Seizure & Status Epilepticus
Objective: Protect the airway, check glucose, time the seizure, and treat status per protocol — then do not call every post-ictal deficit “just a seizure” without a stroke/trauma look.
Why This Is Hard
Bystanders want you to “stop it.” Shoving objects in the mouth causes dental trauma. Status epilepticus (ongoing seizure or recurrent seizures without recovery) is an airway and brain emergency. Post-ictal Todd’s paralysis looks like a stroke. Hypoglycemia looks like a seizure. Your sequence has to be boring and the same every time.
What Counts as Status (Education)
- ILAE 2015 operational timing for convulsive status epilepticus uses a 5-minute t1 (when treatment should be started). Recurrent seizures without recovery between them also count.
- Still seizing when EMS arrives is treated as status in ENLS/RAMPART-style teaching — do not wait for a hospital EEG or a perfect clock if they have been convulsing on your arrival.
- IM midazolam is an evidence-based route when no IV is available (RAMPART). Protocol owns which benzodiazepine, which route, and the dose. This site does not publish milligrams.
During the Seizure
- Scene safety. Do not pin them prone. Protect the head. Nothing in the mouth.
- Time the event. Ask when it started — “a few minutes” is not a clock time.
- Airway position, suction ready, oxygen as indicated. SpO₂ will look terrible while they are not breathing; it often recovers as the convulsion stops.
- Glucose as soon as you can do it safely.
- Benzodiazepines for ongoing/status seizures per protocol (see the benzo lesson). This page does not publish a dose.
After It Stops
- Recovery position if they are breathing and no trauma concern requiring otherwise.
- Reassess ABCs. Persistent hypoxia or gurgling means suction and airway, not a second history interview.
- Focal deficit that does not clear: treat as stroke pathway in parallel (LKW, glucose already done).
- Fever, neck stiffness, pregnancy, head trauma, overdose — say it on the radio. First seizure in an adult is not “refuse and sleep it off” without protocol/medical control rules.
Field Pitfalls
- Bite sticks. Holding them down so hard they cannot breathe.
- Skipping glucose.
- Calling status “just a seizure” because it paused for five seconds.
- Protect the head — nothing in the mouth — time the event
- Glucose as soon as it is safe
- Still seizing or recurrent without recovery → status pathway
- Post-ictal focal deficit → stroke-style look (LKW)
Practice
60-second drill
Out loud, 20 seconds: time → nothing in mouth → suction ready → glucose → benzodiazepine pathway if still seizing. Then one sentence on what you do if a new arm weakness persists after the convulsion stops.
Related: Benzodiazepines, Stroke.
Sources & Further Study
Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.
- ILAE 2015 definition and classification of status epilepticus (convulsive t1 = 5 minutes; recurrent seizures without recovery)
- RAMPART (NEJM 2012) — IM midazolam is an evidence-based route when IV access is not available
- NASEMSO National Model EMS Clinical Guidelines (2022)
- Protect airway, check glucose, time the seizure, treat status with protocol benzodiazepines. Post-ictal focal deficits still get a stroke look.
Education only. Apply learning within your protocols and medical direction. This is not clinical care guidance.
Check Your Understanding
Street decisions from this lesson only. After you check, the key is highlighted. Education practice — not a certification exam.