Updated 13/11/23

SEIZURES & FAINTING

Fainting is a reasonably common and simple condition. It occurs because the brain, for a very short period, does not receive an adequate blood supply and results in collapse and a brief loss of consciousness. The casualty looks pale and their skin can be cold and clammy. Fainting can be due to a number of different reasons such as standing for long periods, lack of food or emotional stress. Fainting is a very short-lived condition and the casualty makes a quick recovery.

Management

• If the casualty is feeling faint lay them down and raise their legs (as high as is practicable)

• If they have already fainted, check ABC to ensure it is a faint then raise their legs

• If you are inside, open doors and windows for fresh cool air

•  As they recover reassure them and sit up slowly, if they start to faint again lay them down

• If they do not regain consciousness reassess ABCDE and place in the recovery position
   

SEIZURES

A seizure is the result of a disturbance of the natural electrical activity in the brain. Not all causes of seizures are understood.

Whilst seizures are most commonly associated with epilepsy, from an MR perspective there are numerous other possible causes.  Although epilepsy can occur for the first time at any age, if there is no clear history of epilepsy, it is relatively unlikely it will occur for the first time on a mountain and other causes should be considered. The following are the main causes of seizures in adults:

• Epilepsy

• Head Injury

• Some brain damaging diseases e.g stroke, brain tumour

• Shortage of oxygen

• Shortage of glucose

• Hyperthermia/febrile

• High blood pressure in pregnant women

• Poisions

In children seizures are most commonly a result of raised body temperature associated with an infectious condition and are referred to as febrile convulsions. However seizures can also occur as a result of epilepsy.

The term “seizure” is often used interchangeably with “convulsion,” but the two should not be confused.  There are many different types of seizures. Some have mild symptoms, no body shaking and can go unnoticed. Convulsions (also known as fits) are when a person’s body shakes rapidly and uncontrollably. During convulsions, the person’s muscles contract and relax repeatedly causing them to flail and bite uncontrollably.

Your main job as a Cas Carer is to protect the casualty’s airway and ensure that they get enough oxygen. During intense or prolonged convulsions the brain risks becoming starved of oxygen due to the continuous convulsions. In addition you will need to protect the casualty from harming themselves.

Types Of Seizures

Depending upon how much of the brain is involved, the effects of seizures can be very different. We need to determine the type of seizure based upon the severity and duration of their symptoms in order to decide upon the appropriate course of management.

There are three types of seizure for us to consider in MR:

• Petite mal

• Grand mal

• Status epilepticus

Petite Mal

Is a short period of ‘absence’, resulting from a localised brain disturbance.  People suffering from a petit mal are often described as appearing to be in their own little world.  The seizure should resolve quickly, require no treatment and the casualty can be walked off the hill after they have recovered.  Therefore it is unlikely we will be call to an isolated petite mal event.

Grand Mal (Tonic /Clonic Seizure)

Grand mal seizures result from full brain disturbance and are what people typically imagine when they think of seizures.  Violent uncontrolled convulsions of the whole body involving flailing arms and thrashing around.

Grand mal siezures occur in two phases called tonic and clonic.

The tonic phase often lasting only a few seconds in which the person rapidly loses consciousness and the skeletal muscles tense, often causing the limbs to be either pulled towards the body or rigidly pushed away from it.

The tonic phase is followed by the clonic phase where the persons muscles rapidly alternate between contraction and relaxation causing convulsions.  The extent of convulsions can vary significantly between exaggerated twitches, vibration of the limbs, violent shaking and wildly flailing limbs.  The eyes often roll back, the tongue often suffers from being bitten and they may become incontinent.

The violent nature of seizures can lead to head, spinal and limb injuries which may require treatment.  However the main cause of permanent damaging resulting from a seizure is hypoxia.  During convulsions the casualty will be using a large amount of energy and may fail to breath properly.  This can result in the brain being deprived of oxygen. Therefore the focus of treatment should be to maintain an airway and avoid hypoxia as during a seizure.

People who have suffered from seizure before, may be able to sense when one is about to occur and warn you. A tonic-clonic seizure will often be proceeded by an ‘aura’ during which the casualty may suffer altered vision and hearing, feel lightheaded and/or dizzy, unusual or inappropriate emotions, intense feelings of discomfort and possibly a sense of deja vu.

Tonic-clonic seizures cause both physical and nervous exhaustion.  Casualties may sleep between or after fits in what’s known as a post-ictal state.  Upon awakening they may be confused, act out of character which may result in verbal or physical aggression.

Most seizures last less than 5 minutes, a single short seizure does not need treatment.

Status Epilepticus

Status epilepticus is a single seizure which lasts for 30 minutes or longer or multiple seizures with no return to consciousness between them. This is a serious medical emergency and potentially life threatening.  Due to the continuous convulsions the brain becomes starved of oxygen and can suffer permanent brain damage if not quickly reversed.  The sooner treatment begins the better.

Be prepared for hypoxic cardiac arrest.

Remember – safety is the priority.  Do not risk your own safety trying to protect the casualty from hurting themselves doing a seizure.

History

Ask the casualty or anyone with them if they:

• Are a known epileptic?

• Take any drugs regularly to prevent seizures? (ask for the names)

• Have they taken it today?

• When was their last seizure?

• Have previously been admitted to hospital for epilepsy?

• Have ever been admitted to intensive care for treatment?

• Have they taken any other drugs?

• Have they changed their medication?

• If they are unresponsive or no bystander look for clues (medi alert, medication in rucksack)

Those with epilepsy sometimes know when a seizure is imminent and can warn you.

If there is no history of epilepsy consider other causes list above.

Signs and Symptoms

Look for:

• Periods of absence

• Fits or convulsions

If there is no known history of epilepsy:

• Look for signs of head injury

• Take a BM – treat reduced blood sugar reading immediately.

• Take a temperature –  to look for possible infection/hyperthermia

• Blood pressure to exclude ‘pre-eclampsia’ in pregnant women

• Look for evidence of alcohol or drug consumptio

Treatment

Remember safety – Keep clear of flailing limbs.

Move objects that the casualty could hurt themselves on if possible
Note the time the seizure started and ended.
Do not attempt to restrain the casualty.
Give high flow oxygen via a non rebreathing at 15 litres per minute if the avaliable supply will last throughout the evacuation.
Never use force to restrain the casualty or attempt to put anything in their mouth.
Do not attempt to insert an OP airway.  Though it can prevent injury to the tongue, it can induce vomiting, potentially blocking the airway and clearing the airway is virtually impossible during a fit. An NP airway would be a useful adjunct to use.
Treat repeated seizures or a seizure lasting longer than 10 minutes with 10mg of buccal midazolam.
A second dose of midazolam can be given after 20 minutes.  A third dose can be given, but only after discussion with a doctor.
When giving multiple doses of midazolam be vigilant for respiratory depression.
Sleeping after fitting is common.  Place the casualty in the recovery position and keep warm.
Urgent evacuation to hospital is always warranted following a grand mal seizure.

Signs of Improvement

Seizures will stop.
Casualty will recover consciousness and memory.
If they have only suffered a short seizure and made a full recovery, they can be walked off the hill.

Non-Epileptic Seizures

As already mentioned, there are multiple possible causes of seizures other than epilepsy.  Non-epileptic seizures will require treatment for the underlying cause in addition to treating the seizure.

Post Head Injury 

• Assess and treat head injury if possible (see head injury for further details).

• Then treat as Grand Mal.

• Be aware that as midazolam depresses the consciousness level this could complicate further monitoring if the casualty has a head injury.

The video below shows a teenager having a seizure following an accident.

Hypoglycaemia 

Treat low blood sugar immediately (see hypoglycemia for further details).
Then treat as Grand Mal.

Hypoxia

Assess and manage the airway and breathing.  Ensure the airway is open.
Administer high flow oxygen at 15 litres per minute, if the supply will last throughout the evacuation.

Hyperthermia

Most common in small children due to fever and Infections, although fitting can occur along side heat stroke.
Check their temperature and cool (see heat illness for further details).

Drugs and Alcohol

Treat as Grand Mal.
Pinpoint pupil size may indicate the consumption of opiates.  Naloxone can be used to reverse the effect of opioid drugs, but should only be given after discussion with a doctor.  See Overdose for more details.

Cerebrovascular (Stroke or TIA)

Treat as Grand Mal.
Then treat for stroke.  See Stroke and TIA for further details.