guidelines include the following assessment:
A) Medical history
- Current seizure duration
- Previous history of seizure, diabetes or hypoglycaemia
- Typical seizure appearance
- Frequency and duration of baseline seizures
- Focality of onset, direction of eye deviation
- Concomitant symptoms of apnoea, cyanosis, vomiting, bowel and bladder incontinence, or fever
- Administration of medication to interrupt the seizure
- Current medication, including anticonvulsants
- Recent dose changes or non-compliance with anticonvulsants
- History of trauma, pregnancy, exposure to heat or toxins
B) Patient’s objective test
- Airway entry/permeability
- Respiratory sounds, respiratory rate and effectiveness of ventilation
- Perfusion signs (pulse, capillary refill, colour)
- Neurological status (GCS, nystagmus, pupil size, focal neurological deficit or signs of stroke).
What is the rescuers’ protocol for convulsive emergencies?
Protocols for pre-hospital treatment of seizures vary by provider, country and may also depend on the patient’s symptoms or history.
Below are the US Epilepsy Foundation’s prehospital treatment protocols.
Prehospital treatment: Convulsive crisis in progress
All BLS operators/response:
- Ensure the safety of the scene, use BSI precautions and uphold the respect, rights and privacy of the patient.
- Do not withhold movement.
- Assess level of consciousness (LOC).
- Ask witnesses how long the crisis has been ongoing, precipitating factors, witnesses’ injuries, and whether they administered medication or attempted treatment to stop the crisis prior to arrival. Establish whether they witnessed blank stares, crying, falling, loss of consciousness, trembling or shaking on one side of the body that progressed to a full-blown seizure, staring, chewing movements of the mouth, followed by confusion and loss of awareness of the environment.
- Time the seizure from the starting point provided by bystanders. If the time extends beyond five minutes, transport the patient with active convulsions to hospital, with or without ALS, and notify the receiving hospital.
- If trauma is not suspected, turn the patient onto their side in the recovery position to allow fluids to drain into the mouth and keep the airway clear.
- Place something soft and flat under the head to protect the patient from injury.
- Protect the patient’s privacy by removing non-essential bystanders.
- Clear the surrounding area of objects that could injure the patient.
Proceed with active seizure management to protect the life and safety of the patient until the seizure ends, as follows:
– Ensure that the mouth and airway are clear of any objects that bystanders may have inserted with good intentions but incorrectly. Do not attempt to block the tongue.
– Loosen restraining garments around the neck and airway.
– Determine the need for airway support (breathing may be interrupted early in the attack when muscles contract, resulting in bluish discolouration of tissues, and may be shallow during the postictal phase).
– Keep the airway open and administer oxygen using an appropriate delivery device, such as a nonrebreather mask with 100% supplemental oxygen at 12-15LPM. (If ventilations require assistance, consider inserting a nasopharyngeal airway (NPA) and maintain this until the patient is able to control their airway).
– Assess the presence of a pulse and carefully monitor the heart rate. This is critical in a patient with active convulsions because of the risk of cardiac arrest due to low oxygen levels (hypoxia).
– Initiate and monitor ventilatory and cardiac status. If available, use BP, ECG, pulse oximetry, eTCO2 and other approved methods to monitor the effectiveness of cardiopulmonary systems.
– Look for a medical identification bracelet or necklace on the patient or in the patient’s wallet, if authorised (“epilepsy”, “seizure”, “seizure disorder”, “diabetic”, etc.). The absence of a medical history does not exclude epilepsy.
– Check the patient’s blood glucose level and treat as authorised.
– Check the patient’s temperature. Ensure that the hyperthermic patient (infant, child and adult) with epileptic seizures is not overdressed or cooled by approved methods. Do not allow the patient to shiver, thereby increasing metabolic rate and body temperature.
– Obtain a focused history from witnesses, family members or carers on any diagnosis of epilepsy and other precipitating events, history of pregnancy, diabetes, alcohol/drug use, history of abnormal ingestion or known head injury.
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