A generalized seizure begins in both hemispheres of the brain at once, so awareness is usually lost from the start. Types include tonic-clonic, absence and myoclonic seizures, and a seizure lasting more than 5 minutes is status epilepticus, an emergency.
Key symptoms
- Sudden loss of consciousness with stiffening, then rhythmic jerking
- Tongue biting and urinary incontinence
- Brief staring spells with no response (absence)
- Sudden muscle jerks, often in the morning (myoclonic)
- Confusion, drowsiness and muscle aches afterward
What you find on exam
- Airway, breathing, oxygen saturation and glucose
- Time the seizure and watch for ongoing activity
- Tongue lacerations, shoulder dislocation and other injuries
- Neurologic exam once recovered
Tests
- Glucose, sodium, calcium, magnesium, toxicology screen, pregnancy test
- EEG: generalized spike-wave patterns
- Brain MRI; CT head in the emergency setting
- Prolactin or creatine kinase can support the diagnosis
Treatment basics
- First aid: protect the head, recovery position, nothing in the mouth
- Status epilepticus: IV lorazepam or IM midazolam, then levetiracetam, fosphenytoin or valproate
- Long term: levetiracetam, lamotrigine or valproate (avoid valproate in pregnancy)
- Absence seizures: ethosuximide
- Counseling on driving, sleep, alcohol and triggers
Red flags
- Seizure lasting over 5 minutes or repeated without waking
- Breathing problems or low oxygen after the seizure
- Seizure with fever and stiff neck, after a head injury or in pregnancy
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Sources: NASEMSO National Model EMS Clinical Guidelines; NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations. Written by Making Synapses. Making Synapses is not affiliated with these organizations.