Guidelines for Seizure Safety and Follow-up
Emergency medical services (EMS) should be activated for individuals with first-time seizure; seizures lasting >5 minutes; multiple seizures without return to baseline; seizures in water; seizures with trauma, breathing difficulty, or choking; seizures in infants <6 months; seizures in pregnant individuals; or if the person doesn't return to baseline within 5-10 minutes after seizure activity stops. 1
Immediate Seizure Management
Safety During a Seizure
- Help the person to the ground and place them on their side in the recovery position 1
- Clear the area around them to prevent injury 1
- Stay with the person throughout the seizure 1
- Do NOT restrain the person having a seizure 1
- Do NOT put anything in the mouth of someone having a seizure 1
- Do NOT give food, liquids, or oral medicines during a seizure or when responsiveness is decreased 1
When to Call Emergency Services
Activate EMS immediately for any of these situations 1, 2:
- First-time seizure
- Seizure lasting more than 5 minutes
- Multiple seizures without return to baseline mental status
- Seizure occurring in water
- Seizure with traumatic injuries
- Breathing difficulties or choking during/after seizure
- Seizure in an infant younger than 6 months
- Seizure in a pregnant person
- Person doesn't return to baseline within 5-10 minutes after seizure stops
- Hypoglycemia-related seizure
Post-Seizure Management
Immediate Post-Seizure Care
- Maintain the recovery position to reduce aspiration risk if vomiting occurs 1
- Monitor breathing and level of consciousness
- Perform a basic assessment once the person regains consciousness
- Document seizure duration, characteristics, and post-ictal state
Medical Evaluation After First Seizure
- Antiepileptic drugs should not be routinely prescribed after a first unprovoked seizure 2
- Medical evaluation should include:
- Complete neurological examination
- Detailed seizure history
- Consideration of EEG and neuroimaging in specialized settings 2
Long-Term Management for Recurrent Seizures
Treatment Approach
- Monotherapy with a standard antiepileptic drug should be the first treatment approach for convulsive epilepsy 2
- Drug selection should be based on seizure type 2, 3
- For focal epilepsy, oxcarbazepine and lamotrigine are first-line options 3
- For generalized epilepsy, medication selection depends on epilepsy syndrome, patient's sex, age, and psychiatric history 3
Medication Management
- Start with monotherapy at the lowest effective dose and titrate gradually 2
- If the first drug fails due to inefficacy, switch to an alternative monotherapy from a different drug class 2
- Add-on therapy may be considered if the first drug is relatively well tolerated but doesn't provide complete seizure control 4
- Monitor for adverse effects, particularly rash with lamotrigine and psychiatric symptoms with levetiracetam 2
Patient and Caregiver Education
- Provide comprehensive education on:
- Seizure management techniques
- Medication adherence importance
- Safety precautions for daily activities 2
- Teach caregivers proper seizure response:
- Place person on their side
- Don't restrain movements
- Don't put anything in mouth
- Time seizure duration
- Remove dangerous objects
- Stay until fully conscious 2
Activity Restrictions and Safety
- Advise on avoiding high-risk activities:
- Swimming only with supervision
- Showering rather than bathing
- Cooking safety precautions
- Height restrictions
- Driving restrictions based on local regulations 2
Special Considerations
Febrile Seizures in Children
- Antipyretics (acetaminophen, ibuprofen) are not effective for stopping or preventing febrile seizures 1
- Febrile seizures are common and generally benign, affecting 2-4% of children 1
Women with Epilepsy
- Use monotherapy at minimum effective dose 2
- Avoid valproic acid due to teratogenic risk 2
- Take folic acid supplementation 2
- Standard breastfeeding recommendations can be followed 2
Follow-up Care
- Regular follow-up appointments to assess:
- Seizure frequency and characteristics
- Medication efficacy and side effects
- Quality of life impact
- Need for medication adjustments
- Consider discontinuation of antiepileptic drugs after 2 seizure-free years, taking into account clinical, social, and personal factors 2
- Avoid abrupt discontinuation which can precipitate withdrawal seizures or status epilepticus 2
Common Pitfalls to Avoid
- Failing to recognize status epilepticus (seizures lasting >5 minutes or multiple seizures without return to baseline)
- Restraining a person during a seizure, which can cause injury
- Putting objects in the mouth during a seizure, which can cause dental damage or aspiration
- Assuming all seizures require immediate antiepileptic drug treatment
- Discontinuing medications abruptly without medical supervision
- Overlooking the impact of seizures on quality of life and psychosocial well-being
By following these guidelines, healthcare providers can optimize seizure management, minimize complications, and improve quality of life for patients with seizures.