What is the immediate treatment for a patient having a grand mal seizure in an ambulance?

Immediate Treatment for Grand Mal Seizure in Ambulance

Administer intravenous lorazepam 0.1 mg/kg (maximum 4 mg) immediately for the actively seizing patient in the ambulance, while simultaneously ensuring airway protection, providing high-flow oxygen, and checking blood glucose. 1

Critical Initial Actions (Simultaneous)

Airway, Breathing, Circulation

• Establish airway patency and position patient on their side to prevent aspiration 1
• Provide high-flow oxygen to prevent hypoxemia from seizure-induced respiratory compromise 1
• Check blood glucose immediately - hypoglycemia can precipitate seizures and must be corrected urgently 1
• Establish IV or intraosseous access for medication administration 1

First-Line Seizure Termination

• Lorazepam 0.1 mg/kg IV (maximum 4 mg) given slowly over 2 minutes 1, 2
• If seizure continues after 1 minute, repeat lorazepam 0.1 mg/kg (maximum 4 mg) - can give up to 2 doses 1
• Do NOT underdose - doses less than 4 mg in adults significantly increase progression to refractory status epilepticus (87% vs 62%) 3

Status Epilepticus Protocol (If Seizure >5 Minutes)

This patient requires status epilepticus management since the seizure is ongoing during transport and likely exceeds 5 minutes. 1, 4

After Initial Benzodiazepines

• If seizures persist after two doses of lorazepam, prepare for:
  • Phenytoin loading dose 18 mg/kg IV over 20 minutes, OR 1
  • Phenobarbital 15-20 mg/kg IV over 10 minutes 1
• Alert receiving hospital for potential need for intubation and intensive care 4, 5

Critical Safety Considerations

Respiratory Monitoring

• Lorazepam causes respiratory depression - the most important risk in status epilepticus treatment 2
• Ventilatory support equipment must be immediately available - bag-valve-mask ready 2, 5
• Monitor for airway obstruction, especially with repeated doses 2

What NOT to Do

• Never restrain the seizing patient 1
• Never place anything in the patient's mouth 1
• Do not give oral medications or fluids during or immediately after seizure 1

Context-Specific Concerns for This Patient

Given the clinical presentation (headaches, neck stiffness for days, disorientation, collapse), this seizure may indicate:

• Possible meningitis/encephalitis - requires urgent hospital evaluation 1
• Possible intracranial hemorrhage or stroke - the combination of headache, stiffness, and seizure warrants immediate brain imaging 1

Activate emergency notification to receiving hospital for suspected stroke or CNS infection requiring immediate CT imaging and specialist consultation. 1

Post-Seizure Management During Transport

• Continue oxygen supplementation 1
• Monitor vital signs continuously - heart rate, blood pressure, oxygen saturation, temperature 1
• Maintain lateral positioning during postictal period to prevent aspiration 1
• Reassess neurological status - level of consciousness, focal deficits 1