The protocol for Seizures:



Let’s break it down!

Seizures are not uncommon events.  Seizures carry a lifetime incidence of 11%, but the far majority are caused by infants and geriatric patients… neither of which represent the common soldier.  Seizures can be caused by many different ailments and processes. Although it can be a disorder by itself (Ex. Epilepsy), it can also be a symptom of something greater.  Seizures can occur because of head trauma, serious infections, drugs, etc.  Seizures can also manifest themselves quite differently from person to person.  For a better understanding, let’s look at the different types:

In general, there are 2 main types of seizures: Generalized and Focal

Screenshot 2020-02-22 at 5.15.39 AM

Generalized Seizures: Affects BOTH sides of the brain, and it includes:

  • Tonic-Clonic Seizures (Grand Mal): involves a stiffening of the muscles (tonic phase) following by rapid jerking movements (clonic phase).
  • Absence Seizures (Petit Mal): involves a short period of time in which you lose a sense of awareness or “space out.


Focal Seizures: Affects 1 portion of the brain; it includes:

  • Simple Focal Seizures: affects a small portion of the brain; still maintains awareness but may involve twitching or a change in sensation, such as a taste or a smell
  • Complex Focal Seizures: affects a small portion of the brain, but may make the patient confused or dazed for a few minutes

If you really want to get into the weeds with it, here’s an awesome Osmosis Video on it:

The kind of seizure that we’re looking out for is the most common one: the Tonic-Clonic seizure.  If you’ve never seen one before, check out these videos:


As you can see, these seizures don’t typically last very long.  Often, the patient will have stopped seizing by the time we arrive on scene and may even be past the postictal state (period of confusion and somnolence).  The question then becomes…. did they actually have a seizure?  Or was it just a syncopal episode?  This is an important question to answer in terms of treatment and prevention for the future.  Two things you can look for are urinary incontinence and tongue biting.  Although these things don’t definitively rule in or rule out a seizure, they’re clues that can be taken into consideration.

Although it’s still a hotly debated topic about what exactly is causing seizure patients to die when they do, the evidence shows that hypoxia (lack of oxygen) may play a strong role.  During seizures, it can be difficult for patients to maintain control of their airway and deep, adequate ventilation.  With that being said, the first two steps are crucial in treatment.  Placing them on their side will help drain any excess saliva build-up and a good non-re-breather or nasal canula will help oxygenate.

Image result for left lateral recumbent position with oxygen

And of course, don’t put anything in their mouth!  It used to be common practice to place a spoon in the mouth of a seizing patient to prevent tongue swallowing, but this is largely a myth.  Although it is common for patients to bite their tongue, it is impossible for them to bite their tongue off completely and cause a choking hazard.

Most patients will have stopped seizing on their own by the time we arrive to help.  If they don’t, then we’re in trouble.  Any seizure or series of seizures lasting longer than 5 minutes is considered Status Epilepticus, which carries a fairly high mortality (20% after the first episode).  Without a doubt, these seizures MUST be stopped.

Your weapons of choice, Diazepam and Midazolam, are both benzodiazepines that work on GABA receptors in the brain to essentially slow down the central nervous system and prevent excitatory signals from firing off.  Midazolam is generally preferred for active seizures because it works faster and it can be given intranasally.  As you can imagine, it’s very difficult to get an IV on an actively seizing patient.

If you’ve never given a medication intranasally before, here’s a quick rundown video of how to do it:

Remember how I said seizures could just be a symptom of something greater?  No seizure should be accompanied by a fever unless your patient happens to be is a 3-year-old child having a febrile seizure (different discussion).  In adults, if the patient has a fever with their seizure, be sure to consider meningitis, malaria, or any other infectious process!

If you want to learn more about febrile seizures in kids though, check out this video:

Most seizing patients will stop seizing on their own, or at least respond well to a round of benzos.  But regardless of whether or not they continue to seize, they need to be taken to a higher level of care for follow up and preventative management for future seizures.


Good luck out there!




  • EMRAP CorePendium: Adult Seizures
  • Logroscino G, Hesdorffer DC, Cascino G, et al. Mortality after a first episode of status epilepticus in the United States and Europe. Epilepsia. 2005;46 Suppl 11:46–48. doi:10.1111/j.1528-1167.2005.00409.x
  • Annegers JF, Hauser WA, Lee JR, Rocca WA. Incidence of acute symptomatic seizures in Rochester, Minnesota, 1935-1984. Epilepsia. 1995;36(4):327–333. doi:10.1111/j.1528-1157.1995.tb01005.x
  • Advanced Tactical Paramedic Protocols Handbook. 10th ed., Breakaway Media LLC, 2016.

Brandon Simpson, PA-C
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