3.2 Protocol 12: Convulsions / Seizures

Protocol 12: Convulsions / Seizures

Seizures represent sudden, transient episodes of abnormal, excessive, and hypersynchronous neuronal electrical activity within the brain. To 9-1-1 callers, witnessing a generalized convulsion is terrifying, frequently prompting frantic reports of "He's dying!" or "She's stopped breathing!" The emergency medical dispatcher must navigate this emotional threshold with calm authority, rapidly triaging active status epilepticus from self-limiting convulsions, safeguarding the airway, and ruling out the catastrophic presentation of cardiac arrest masquerading as a seizure.

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1. Clinical Phases: Active Seizure vs. Post-Ictal State

A generalized tonic-clonic convulsion progresses through distinct neurophysiological phases, each requiring different dispatch handling.

The Tonic, Clonic, and Post-Ictal Sequence

1. Aura / Prodrome (Pre-Seizure): Some patients experience sensory distortions, epiphora, or sudden fear, though dispatchers rarely receive calls during this fleeting premonitory phase.
2. Tonic Phase (10–30 Seconds): Extreme continuous muscle contraction causes full-body stiffening. Airway occlusion occurs as intercostal muscles and diaphragm lock, forcing an epileptic cry as residual air is squeezed through contracting vocal cords. The patient loses consciousness, falls, and becomes cyanotic.
3. Clonic Phase (30–90 Seconds): Rapid, violent, rhythmic alternating contractions and relaxations of extremities (convulsive jerking). Patients exhibit autonomic hyperactivity: heavy salivation, diaphoresis, pupillary dilation, and tongue/cheek biting. Cyanosis deepens.
4. Post-Ictal State (5–30+ Minutes): Convulsive motor activity abruptly halts. The patient enters a profound state of central nervous system exhaustion and metabolic acidosis. Muscles become completely flaccid, and consciousness is severely depressed.

Clinical Comparison Matrix

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2. Status Epilepticus: Definition and Acuity

Most isolated generalized tonic-clonic seizures are self-limiting, spontaneously terminating within 60 to 120 seconds. When a seizure fails to resolve spontaneously, the patient enters status epilepticus.

⚡ Critical Clinical Definition: Status Epilepticus

Within prehospital emergency medicine and MPDS, status epilepticus is defined as:

1. Continuous, unremitting seizure activity lasting 5 minutes or longer, OR
2. Two or more discrete seizures occurring sequentially without the patient regaining full consciousness between episodes.

Physiological Consequences of Status Epilepticus

Prolonged continuous convulsions rapidly deplete cerebral glycogen and adenosine triphosphate (ATP) reserves. Hyperthermia, systemic lactic acidosis, rhabdomyolysis (muscle breakdown causing acute renal failure), hypoxemia, and pulmonary edema develop. After 20 to 30 minutes of continuous status, irreversible excitotoxic neuronal apoptosis occurs, producing permanent cognitive and neurological deficits or cardiovascular collapse. In MPDS, continuous or multiple seizures mandate an immediate DELTA level response (12-D-2 — Continuous or multiple seizures). Note that 12-D-1 is Not breathing at all and 12-D-3 is Agonal/ineffective breathing.

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3. Structured Key Question Interrogation and Triage

When Protocol 12 is selected, the dispatcher systematically works through standardized Key Questions to determine acuity and secondary complications.

                      [Protocol 12: Convulsions / Seizures]
                                        |
                    [KQ 1: Is the patient actively seizing NOW?]
                                        |
                   -------------------------------------------
                   |                                         |
                 [YES]                                     [NO]
                   |                                         |
        [How long has it lasted?]                 [KQ 2: Is the patient breathing?]
        [Is it continuous / multiple?]                       |
                   |                           -----------------------------
         [>= 5 min or Multiple]                |                           |
                   |                        [YES]                         [NO]
            [12-D-2 DELTA]                     |                           |
     (Continuous or multiple)      [Normal vs. Snoring?]           [Shunt to Protocol 9]
             [PDI Safety]                      |                     [ECHO Cardiac Arrest]
                                   --------------------------
                                   |                        |
                         [Breathing Normally]       [Agonal / Ineffective]
                                   |                        |
                         [KQ 3: Pregnancy?]         [12-D-3 DELTA or Protocol 9]
                                   |                        
                     -----------------------------
                     |                           |
               [Pregnancy YES]             [Pregnancy NO]
                     |                           |
              [12-C-2 CHARLIE]           [KQ 4: Seizure History?]
           (Pregnancy / Eclampsia)              |
                                   -----------------------------
                                   |                           |
                             [Known History]            [First Seizure / Unknown]
                                   |                           |
                             [12-A-1 ALPHA]              [12-A-2 ALPHA]

Key Question Analysis

1. "Is the person actively seizing right now?" Determines active convulsion vs. post-ictal evaluation.
2. "Is the person breathing normally?" This is the single most critical diagnostic pivot in Protocol 12. The dispatcher must never accept a vague "Yes, I think so" from an excited caller.
3. "Does the person have a history of seizures or epilepsy?" An isolated seizure in a patient with diagnosed epilepsy who forgot a dose of levetiracetam (Keppra) or phenytoin (Dilantin) is clinically distinct from a first-time seizure in a 65-year-old, which may herald a hemorrhagic stroke, glioblastoma, or intracranial mass.
4. "Is the patient female between the ages of 12 and 50? Is she pregnant?" A convulsion occurring in pregnancy indicates eclampsia—a severe endothelial and vascular complication of pre-eclampsia characterized by severe hypertension, cerebral vasospasm, and microvascular thrombosis. Eclampsia carries high maternal and fetal mortality. In the MPDS this has its own determinant, 12-C-2 (Pregnancy); although it is a CHARLIE code, the EMD must flag the suspected eclampsia in the CAD narrative so responders and the receiving obstetric unit prepare for magnesium therapy and possible emergent delivery.

4. The Critical Post-Ictal Airway: Snoring vs. Cardiac Arrest

Up to 40% of sudden cardiac arrest victims exhibit brief, generalized myoclonic seizure activity at onset. When the heart abruptly ceases pumping (ventricular fibrillation), the brain is deprived of oxygen within six seconds. The cerebral cortex produces an immediate, brief convulsive discharge lasting 10 to 15 seconds. Callers report a "seizure," but when the convulsion stops, the patient is in full cardiac arrest.

Sonorous Post-Ictal Breathing vs. Agonal Gasps

During the post-ictal phase, profound neurological depression causes relaxation of the genioglossus muscle, allowing the base of the tongue to fall backward against the posterior pharyngeal wall. When the patient breathes deeply, the soft palate and tongue vibrate, generating loud, snoring sounds (stertor). While frightening to callers, this is benign provided airway patency and regular respiratory rate are maintained.

Conversely, agonal breathing represents primitive brainstem reflexes attempting to draw air into anoxified lungs during cardiac arrest. Agonal respirations are slow (2–6 breaths per minute), irregular, gasping, snorting, or groaning, accompanied by unresponsiveness and lack of true chest rise.

EMD Verification Diagnostic Technique

If the caller states, "He stopped shaking, but he's making weird snoring noises and won't wake up," the EMD must immediately verify:

• "Listen closely to his chest and mouth. Tell me every single time he takes a breath in—say 'now' every time he breathes."
• If breaths are regular and frequent (12–20 times per minute with chest rise), the airway is obstructed by the tongue: coach the caller to roll the patient onto their side into the recovery position and tilt the head back to lift the tongue off the pharynx.
• If breaths are separated by long pauses (>8–10 seconds), sound like heavy gasps or snorts, or are irregular and shallow, the EMD must instantly shunt to Protocol 9 and begin Telephone CPR.

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5. Post-Dispatch Safety Instructions (PDIs) and Common Pitfalls

Dispatch life support during an active seizure focuses on environmental protection and preventing secondary trauma.

Mandatory Scripted PDIs for Active Seizures

1. Clear Dangerous Objects: Move sharp, hard, hot, or heavy objects (furniture, glass tables, heaters, appliances) away from the patient's thrashing limbs.
2. Protect the Head: Place a soft, flat object (folded towel, pillow, jacket) beneath the patient's head to cushion violent impacts against the floor.
3. Do Not Restrain: Strictly instruct the caller not to pin down limbs or fight the convulsive spasms. Restraining active clonic jerking causes avulsion fractures, joint dislocations (especially shoulder dislocations), and severe muscle tears.
4. Never Place Anything in the Mouth: This is an absolute, non-discretionary rule. Callers still hold dangerous archaic beliefs that a seizing patient will "swallow their tongue." Physically, it is anatomically impossible to swallow the tongue because it is anchored firmly to the hyoid bone and mandibular symphysis via the lingual frenulum. Inserting spoons, fingers, bite sticks, or cloths breaks teeth, punctures the palate, causes fatal aspiration of tooth fragments, and causes traumatic amputation of caller fingers.
5. Post-Seizure Positioning: Once convulsive activity halts and effective breathing is confirmed, coach the caller to turn the patient onto their side (lateral recumbent / recovery position). This allows accumulated blood (from tongue lacerations), saliva, and gastric secretions to drain freely out of the oral cavity under the pull of gravity rather than pooling into the larynx.