The document discusses seizures, their classification, and treatment considerations for EMS. It describes how seizures are classified based on mental status (simple vs complex) and laterality (partial vs generalized). Generalized seizures involve both hemispheres and can cause loss of consciousness, while partial seizures originate in one hemisphere and may or may not affect consciousness. Status epilepticus is a medical emergency defined as continuous seizure activity. The document provides guidance for EMS on safely managing patients during and after seizure activity without forcing interventions.

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SEIZURES

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This is why it is very sensitive to lack of blood flow and oxygen.

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The muscle cells have energy stores (glycogen) and even the
heart has an ability to store energy (more mitochondria than any
other cell in your body). But the brain has nothing.

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If things aren’t fixed pretty quickly, then altered mentation progresses to
irritability/agitation, seizure, coma and finally death.

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Seizures that occur in the cerebral cortex and spread bilaterally
impair consciousness and are known as generalized seizures (grand
mal). This is the most common type of seizure EMS is called to treat.

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Seizures in the brain stem almost always result in sudden jerk-like movement.

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Any area of the brain can be adversely affected by seizure activity, thus
resulting in side effects besides the expected headache, abdominal pain,
thirst and need for sleep that usually is observed after most generalized
seizures (grand mal).

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Likewise, seizures may result from insults in any of the areas of the
brain.

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In a nutshell – anything that irritates the brain or deprives it of nutrients
has the potential to cause a seizure.

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Catecholamine is the "fight-or-flight" hormones that are released
by the adrenal glands in response to stress.
ATP transports chemical energy within cells for metabolism.

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Because acidosis accelerates and predisposes to brain necrosis, the
older the patient, the less tolerated the seizure.

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Because seizures do not affect consciousness uniformly, partial simple
and partial complex seizures are often confusing to both the health care
provider and the EMR

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Getting a good history is extremely important.

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Posturing and grinding teeth are brain stem reflexes that will occur as a
response to stimulation (such as noise, touch, pain, etc.). During a
seizure, irritating stimuli (such as loud noises) may be interpreted as a
threat [remember the reptilian system?] and a response may occur.

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Not all seizures are recurrent. For many people they are single, isolated
events. However, for other patients, seizures may become recurrent. In
that case the condition of recurrent seizures are referred to as “epilepsy”.

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Epilepsy is the condition of recurrent seizures. Exactly why this
happens is theory. Some think it is due to an undeveloped bit of tissue
in the brain that becomes the focus of irritation as a child grows. Others
think it is due to hypoxia during the perinatal period. Still others think it
is due to some type of trauma.

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In 1981 there was an attempt by neurologists to reclassify seizures.
This resulted in two main types of seizures, generalized and partial

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Classification of Seizures Based
on . . .
Mental Status:
Seizures that DO NOT
cause a change in mental
status are known as
“simple.”
Seizures that do cause a
change in mental status
are known as “complex.”
Unilateral vs Bilateral:
Seizures that stay in one
hemisphere are known as
“partial” seizures.
Seizures that cross from
one hemisphere to the
other are known as
“generalized.”
When any seizure is witnessed, it is important to note the following: 1)
mental status and type of alteration, (i.e. total unconsciousness to lack of
awareness of environment to full awareness); 2) what activity is
observed, such as stiffening of muscles, contraction of muscles, tics, etc.;
and 3) where the activity occurred, such as all extremities, one side of the
body or isolated to one body part.

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Seizure Classification
A Generalized Seizures
 􀀨involves both hemispheres
 􀀨 loss of consciousness
 􀀨 bilateral and symmetric
B. Partial (Focal) Seizures
 􀀨 involves one hemisphere
 􀀨 consciousness may or may not be impaired
 􀀨 2 types: Simple and Complex
C. Other (unclassifiable – lack of data)

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Seizure Classification
Generalized (involves both
hemispheres)
􀂻 Absence (no loss of muscle tone
􀂻 Tonic/Clonic (unconsciousness)
􀂻 Tonic
􀂻 Clonic
􀂻 Myotonic
􀂻 Atonic

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Seizure Classification
Generalized seizures are typically tonic-clonic
(grand mal) seizures. Tonic-clonic refers to
rapid alternating between the two actions.
Usually the first movement observed is a
stiffening or spasm of skeletal muscles. This is
called tonus or the tonic action. The next
action is a rapid contraction of skeletal
muscles. This is called clonus or the clonic
action.
Most of the seizures EMS is called for involves
tonic-clonic seizures.

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Seizure Classification
There are other types of seizures that are
generalized: tonic seizures involve muscle
stiffening; clonic seizures involve muscle
contraction; myoclonic seizures involve a
sudden, involuntary jerking of the body; and
atonic seizures involve sudden loss of muscle
tone. Both myoclonic and atonic seizures result
in falls.

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Seizure Classification
►Partial (focal) Seizures (begin locally)
􀂻 Simple (no loss of consciousness)
Motor
Sensory
Autonomic
Psychic
􀂻 Complex (impaired consciousness)
􀂻 Partial becoming generalized

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Seizure Classification
Partial seizures stay in one hemisphere. Partial
simple seizures usually involve one limb or one
body part such as the cheek or lips. These may be
motor in nature with rhythmic jerking movement
of the extremity or body part; or sensory, such as
a feeling of floating; or autonomic such as lip
smacking; or psychic such as reliving a past
memory. These seizures may also cross over into
another hemisphere and result in a generalized
seizure.

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Absence seizures is the term used for petit mal seizures which are more
common in children and usually noticed by teachers first. The child may
be characterized as a “day dreamer”. These seizures rarely last more
than 60 seconds and have no postictal phase. Usually there is a change
in these seizures around the time of puberty, either the seizures will end
(most frequent) or will evolve into some other type of seizure activity.

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Generalized tonic-clonic seizures have a postictal phase. The postictal phase
usually lasts longer than the skeletal muscle activity. This implies that a seizure
lasting 10 minutes may have a 20 minute postictal phase. This doesn’t always
happen. However, it is best to be aware that it might. The exceptions are absence
and febrile seizures which do not have a postictal phase.

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Status epilepticus is the term for a seizure that continues. It is a threat
to life, especially in the adult. The older the adult, the more serious the
consequences. Status epilepticus can break bones, tear muscles,
cause severe acidosis and extreme hypoxia

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The approach for EMS considers any patient who is still having seizure-like
activity when EMS arrives, is a patient that needs to be treated.

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Partial simple seizures are not commonly treated in the field. Since the
person who has them is still alert, oriented and knows what is
happening, these seizures are generally managed by the patient
themselves. Rarely is EMS called.

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Since there is altered mental status, but not necessarily unconsciousness, the
patient may be mistaken for a drug overdose or a mental illness such as
schizophrenia or a catatonic state. These patients are, however, extremely
sensitive to touch and sound. Do NOT touch them unless you have taken time to
assure that your presence is accepted. Usually a family member is present and
they may be able to help you determine the best course of action.

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The normal postictal period for anyone with a generalized or partial complex seizure is
usually longer than the observable event itself. A normal postictal phase consists of a
gradual and sustained improvement of level of consciousness.

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You may note that the patient is unresponsive but there doesn’t seem to be
much physical activity. You may think the patient is in the postictal phase. To
check, look for muscle twitching, nystagmus or eye deviation. These are subtle
signs that the seizure activity is continuing but not much energy left for gross
motor activity. The implication is the person’s blood glucose level is low. This is
especially true of children.

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There are subtle signs of a biologic event, such as staring off in the distance.
Generally, if you look at the eyes and nystagmus has stopped, there is no
deviation and there is no subtle twitching of muscle groups, signs of the
seizure have stopped and the patient is entering the postictal phase

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First make sure the patient is safe, remove all furniture or anything that may harm
the patient. For small patients, rolling them on their side and bracing them on your
thighs may help keep the airway clear. Just make sure you aren’t in the way of a
moving extremity. If they are banging their head or another body part, find a
pillow, blanket or cushion to place beneath the effected part. Do NOT use your
hands. Help control the environment. Irritants such as loud noises may serve as a
stimulant. Anything that stimulates the patient may actually extend the length of
the seizure.

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Do NOT try to force anything in the mouth of a seizing patient

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Partial complex seizures are difficult to treat in the field. Once this condition is
suspected, remove all unnecessary persons and noise from the area. Use family
members to help you determine how to approach and what is the best management.
Usually, speaking slowing in a normal tone of voice and approach from the side is
helpful. The victim will not be able to understand what you say, but will interpret your
tone of voice as threat or non-threat.

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Once the postictal phase has started, do not assume all seizure activity has completed.
Be observant for another seizure and suspect status if it recurs, treating accordingly.