14.1 Seizure Disorders

A convulsion in a helicopter is a neurologic emergency and a cabin-safety problem at the same time. Domain 4.A of the August 2026 Board of Certification for Emergency Nursing (BCEN) Certified Flight Registered Nurse (CFRN) outline tests seizure disorders because status epilepticus (SE), a missed reversible cause, and a clenched jaw in a two-foot aisle are all flight-nurse work. Stop the seizure, protect the airway without wrecking cerebral blood flow with over-ventilation, and fly to a destination that matches the cause.

Status epilepticus: treat at five minutes

Operational definition, not a thirty-minute wait

Status epilepticus is a continuous convulsive seizure lasting five minutes or longer, or recurrent seizures without a return to neurologic baseline between them. That five-minute mark is the operational definition used in emergency and transport medicine. The International League Against Epilepsy (ILAE) later-injury time is near thirty minutes. Do not wait for it to give a benzodiazepine.

Last known well (LKW) and witnessed onset are not the same clock. Witnessed onset tells you how long the brain has been seizing and whether you have already crossed five minutes. LKW is what you use when the patient is found down: the seizure may have started any time after they were last seen normal. Write both times. Unwitnessed collapse plus a bitten tongue is a seizure until you also rule out trauma, stroke, hypoglycemia, and eclampsia.

First-line benzodiazepines, then a protocol second-line drug

First-line therapy is a benzodiazepine. In the aircraft and on the ramp, the practical routes are:

• Midazolam intramuscular (IM) or intranasal (IN) when you do not yet have a line, and intravenous (IV) once you do. IM midazolam is the flight-friendly first shot because you can give it through clothing while someone else pads the litter. Emergency-medicine teaching often uses about 10 mg IM in an adult.
• Lorazepam IV when a working line already exists. Lorazepam stays in the central nervous system longer than diazepam; a typical adult IV dose in status is about 4 mg.
• Do not stack three different benzodiazepines hoping the fourth milligram will behave. Give an adequate first dose, support the airway, and move to a second-line agent if convulsions continue.

Second-line therapy follows program protocol. Contemporary emergency teaching—informed by the Established Status Epilepticus Treatment Trial (ESETT)—treats levetiracetam, valproate, and fosphenytoin as comparably effective second-line choices. That is protocol teaching, not a BCEN statute. Avoid valproate in pregnancy and in patients who might be pregnant. Fosphenytoin can drop blood pressure and provoke arrhythmia if you push it like a flush. If the patient is still seizing after a second-line load, you are in refractory status: a midazolam or propofol infusion and an intensive-care unit (ICU) destination, not another community clinic.

Airway, glucose, and the cause that changes the pad

Check glucose early. Hypoglycemia looks like a seizure and is treated with dextrose, not another antiepileptic. Do not force objects—bite blocks, padded tongue blades, fingers—into a clenched jaw. You will break teeth, obstruct the airway, and injure a crew member. Pad the head, loosen restraints that will tear a shoulder, and wait for the jaw to relax after the benzodiazepine.

Hunt the cause that changes destination:

Eclampsia is not ordinary epilepsy. Magnesium is the disease-specific drug. Benzodiazepines still stop the motor seizure if magnesium has not. The pad is L&D or an obstetric-capable hospital, not a clinic without an operating room. Alcohol (ETOH) withdrawal seizures are benzodiazepine-responsive and a hint that delirium tremens may follow. Post-traumatic seizures belong with Chapter 11 packaging.

Cabin safety, ventilation, and what not to do after the benzo

A small cabin turns a generalized tonic-clonic seizure into an injury factory. Before lift, or the instant a seizure starts, pad bony prominences and the litter rails. Do not hog-tie a convulsing patient into a rigid package. Keep suction staged: vomit plus a clenched jaw is an airway, not a housekeeping problem.

If the patient is already intubated and seizes, watch end-tidal carbon dioxide (ETCO2). During the convulsion, metabolism and carbon dioxide production rise. After the benzodiazepine, respiratory drive falls. Over-bagging then produces hypocapnia, cerebral vasoconstriction, and a stomach full of air. Confirm the tube did not displace when the torso thrashed.

Dalton's law still applies: cabin altitude drops inspired oxygen tension. A post-ictal, benzodiazepine-sedated patient will desaturate on climb unless you raise fraction of inspired oxygen (FiO2) or request a lower cabin. Do not treat that desaturation by squeezing the bag faster.

• Treat status at five minutes with an adequate benzodiazepine, then a protocol second-line drug.
• Check glucose; never pry a clenched jaw open with an object.
• Eclampsia goes to L&D on magnesium; after the benzodiazepine, support ventilation without over-bagging.

CFRN practice bankPractice questions with detailed explanations