How should a seizure be managed on an aircraft, including immediate airway protection, positioning, rescue medication dosing, and pre‑flight planning for passengers with known epilepsy?

Management of Seizures In-Flight

Place the seizing passenger on their side in the recovery position, clear the surrounding area of objects, stay with them throughout the event, and activate emergency medical services if the seizure lasts >5 minutes, occurs in water, involves trauma or breathing difficulty, or if the passenger does not return to baseline within 5–10 minutes after seizure activity stops. 1

Immediate In-Flight Management

Airway Protection and Positioning

• Turn the passenger onto their side immediately to reduce aspiration risk if vomiting occurs during or after the seizure 1, 2
• Help the person to the ground if they are standing or seated when seizure activity begins to prevent fall-related injuries 1
• Clear the area around the seizing passenger of hard objects, furniture, or anything that could cause injury during seizure movements 1, 2

Critical Actions During the Seizure

• Stay with the passenger throughout the entire seizure episode to monitor for complications and provide reassurance once consciousness returns 1, 2
• Do not restrain the person during seizure activity, as this can cause musculoskeletal injury and does not stop the seizure 1, 2
• Do not put anything in the passenger's mouth, as this can cause dental trauma, airway obstruction, or injury to the responder 1, 2
• Do not give food, liquids, or oral medications during the seizure or immediately afterward due to aspiration risk and decreased responsiveness 1, 2

When to Activate Emergency Medical Services

Immediately notify the flight crew to activate ground-based emergency medical services for:

• First-time seizure in a passenger with no known epilepsy 1
• Seizure lasting >5 minutes (potential status epilepticus) 1
• Multiple seizures occurring without the person returning to baseline mental status between episodes 1
• Seizure with associated traumatic injuries, difficulty breathing, or choking 1
• Seizure in an infant <6 months of age 1
• Seizure in a pregnant passenger 1
• Passenger does not return to baseline within 5–10 minutes after seizure activity stops 1

Rescue Medication Limitations

Be aware that in-flight medical emergency kits generally do not contain easily applicable seizure rescue medications such as buccal midazolam, nasal midazolam spray, or intranasal diazepam 3. Injectable diazepam may be available on approximately 57% of airlines, but requires physician administration and intravenous access 3, 4. This represents a significant gap in emergency preparedness, as most cabin crew cannot administer injectable anticonvulsants without physician assistance on board 3.

Ground-Based Medical Consultation

• Request ground-to-air medical assistance through the airline's medical support service to help optimize diagnosis and guide the decision for aircraft diversion 5
• Provide clear information about seizure duration, passenger's baseline mental status, vital signs if available, and any known medical history 5

Pre-Flight Planning for Passengers with Known Epilepsy

Airline Medical Clearance Requirements

Airline medical clearance via Special Assistance Form (SAF) and Medical Information Form (MEDIF) is required when:

• Seizures are uncontrolled or frequent 6
• The passenger cannot self-care or follow safety instructions 6, 7
• There is potential behavioral risk to other passengers 6
• The passenger has had breakthrough seizures within the past six months despite medication adherence 6

No special airline medical clearance is typically needed for passengers with stable, well-controlled seizures who are adherent to medication and have had no recent breakthrough seizures 6.

Medication Management

• Carry an adequate supply of antiepileptic medication for the entire trip plus extra for unexpected delays, stored in carry-on luggage (never checked baggage) 6
• Bring a photocopy of the prescription and a concise list of diagnosed conditions to present to airline or security personnel if needed 6
• Adjust medication timing for long-haul flights crossing multiple time zones to avoid missed doses 6
• Do not adjust antiepileptic drug doses solely for travel unless clinically justified; unnecessary dose escalation is not recommended 6

Travel Logistics Optimization

• Prefer direct flights to reduce travel stress and limit time spent in the aircraft environment 6, 7
• Schedule flights in late morning or early afternoon to help maintain consistent medication timing across time zones 6, 7
• Request aisle seating to facilitate easy access to lavatories and allow the passenger to move more freely if a seizure occurs 6, 7
• Request early boarding to reduce stress and allow time to settle before other passengers board 7

Mandatory Caregiver Accompaniment

A familiar caregiver must accompany the passenger throughout the journey if:

• The passenger cannot follow safety instructions independently 6, 7
• There is cognitive impairment associated with the underlying neurological condition 7
• Seizures are frequent or unpredictable 6

The presence of a familiar caregiver reduces anxiety, helps detect early signs of distress, and ensures someone can communicate with cabin crew during or after a seizure 7.

Absolute Contraindications to Air Travel

Defer air travel in passengers with epilepsy when:

• Recent hospitalization for status epilepticus or seizure-related complications with ongoing instability 6, 7
• Severe uncontrolled psychiatric conditions that could lead to agitation or unsafe behavior 6, 7
• Inability to follow safety instructions without a healthy accompanying adult, and the airline denies clearance 6, 7
• Severe cognitive impairment with documented history of severe agitation in unfamiliar environments 7

Common Pitfalls and How to Avoid Them

Clinical Pitfalls

• Underestimating the stress of air travel on passengers with neurological conditions; cabin pressurization to ~2,400 m altitude reduces oxygen partial pressure, which could theoretically lower seizure threshold 6
• Assuming all airlines carry seizure rescue medications; confirm availability before flight or ensure the passenger travels with a physician companion if high-risk 3
• Failing to recognize that most seizures are self-limited and resolve within 1–2 minutes; unnecessary interventions during this time can cause harm 1

Administrative Pitfalls

• Overlooking the need for airline medical clearance in passengers with uncontrolled seizures, which can result in denied boarding 6, 7
• Not obtaining a FREMEC (Frequent-Traveller Medical Clearance) card for frequent travelers with epilepsy, which streamlines future airline medical clearances 6
• Failing to inform cabin crew about the passenger's condition before departure, which can lead to unnecessary misunderstandings and delays in appropriate response 1, 7

Post-Seizure Management

• Monitor the passenger during the postictal period, which typically lasts several minutes and is characterized by tiredness and confusion 1
• Ensure the passenger has returned to baseline mental status before allowing them to walk unassisted or resume normal activities 1
• Document the event thoroughly including seizure duration, description of movements, any injuries sustained, and time to return to baseline for ground-based medical evaluation 4