2 Seizures and Status Epilepticus

Classifying seizure presentations

Classify seizures by how they begin and by their features. In particular, note whether a seizure begins focally or is generalized from the start, and whether consciousness is preserved or impaired.

Onset, consciousness, and seizure features

A focal seizure may include behavioral arrest or automatisms, such as repetitive lip movements. A focal seizure with impaired consciousness involves impaired awareness and/or responsiveness; both are considered when assessing consciousness. The older term for this type is focal impaired-awareness seizure.

A seizure that begins with a focal symptom, such as tingling in one hand while the person remains responsive, and then progresses to loss of consciousness and bilateral stiffening and jerking is classified as focal to bilateral tonic–clonic. Its focal beginning distinguishes it from a generalized tonic–clonic seizure, which is generalized from the start.

A generalized absence seizure may appear as a brief episode of abruptly stopping activity and staring, followed by an immediate return to activity without confusion. Brief staring alone does not confirm the diagnosis; clinical assessment and often EEG help distinguish it from other causes of behavioral arrest.

Recognizing status epilepticus

Convulsive status epilepticus is a concern when convulsive activity continues for 5 minutes or more, or when convulsions recur without the person regaining consciousness between them. Treat either presentation as an emergency. Activate the emergency response and begin treatment without waiting for the seizure to stop on its own.

Priorities during an active convulsion

For a person who is actively convulsing, call for help and time the seizure. Protect the person from injury, assess and support airway, breathing, and circulation, monitor oxygenation and vital signs, check bedside glucose, and obtain IV access if feasible.

Give a benzodiazepine promptly under the applicable emergency protocol. If seizures continue after first-line treatment, escalate to a second-line antiseizure medication and appropriate critical-care support.

Safe seizure first aid

Do not restrain a person who is convulsing or put anything in their mouth. Move nearby hazards, cushion the head if possible, and turn the person onto their side when it can be done safely. Stay with them and time the seizure.

Supporting recovery and recognizing urgent concerns

After a convulsion stops, stay with the person and maintain a safe position. Keep them on their side if they are not fully awake, check their breathing and look for injuries, and reassess responsiveness as they recover. Reassure them calmly. Do not offer food, drink, or oral medication until they are fully alert and can swallow safely.

Seek urgent medical assessment if the person remains unusually difficult to awaken. Check airway, breathing, oxygenation, glucose, and for injury or other causes of altered mental status. Persistent impaired responsiveness may reflect a prolonged postictal state, ongoing nonconvulsive seizure activity, or another emergency; urgent evaluation and EEG may be needed.

Call emergency services if the person has trouble breathing or waking, has another seizure without recovery, is injured, or the event meets other emergency criteria.