# Airway Management in Seizures



## TreySpooner65 (Sep 7, 2011)

I am currently not working in ems but looking for work. Since I am not practicing I try to quiz myself on things regularly. One thing I cant remember from my EMT class is how to maintain an airway during a seizure. 

My local protocols say "Maintain airway as indicated"

So my question is, what is the proper way? 

Head tilt? Do you have to worry about the tongue?


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## ArcticKat (Sep 7, 2011)

There is no airway to maintain during a seizure.  The patient isn't breathing.  That's why seizures lasting more than a few minutes are so critical.


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## Cup of Joe (Sep 7, 2011)

An OPA might give them something to bite down on instead of their tongue (if you can get one in while their siezing), but you're not gonna be able to bag them, and when they regain their gag reflex, you'll have to pull it out.

Also, I was taught that you NEVER put anything in the mouth of a person while their seizing, anyone else hear that too?


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## DesertMedic66 (Sep 7, 2011)

There is nothing you can really do for airway during a seizure. You just have to wait until it's over and then reassess to decide what would be the best thing (ie NC, NRB, BVM, NPA, OPA)


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## TreySpooner65 (Sep 7, 2011)

I know you're not supposed to put anything in their mouth... So I guess the reason I can't remember how to maintain the airway is because you can't.


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## ArcticKat (Sep 7, 2011)

Cup of Joe said:


> An OPA might give them something to bite down on instead of their tongue (if you can get one in while their siezing),



Once the teeth are clenched there is nothing to be concerned about.  Either the tongue escaped injury or the injury has already occured.  The only way to prevent any injury to the tongue is to place something between the teeth before the seizure happens.

Having said that I have never once seen a patient with a tongue injury as a result of a seizure.


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## usafmedic45 (Sep 7, 2011)

> There is no airway to maintain during a seizure. The patient isn't breathing. That's why seizures lasting more than a few minutes are so critical.



They aren't fully apneic most of the time.  Actually the derangement of less oxygen in, less CO2 out and an increase in metabolic demand is what makes them so dangerous. The three big reasons for negative outcome in seizures are hypoxia, hypoglycemia and hyperthermia.  



> An OPA might give them something to bite down on instead of their tongue (if you can get one in while their siezing), *but you're not gonna be able to bag them*, and when they regain their gag reflex, you'll have to pull it out.



Wanna bet?  Which blithering moron told you that one?



> Having said that I have never once seen a patient with a tongue injury as a result of a seizure.



I've seen minor injuries to the tongue from it.  Getting punched in the mouth carries a greater risk of injury to the tongue though to be quite honest.  



> So I guess the reason I can't remember how to maintain the airway is because you can't.



Yeah, you can.  There are two other ways into the trachea that are not the mouth.  Normal procedure for me is to drop an NPA and bag if necessary.  If things get really FUBAR, you can paralyze them and tube them (remember though, the seizure is still ongoing even if you give paralytics; even if the patient isn't convulsing, you can still get a lot of bad effects from protracted seizures) or you can do a surgical airway if all other options fail in a status epilepticus case.


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## MasterIntubator (Sep 7, 2011)

NPA is our tool of choice.  Its easy, quick and when properly set it will do its job when they come out of the seizure. ( reduce the snoring, etc. ).   Every couple of months we get a "seizure" that miraculously stops seizing and avoid the NPA at all costs.  
:rofl:


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## sir.shocksalot (Sep 7, 2011)

Cup of Joe said:


> An OPA might give them something to bite down on instead of their tongue (if you can get one in while their seizing)


Yeah, that sounds like a bad idea to me. I would second the NPA and BVM, I usually don't worry too much about the airway unless the seizure has been going on for a while and I have tried everything to stop it. That's when it's time to check a sugar, put in a line, and hall balls to the hospital.


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## EMT-IT753 (Sep 7, 2011)

The other airway concern I have that was not mentioned is suctioning. Most seizures I have encountered have a fair amount of drooling which I would prefer to not have them aspirate. You can still get a Yankauer tip on the side of the teeth if absolutely necessary.


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## medicsb (Sep 7, 2011)

Use an NPA, place a NRB.  You could try to bag them, I suppose, but you also risk gastric insufflation.  

IIRC, the conventional definition of status epilepticus was a seizure lasting >30 minutes.  So... they can flop for quite a while.  If they weren't breathing at all, they'd code pretty quickly.


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## Strap (Sep 7, 2011)

medicsb said:


> Use an NPA, place a NRB.  You could try to bag them, I suppose, but you also risk gastric insufflation.
> 
> IIRC, the conventional definition of status epilepticus was a seizure lasting >30 minutes.  So... they can flop for quite a while.  If they weren't breathing at all, they'd code pretty quickly.



We were taught status epilepticus > 5 minutes, or two consecutive seizures without a period of responsiveness between them.


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## medicsb (Sep 7, 2011)

Strap said:


> We were taught status epilepticus > 5 minutes, or two consecutive seizures without a period of responsiveness between them.



I should have been more clear - the OLD definition was 30 minutes.  (Actually, at one point is 60 minutes.)  But, yes, what you were taught is the modern definition, which is much more applicable as seizures usually do not self terminate if they haven't by 5 minutes.


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## ArcticKat (Sep 7, 2011)

usafmedic45 said:


> If things get really FUBAR, you can paralyze them and tube them (remember though, the seizure is still ongoing even if you give paralytics; even if the patient isn't convulsing, you can still get a lot of bad effects from protracted seizures) or you can do a surgical airway if all other options fail in a status epilepticus case.



I didn't bother commenting to that stuff because this is a BLS forum and I thought it best to leave things at the BLS level.


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## Cup of Joe (Sep 7, 2011)

usafmedic45 said:


> Wanna bet?  Which blithering moron told you that one?



I was taught to move objects that could be hazardous, like furniture, and just let them seize because there's nothing we can do for them.  If it goes on for an extended period of time, call ALS.

I also remember some first aid class I took long before EMT class saying to roll them into a lateral recumbent position and place something soft under their head so they don't aspirate.


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## usafmedic45 (Sep 7, 2011)

Cup of Joe said:


> I was taught to move objects that could be hazardous, like furniture, and just let them seize because there's nothing we can do for them.  If it goes on for an extended period of time, call ALS.
> 
> I also remember some first aid class I took long before EMT class saying to roll them into a lateral recumbent position and place something soft under their head so they don't aspirate.


Right but who told you that you couldn't bag them?  Welcome to one bit of information almost as dangerous as the old "shove a spoon in their mouth" trick....


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## Cup of Joe (Sep 7, 2011)

usafmedic45 said:


> Right but who told you that you couldn't bag them?  Welcome to one bit of information almost as dangerous as the old "shove a spoon in their mouth" trick....



EMT instructor as part of the "leave em alone, theres nothing you can do till they stop." lecture we received.


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## usafmedic45 (Sep 7, 2011)

Cup of Joe said:


> EMT instructor as part of the "leave em alone, theres nothing you can do till they stop." lecture we received.



Assuming that you heard him correctly, to put it mildly your instructor is a :censored::censored::censored::censored:ing moron.  Just because they are seizing does not mean you are precluded or excused from providing basic life support skills.


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## Cup of Joe (Sep 7, 2011)

usafmedic45 said:


> Assuming that you heard him correctly, to put it mildly your instructor is a :censored::censored::censored::censored:ing moron.  Just because they are seizing does not mean you are precluded or excused from providing basic life support skills.



Would you bag them in a lateral recumbent position or supine?


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## usafmedic45 (Sep 7, 2011)

Usually supine.  If you're on scene, one would most likely have access to some form of suction.  Also, despite my loathing of anecdotal evidence, I can't recall having ever seen a seizure patient (other than toxic or traumatic seizures) spontaneously vomit in 15 years.


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## Melclin (Sep 7, 2011)

We have closed circuits with soft bags which allow the pt to breath spontaneously and for you to monitor the Vt, resp rate. This has been, and is, my preference +/- a nasal airway.


I suppose a BVM would do if I didn't have anything else, but its never crossed my mind.

A first aid course? You don't think that maybe there might be some differenced between first aid for the lay person and professional management of a seizure? These people who say there is nothing to do for seizure pts, are they not even advocating supplemental oxygen?



usafmedic45 said:


> Usually supine.  If you're on scene, one would most likely have access to some form of suction.  Also, despite my loathing of anecdotal evidence, I can't recall having ever seen a seizure patient (other than toxic or traumatic seizures) spontaneously vomit in 15 years.



I went to a bloke two months ago, seizure disorder since having a stroke several years ago, he'd vomited a lot when we arrived and was continuously seizing. He continued to vomit periodically throughout the seizure. It was a nightmare airway to manage. So this is rare? That's good to hear.


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## Cup of Joe (Sep 8, 2011)

Melclin said:


> A first aid course? You don't think that maybe there might be some differenced between first aid for the lay person and professional management of a seizure? These people who say there is nothing to do for seizure pts, are they not even advocating supplemental oxygen?



First aid course was when I was like 12.  And I never said not to do anything for them, just was told we should not do anything for them while they are seizing, but have now learned otherwise.

Knowing how stupid some people can be, what would you say EVERY EMT should do for EVERY seizure case?  Someone thought it would be to move objects they could hurt themselves with and wait for them to stop seizing before continuing with patient care.


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## the_negro_puppy (Sep 8, 2011)

As others have said NPA usually due to trismus. Hopefully if you are ALS you can get midazolam (or equiv) on board quickly. If you dont need to bag, lateral position with NRB is the next go to for us.


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## usafmedic45 (Sep 8, 2011)

> I went to a bloke two months ago, seizure disorder since having a stroke several years ago, he'd vomited a lot when we arrived and was continuously seizing. He continued to vomit periodically throughout the seizure. It was a nightmare airway to manage. So this is rare? That's good to hear.



I can't recall the last epileptic I saw vomit.  It's not uncommon at all with seizures due to toxidromes or increased intracranial pressure.


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## Handsome Robb (Sep 8, 2011)

Cup of Joe said:


> Knowing how stupid some people can be, what would you say EVERY EMT should do for EVERY seizure case?  Someone thought it would be to move objects they could hurt themselves with and wait for them to stop seizing before continuing with patient care.



Cookbook medicine much? Treat the pt with what is necessary for that pt. 

Protect the pt from harming themselves and supply o2 and airway support as needed.


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## Melclin (Sep 8, 2011)

Cup of Joe said:


> First aid course was when I was like 12.  And I never said not to do anything for them, just was told we should not do anything for them while they are seizing, but have now learned otherwise.
> 
> Knowing how stupid some people can be, what would you say EVERY EMT should do for EVERY seizure case?  Someone thought it would be to move objects they could hurt themselves with and wait for them to stop seizing before continuing with patient care.



Ah okay. Fair enough then. Perhaps I should have paid more attention to the post. 

I teach my volly FRs:
- Call an ambulance (In an EMTs case, ALS).
- Apply oxygen therapy.
- Note the time at the start of the seizure/approximate the time. 
- Support: Lateral position if possible (but don't force the issue), cushion for the head, move nearby objects. (I think this is mostly window dressing, I've not come across a seizure pt who was flailing so wildly that I needed a 4 metre safey cordon, but I could be wrong). 
- Collect medical/recent history from family/friends. 

I think the first two are the most important with a decent shot at the third. Whether or not this is appropriate for an EMT, is up to you and of course, I may be mistaken. I like the sound of my own voice enough to know that I'm wrong occasionally.


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## Melclin (Sep 8, 2011)

usafmedic45 said:


> I can't recall the last epileptic I saw vomit.  It's not uncommon at all with seizures due to toxidromes or increased intracranial pressure.



Ah well this could easily have been another bleed with ^ICP.


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## mgr22 (Sep 8, 2011)

Not sure if this was already covered, but sometimes simply positioning the seizing pt on his/her side will help maintain the airway.


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## AlphaButch (Sep 8, 2011)

Do what you can do when you can do it. Have everything ready for when you get the chance (NPA, O2, BVM, Suction, etc). Depending on the type and severity of the seizure, you may or may not be able to treat your patient while she/he is actively seizing.

Clearing the immediate area is a good thing (depending on the seizure, throw  pillows down), for both the patient's safety and to allow the provider access. Alot of the seizure calls I've done, I arrived to find the pt stuffed someplace where I end up playing contortionist or the pt has secondary injuries (normally from the initial fall upon seizing).


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## mycrofft (Sep 8, 2011)

*Most of the bases are covered.*

As with any pt contact, the biggies are what NOT to do, and the list for laypersons/bystanders is longer than those we have, right? (That presumes we all know the "wrongs" already).

EMT-B support: oxygen, call for higher EMS (might need Rx if seizures return or won't stop) , prevent harm including from bystanders, do what is needed and what can be accomplished for airway (including positioning, NPA, suction as needed). During the seizure, not too much you can do, but do what you can. Gather data as to the cause (extant disorder, poison, electricity, post-vasovagal, etc). NO ad hoc cricothyrotomies. NO thrusting of foreign objects to try to open the jaws. If you ahve an old "bite stick", toss it right now.












In the jail, first step was to spend one half second with an ammonia capsule as contact was made, but I never approached without oxygen and suction being on the way too. Easier to call it off than start it up tardily.

I have seen vomit from the onset but not during the seizure, no significant tongue lacs, some lip and gum bleeding from trauma, some pretty impressive but not serious buccal excoriations; drool was an issue more often than other fluids. Retronasal bleed from falling or being punched was sometimes apparent, but actually spotted only after the trismus had relaxed. Since we were mostly addressing saliva or fresh/little blood, just sliding the suction tip along the buccal margin was pretty good until that one guy shattered the Yankauer by biting it and the bits disappeared into his maw.


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## MonkeySquasher (Sep 9, 2011)

usafmedic45 said:


> I can't recall the last epileptic I saw vomit.  It's not uncommon at all with seizures due to toxidromes or increased intracranial pressure.



Same.  Only seizure I had vomit during was due to ICP.  Got them to the ER, seized again, coded.  Older person + anticoags + head trauma.



Cup of Joe said:


> I was taught to move objects that could be hazardous, like furniture...
> 
> I also remember some first aid class I took long before EMT class saying to roll them into a lateral recumbent position and place something soft under their head so they don't aspirate.



I tend to have my partner move furniture, I sit and craddle their head in my lap.  This allows me to both prevent the head from impacting hard surfaces, and maintain an open airway as much as possible.  It also allows me to do the third thing....



MasterIntubator said:


> NPA is our tool of choice.  Its easy, quick and when properly set it will do its job when they come out of the seizure. ( reduce the snoring, etc. ).   Every couple of months we get a "seizure" that miraculously stops seizing and avoid the NPA at all costs.
> :rofl:



^ THIS.  If they're seizing by the time I get there (initial action, 911 call, dispatch, response time), it's either a very prolonged seizure, or another seizure without a period of responsiveness.  Either way, they're serious, and I need to treat a bit more aggressive.  I hold the head, ensure an open airway, and put in an NPA.  They either take it like a champ or, more often than not, suddenly wake up from the seizure.  And strangely enough, those are usually the people in police custody....


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## usafmedic45 (Sep 9, 2011)

> If you ahve an old "bite stick", toss it right now.



Hey....they make good finger splints. LOL


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## Shishkabob (Sep 9, 2011)

NPA schem-pa.


Roc/Etomidate and an ETT!  h34r:


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## usafmedic45 (Sep 9, 2011)

Linuss said:


> NPA schem-pa.
> 
> 
> Roc/Etomidate and an ETT!  h34r:



Yeah, except it's not going to fix the problem and it's going to piss off the ER doc.

BTW, I realize you're being sarcastic


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## Shishkabob (Sep 9, 2011)

Meh, if crap tons of ativan and versed aren't terminating the seizures, they're in status, flight (who has barbs) is really far away, and it will take me a real long time to get to the hospital, and they're desatting despite bagging... that's really all that's left.  :unsure:



Having said that, my only "status" patient wasn't TOO status as to even contemplate that route


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## Bullets (Sep 9, 2011)

One more reason i love the NPAs and pretty much allow the OPAs to gather dust. They are great at securing an airway quickly, and shoving a tube up someones nose is a quick way of sorting out real seizures from the fakers in a far more hilarious way then the arm drop.

Also, jaw screw? i actually know a squad that used to carry that as recently as 2 months ago. I threw it out


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## neslar (Sep 9, 2011)

you don't touch the PT while he is seizing just move furniture away and hard objects.
after PT is done seizing if he can maintain his own airway non rebreather mask will be fine.
if Pt is unresponsive head tilt chin lift will be fine, unless you suspect PT injured his spine or neck whilst seizing then insert an NPAincase he starts seizing again, you wouldn't want an OPA in his mouth and bag im with supplmental O2.


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## Medicman59 (Nov 18, 2020)

Wow! some of you people scare me! your going to attempt to put an OPA in a Pt. having a seizure! GO BACK TO SCHOOL!


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## CCCSD (Nov 18, 2020)

9 year old post...


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## ffemt8978 (Nov 18, 2020)

CCCSD said:


> 9 year old post...


Not the record but this one is done.


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