Seizures result from abnormal, excessive neuronal activity in the brain and may be provoked (e.g., hypoglycemia, hypoxia, electrolyte imbalance, toxic exposure) or unprovoked (e.g., epilepsy). Seizure presentations vary widely, and not all seizure-like activity represents epileptic disease. Most generalized seizures are self-limiting and resolve within 1 to 2 minutes, followed by a post-ictal period. The role of paramedics is to identify seizure type, treat reversible causes, terminate active seizures when indicated, and determine the appropriate disposition. Under ALS-PCS v5.4, selected patients who have returned to baseline may be considered for treat and discharge, provided strict criteria are met.

By the end of this tip, paramedics will be able to recognize common seizure types and determine which patients meet ALS-PCS criteria for treatment and discharge versus mandatory transport.

You respond to a 27-year-old patient with a known history of epilepsy. Family report a generalized tonic-clonic seizure lasting approximately 90 seconds, consistent with the patient’s usual seizures. On arrival, the seizure has stopped. The patient is initially post-ictal but gradually becomes alert, oriented, and returns to their normal baseline. Vital signs and blood glucose are normal.
Does this person require ongoing care, or are they safe to discharge?

Common seizure types paramedics may encounter include:

1. Generalized Seizure
   1. Sudden LOC, tonic stiffening followed by rhythmic clonic movements
   2. Often followed by post-ictal phase
   3. May be epileptic or provoked by metabolic/toxic causes  
2. Focal (partial) Seizures
   1. Motor, sensory, or behavioural changes without full loss of consciousness
   2. Post-ictal confusion may be minimal or absent
3. Absence Seizures
   1. Brief staring spells, typically no post-ictal state
   2. More common in pediatric population
4. Status Epilepticus
   1. When any seizure lasts more than 5 minutes or when seizures occur very close together and the person does not recover consciousness between them
5. Physcogenic Nonepileptic Seizures (Functional Seizures)
   1. Prolonged or fluctuating episodes
   2. Eye tightening, crying, talking, or purposeful movement
   3. Rapid return to baseline

Important note: PNES are real medical events, not intentional or “faked”. Management focuses on patient reassurance, assessment for injury or medical illness, and disposition based on overall presentation.

Treat and discharge is an appropriate, evidence-based outcome for select seizure patients who fully recover and meet ALS-PCS criteria. Recall your IDEAL discharge planning framework:

I - Incldue the patient and family as full partners

• Engage the patient and caregivers early
• Confirm who will assist at home
• Encourage questions
• Avoid provider-only decision making

D - Discuss key areas

Specifically:

• Medications (changes, new prescriptions, stopped meds)
• Warning signs and symptoms
• Follow-up appointments
• Daily living needs
• Test results

E - Educate using teach-back 

• Use plain language
• Ask the patient to repeat instructions in their own words
• Clarify misunderstandings immediately
• Provide written instructions (if required)

A - Assess understanding and barriers

• Health literacy
• Transportation
• Financial constraints
• Home supports
• Cognitive limitations 

L - Listen to and honor patient preferences

• Cultural considerations
• Goals of care
• Capacity and autonomy
• Feasibility of the plan 

When a patient with known epilepsy returns to baseline after a typical seizure, consider how applying ALS-PCS criteria can safely support treat and discharge as the right clinical decision.