In the past three years (2021–2024), Medical Priority Dispatch System™ (MPDS®) Protocol 12: Convulsions/Seizures was sixth in the lineup of most commonly used protocols, right after Protocol 10: Chest Pain/Chest Discomfort (Non-Traumatic) and before Protocol 29: Traffic Collision/Transportation Incident. Like these two other protocols, calls that are handled with Protocol 12: Convulsions/Seizures can vary in severity. As with every other Chief Complaint, the only way to sort out the high-acuity from the low-acuity is by finding out exactly what happened.
Generally speaking, a seizure can be caused by “[a]nything that interrupts the normal connections between nerve cells in the brain.” Potential causes range from a high fever, high or low blood sugar levels, or alcohol or drug withdrawal or overdose to past or present brain trauma or cardiac arrest. It’s not until a patient has two or more seizures with no known cause that they are diagnosed with epilepsy.1
Due to the many different potential causes of seizures, there are obviously many different names and definitions for each of them, and because of the nonvisual nature of prehospital response, the way the MPDS differentiates between the varying types of seizures is different from the clinical definitions that EMTs or doctors might use.
There are nine seizure definitions provided for you in the protocol, but there are three main definitions you should commit to memory:
“GENERALIZED Seizure: An abnormal firing of brain cells, usually resulting in a period of unconsciousness and full-body jerking movements. Also known as convulsions, epilepsy, or fits.” This is probably what you picture when someone says the word “seizure,” and indeed, this is by far the most common type of seizure reported to dispatch. GENERALIZED seizures generally last from one to two minutes, although with some conditions they last a little bit longer. If you get through the Key Questions and they’re still seizing, pay special attention—this is unusual and may signify a more serious, underlying condition.
“FOCAL Seizure: Localized twitching of a part of the body, such as the hand, arm, leg, or face, in a conscious patient.” This might be less familiar to you. It’s less dramatic than a GENERALIZED seizure and might go unnoticed completely in certain settings. For the purposes of prehospital triage, an ABSENCE seizure (“a brief ‘staring spell’ in a conscious patient”) will be handled like a FOCAL seizure.
“ATYPICAL Seizure: A seizure that is mentioned as different from or not normal as compared to the patient’s previous seizures.” This is important! The caller knows the patient best, and if they’re telling you that something is wrong, chances are they’re right. One of the Axioms states that “[the] mention of an ATYPICAL seizure is associated with poor patient outcomes and may indicate a serious underlying cause unrelated to a seizure disorder.” Ignoring the caller’s observation could be a fatal decision.
Why is that? Because there’s another condition you should seriously consider if someone calls with a seizure complaint—cardiac arrest.
According to Brett Patterson, Academics and Standards Associate and the Chair of the Medical Council of Standards for IAED™, you should consider the following when contemplating GENERALIZED seizure versus cardiac arrest: 1) Is the patient breathing after the seizure? 2) Is the patient waking up after the seizure? 3) Is the patient getting better or worse after the seizure?
Context matters. “We want the calltaker to consider the scenario, not just the status of breathing,” Patterson said. Knowing exactly what happened is key because cardiac arrest and GENERALIZED seizure have very different presentations. Additionally, either of these scenarios may be initially described as what the caller saw—a fall. That’s why knowing exactly what happened is so important. A seizure can cause a fall, as can cardiac arrest. In fact, this outcome is nearly guaranteed if the patient was previously standing. However, it is extremely unlikely that a patient will become unconscious from ground-level fall trauma, making unconsciousness an important clue. Sudden unconsciousness following a ground-level fall is indicative of cardiac arrest in the absence of a seizure complaint, especially when the complaint is fall, not seizure.
There are other important clues as well. Most people can recognize a GENERALIZED seizure, so listen carefully to that complaint description. If they seem unsure or the complaint is vague—e.g., “it’s kind of/sort of like a seizure,” “a weird/strange seizure,” or “s/he’s twitching a little bit”—being suspicious and diligent is a good thing. Even if the patient has epilepsy, cardiac arrest should be suspected if the complaint is not typical of a seizure. Any hedging on the caller’s part should make you consider the possibility that it could be a cardiac arrest.
“History is important, too,” wrote Patterson, “because our data shows that the complaint of seizure is 75 times less likely to be associated with cardiac arrest outcome when a history of seizures is known.”2
Speaking of history, what if the chosen Chief Complaint is Protocol 12: Convulsions/Seizures but a recent history of drug overdose is discovered during Key Questioning? No worries. Determinant Descriptor 12-C-6 for OVERDOSE/POISONING (ingestion) is available on Protocol 12, as are important PDIs for the seizure patient. And one can then use the Target Tool to access Narcan instructions if opioid/narcotic overdose is suspected.
If the seizure patient isn’t breathing or has INEFFECTIVE or AGONAL BREATHING after Key Questioning, you will read the PDI telling the caller to go get a defibrillator (AED) if one is available. The AED will be able to tell if the patient needs a shock administered, so don’t worry about potentially harming a patient who doesn’t actually need a shock. If the pads of a defibrillator are attached to a patient who has had a seizure and is breathing ineffectively but is NOT in cardiac arrest, the AED will simply say “No shock needed.” It’s better to have an AED and not need it than to not have one and need it. Do not instruct the patient to perform CPR on a patient who is still seizing, but be prompt with CPR instructions if the patient has stopped seizing and breathing is absent or not effective.
Anti-epileptic drugs relate to a group of medicines typically prescribed to epileptic patients, and such medicines may be available at the scene. If the caller asks if they should administer the patient’s epilepsy medicine, tell them to use the medication as instructed by their doctor.
Both Patterson and the protocol itself recommend staying on the line with seizure patients until it is clear that they are waking up and their condition is improving. Note that staying on the line and checking breathing often when the patient is not awake is mandated by the red question mark symbol at PDI-e and by the related CEI below the PDIs. This is because you want to make certain the patient who had the seizure is getting better, not worse. Someone having a GENERALIZED seizure will get better after the seizure as time passes. Slow but regular breathing will increase in frequency, and their level of consciousness will also improve. But someone having a hypoxic seizure because of a cardiac arrest will continue to deteriorate—their color will get worse, and their breathing will diminish.
In the unlikely event that you haven’t already taken a seizure call, you likely will relatively soon, and it’s best to be prepared for all eventualities. While it’s interesting to watch videos and listen to audios of the different types of seizures to prepare, don’t worry if you can’t remember every definition and its symptoms exactly. Focus on the patient’s status and its progression, and the protocol will guide you the rest of the way.
Sources
1. “Evaluation of a First-Time Seizure.” Johns Hopkins Medicine. hopkinsmedicine.org/health/conditions-and-diseases/epilepsy/evaluation-of-a-firsttime-seizure (accessed Jan. 26, 2024).
2. Patterson B. “What Is an EMD to Do?” The Journal of Emergency Dispatch. 2017; November 27. iaedjournal.org/what-is-an-emd-to-do (accessed Jan. 26, 2024).
