What is the immediate prehospital treatment for a seizure?

From the Guidelines

The immediate prehospital treatment for a seizure should prioritize ensuring patient safety, preventing injury, and administering benzodiazepines if the seizure lasts longer than 5 minutes. To achieve this, first, move dangerous objects away from the person and gently guide them to the ground if the seizure is beginning. Place something soft under their head and turn them onto their side (recovery position) to prevent aspiration if vomiting occurs. Never restrain the person or put anything in their mouth. Time the seizure, as those lasting longer than 5 minutes (status epilepticus) require emergency medical services, as indicated by the 2024 American Heart Association and American Red Cross guidelines for first aid 1. For prolonged seizures, emergency responders may administer benzodiazepines such as midazolam (10 mg intramuscular or intranasal for adults), as supported by a prehospital study comparing dosing of 10 mg intramuscular midazolam to 4 mg intravenous lorazepam 1. After the seizure ends, stay with the person until they are fully alert, as they will likely be confused and drowsy during the postictal phase. Some key scenarios that necessitate immediate emergency medical services include first-time seizures, seizures lasting more than 5 minutes, multiple seizures without return to normal, seizures in water, seizures with injuries, breathing difficulty, or choking, seizures in infants less than 6 months of age, and seizures in pregnant individuals or if the person does not return to baseline mental status within 5 to 10 minutes after seizure activity stops, as outlined in the 2024 guidelines 1. The primary goal is to ensure the patient's safety and prevent complications, making supportive care the primary intervention for most cases. Key considerations include:

• Ensuring a safe environment
• Timing the seizure
• Administering benzodiazepines for prolonged seizures
• Providing supportive care after the seizure ends
• Activating emergency medical services when necessary, based on the latest guidelines 1.

From the FDA Drug Label

For the treatment of status epilepticus, the usual recommended dose of lorazepam injection is 4 mg given slowly (2 mg/min) for patients 18 years and older. If seizures cease, no additional lorazepam injection is required. If seizures continue or recur after a 10- to 15-minute observation period, an additional 4 mg intravenous dose may be slowly administered

• The immediate prehospital treatment for a seizure is administration of lorazepam injection at a dose of 4 mg given slowly (2 mg/min) for patients 18 years and older 2.
• It is crucial to have equipment necessary to maintain a patent airway and ventilatory support readily available during administration of lorazepam injection.
• If seizures continue or recur after a 10- to 15-minute observation period, an additional 4 mg intravenous dose may be slowly administered 2.

From the Research

Prehospital Treatment of Seizures

• The immediate prehospital treatment for a seizure typically involves the administration of benzodiazepines, which are considered the first-line treatment for status epilepticus worldwide due to their efficacy, tolerability, and rapid onset of action 3.
• Benzodiazepines such as midazolam, diazepam, and lorazepam can be administered through various routes, including intravenous, intramuscular, rectal, and intranasal, with different pharmacokinetic and pharmacodynamic properties 3, 4.
• For prehospital treatment, intramuscular midazolam and rectal diazepam are considered effective options when intravenous access is not available, with midazolam showing superiority over intravenous lorazepam in some studies 4, 5.
• The dosage of benzodiazepines can vary depending on the route of administration, age, and weight of the patient, with protocols varying widely across different emergency medical services agencies 5.
• Other treatments, such as magnesium sulfate, may be considered for specific conditions like eclampsia, but benzodiazepines remain the primary treatment for seizures in the prehospital setting 5.
• The role of benzodiazepines in the treatment of epilepsy is well established, with their ability to act on the GABAA receptor making them effective in promoting a state of central nervous system depression and controlling seizures 6.