What should I do if I'm having seizures?

What to Do If You're Having Seizures

If you are actively having a seizure right now, someone should call 911 immediately if the seizure lasts more than 5 minutes, if this is your first seizure, or if you have multiple seizures without waking up fully between them. 1

Immediate Safety During an Active Seizure

If someone is with you during a seizure, they should take these critical protective actions:

• Help you to the ground immediately to prevent fall-related injuries, which are a major source of harm during seizures 1
• Turn you on your side (recovery position) to reduce aspiration risk if vomiting occurs 1
• Clear the area of any objects that could cause injury during seizure movements 1
• Stay with you throughout the entire episode to monitor for complications 1

Critical Actions to AVOID

• Never restrain you during the seizure, as this causes musculoskeletal injuries and doesn't stop seizure activity 1
• Never put anything in your mouth (fingers, bite blocks, tongue blades, spoons) as this causes dental trauma, airway obstruction, or injury to the rescuer 1
• Never give food, liquids, or oral medicines during a seizure or when you have decreased responsiveness afterward due to aspiration risk 1

When to Call 911 Immediately

Emergency medical services must be activated for: 1

• Seizure lasting more than 5 minutes (may not stop spontaneously and requires emergency anticonvulsant medications)
• First-time seizure (requires evaluation for underlying cause)
• Multiple seizures without return to baseline mental status between episodes
• Seizure with traumatic injury (head injury, significant bleeding, suspected fractures)
• Failure to return to baseline within 5-10 minutes after the seizure stops
• Seizure occurring in water
• Seizure with choking or difficulty breathing

After the Seizure Stops: Emergency Department Evaluation

What the Emergency Physician Will Determine

The emergency physician needs to classify your seizure as either provoked (caused by an identifiable acute trigger) or unprovoked (no clear immediate cause), as this determines whether you need anti-seizure medication: 2

For provoked seizures (caused by low blood sugar, low sodium, infection, drug toxicity, alcohol withdrawal, head injury):

• You do NOT need anti-seizure medication started in the ED 2
• Treatment focuses on correcting the underlying medical condition
• The precipitating condition should be identified and treated

For first unprovoked seizure WITHOUT brain disease or injury:

• You do NOT need anti-seizure medication started in the ED 2
• Only 1/3 to 1/2 of patients will have another seizure within 5 years 2
• Starting medication immediately doesn't improve 5-year outcomes 2
• The strategy of waiting until a second seizure before starting medication is considered appropriate 2

For first unprovoked seizure WITH history of stroke, brain trauma, tumor, or other CNS disease:

• The emergency physician may start anti-seizure medication in the ED, or coordinate with your outpatient neurologist 2
• These patients have higher seizure recurrence rates, making treatment appropriate after just one seizure 2

Hospital Admission Decision

If you've returned to your normal baseline mental status in the ED after a first unprovoked seizure, you do NOT need to be admitted to the hospital 2

If You Have Status Epilepticus (Prolonged Seizure)

If your seizure continues despite benzodiazepines (like Ativan or Valium), you must receive an additional anti-seizure medication immediately 2

The emergency physician will administer one of these second-line medications: 2

• Intravenous phenytoin, fosphenytoin, or valproate (Level B recommendation - strong evidence)
• Alternatively: levetiracetam, propofol, or barbiturates (Level C recommendation)

Valproate is particularly effective, stopping seizures in 88% of patients within 20 minutes, with fewer side effects than phenytoin 2

Critical Medication Safety Information

If You're Already Taking Anti-Seizure Medication

Never stop your seizure medication suddenly without talking to your healthcare provider 3, 4

• Stopping abruptly can cause life-threatening continuous seizures (status epilepticus) 3
• Medication must be withdrawn gradually to minimize risk of increased seizure frequency 3, 4

Common Pitfalls to Avoid

• Do not take fever-reducing medications (acetaminophen, ibuprofen) during or immediately after a seizure - they do NOT stop seizures or prevent future ones 1
• If you had a head injury before the seizure, you need an immediate CT scan of the brain to rule out bleeding, even if the seizure was brief 5
• Do not assume you have epilepsy after one seizure - most people with a single seizure do not go on to develop epilepsy 6

Follow-Up Care Required

After your ED visit, you need: 6

• Electroencephalography (EEG) to assess brain electrical activity
• Epilepsy protocol-specific MRI of the brain with thin-cut coronal slices to determine recurrence risk
• Neurology consultation to determine if long-term treatment is necessary

The goal is to distinguish between acute symptomatic seizures (which don't require long-term treatment), single unprovoked seizures (which may not require treatment), and true epilepsy (which does require treatment) 6, 7