What are the recommended precautions and interventions for individuals at risk of seizures?

Seizure Precautions and Rationale

The primary goal of seizure precautions is to prevent physical injury during seizure activity by protecting the patient from trauma, maintaining airway patency, and preventing aspiration—interventions that directly reduce morbidity and mortality from seizure-related complications. 1

Essential Physical Safety Measures

Injury prevention is paramount because seizure movements involve erratic movements of the head, body, and extremities that can result in significant traumatic injury during a fall or from the seizure movements themselves. 1

During Active Seizure Activity

• Help the person to the ground immediately to prevent fall-related injuries, which are a major source of morbidity in seizure patients 1
• Place the person on their side in the recovery position to reduce the risk of aspiration if vomiting occurs during the seizure or postictal period 1
• Clear the area around them of any objects that could cause injury during seizure movements 1
• Stay with the person throughout the entire seizure episode to monitor for complications and provide continuous protection 1

Critical Actions to AVOID (Harm Prevention)

• Never restrain the person having the seizure as this can cause musculoskeletal injuries and does not stop seizure activity 1
• Never put anything in the mouth including bite blocks, tongue blades, or fingers—this can cause dental trauma, airway obstruction, or injury to the rescuer 1
• Never give food, liquids, or oral medicines during a seizure or when the person has decreased responsiveness after a seizure due to aspiration risk 1

When to Activate Emergency Medical Services

Seizures lasting >5 minutes may not stop spontaneously and require emergency medical intervention such as anticonvulsant medications to prevent status epilepticus, a life-threatening condition associated with high risk of permanent neurological impairment. 1, 2

Mandatory EMS Activation Criteria

• First-time seizure (requires evaluation for underlying cause) 1
• Seizure lasting >5 minutes (risk of status epilepticus) 1
• Multiple seizures without return to baseline mental status between episodes 1
• Seizure in an infant <6 months of age 1
• Seizure in pregnant individuals 1
• Seizures occurring in water (drowning risk) 1
• Seizures with traumatic injuries, difficulty breathing, or choking 1
• Person does not return to baseline within 5-10 minutes after seizure stops 1

Rationale: Why These Precautions Matter

Mortality Prevention

Mortality rates are 4-7 times higher in people with medically refractory seizures, and uncontrolled seizures constitute a serious threat to health and well-being. 3 Most seizures are self-limited and resolve spontaneously within 1-2 minutes, but prolonged seizures can lead to respiratory depression, aspiration pneumonia, and status epilepticus—all potentially fatal complications 1, 2.

Morbidity Reduction

Injury rates in people with seizures are substantial, ranging from one per 20 person-years to as much as one per 3 person-years. 3 The recovery position specifically addresses the risk of aspiration, which can cause aspiration pneumonitis or pneumonia, leading to significant respiratory morbidity 1.

Airway Management Considerations

The most important risk associated with seizures is respiratory depression and airway obstruction, particularly in heavily sedated patients or during the postictal period. 2 Positioning on the side allows secretions and vomit to drain from the mouth rather than being aspirated into the lungs 1.

Special Considerations

Febrile Seizures in Children

Antipyretics such as acetaminophen, ibuprofen, or paracetamol are NOT effective for stopping a seizure or preventing subsequent febrile seizures. 1 This is important because it prevents unnecessary medication administration and focuses care on appropriate seizure management rather than fever reduction 1.

Metabolic Causes

Always consider correctable acute causes such as hypoglycemia, hyponatremia, or other metabolic derangements, as these require specific metabolic correction rather than anticonvulsants. 4, 2, 5 Hypocalcemic seizures, for example, resolve with calcium correction alone and do not require anticonvulsant medications 4.

Common Pitfalls to Avoid

• Do not assume all seizures are epilepsy—many are provoked by reversible metabolic causes that require specific treatment 4, 5
• Do not delay EMS activation for prolonged seizures thinking they will self-resolve—status epilepticus requires immediate medical intervention 1, 2
• Do not leave the patient alone even after seizure activity stops, as the postictal period carries risks of aspiration, respiratory depression, and injury from confusion 1
• Do not attempt oral administration of anything during or immediately after a seizure due to aspiration risk and potential airway compromise 1