What to Do if You Witness a Seizure, and Other Seizure Basics for Primary Care

Matthew F. Watto, MD; Paul N. Williams, MD


April 23, 2021

This transcript has been edited for clarity.

Matthew F. Watto, MD: We are The Curbsiders. I'm Dr Matthew Frank Watto, here with my good friend, Dr Paul Williams. Tonight we're going to tell you about our favorite pearls from a recent podcast interview with Dr Sara Dawit on the topic of seizures, with a particular bent toward primary care or the patient with new seizures.

Paul, what do you think about the seizure rapid response? We talked about happening upon a patient who was having a seizure, and Dr Dawit gave us some great tips on what we should do in that situation.

Paul N. Williams, MD: I love that stuff. It was helpful and also reassuring that I haven't done anything too profoundly stupid. The House of God was even referenced; the first thing you do in any kind of rapid-response situation is check your own pulse, which I think is a wise thing to do. Take three deep breaths; just reorient yourself. Even though seizures are kind of scary to witness, especially if you don't see them very often, you'll do better if you're not freaking out.

The next part is confirming patient safety. She gave us a lot of practical advice about that, and it always comes down to fundamentals. Assess your ABCs, make sure their airway is clear, that they're breathing okay, and there doesn't seem to be any impending circulatory collapse. Keep the patient on their side if possible.

She also gave more practical pointers, things that I hadn't thought of, that you should do if you have the presence of mind, such as filming the seizure with your phone so that you can replay it for the treating team. It's a great piece of advice. Timing the seizure is something else I never would have thought to do because they feel like they last about 17 hours when you're witnessing them. It can be a potentially traumatic event.

But don't put anything in their mouth. Just keep them as safe as possible is the takeaway point. Dr Dawit had a lot of really great practical pointers for a witnessed seizure, which is not often the context that we see, but it can happen sometimes.

Watto: I loved all of that. I would have no idea what to do. I think maybe I would try to hold somebody away from dangerous objects. But other than that, I don't think I would have known to time it and to video it.

She gave us some good, easy-to-remember primary care pearls. One was to check the levels of the meds they're on once a year, especially if they haven't been seeing their neurologist. Usually those levels will come up. They tell you what the normal range is in the record.

What were your favorite primary care pearls?

Williams: We see this a lot in primary care, especially if someone is very stable from a seizure standpoint and they don't need to talk with their neurologist as frequently. It falls to us to monitor the medication levels.

The primary care point that really stuck with me, because it's not something I was as cognizant of, was the frequent comorbidity of mood disorders among patients who are living with seizure disorder. There's upwards of a 50% prevalence of depression and anxiety among patients with seizures, and these patients are 3.5 to 5.8 times more likely to die from suicide than patients without seizures, which is a really sobering number. I will be much more diligent about screening and being mindful of possible accompanying mood disorders in someone who has a diagnosis of seizure disorder as well.

Dr Dawit had some great practical tips in terms of seizure precautions, which also tend to fall through the cracks.

Watto: The driving restrictions vary by state. She also mentioned supervision around water and taking showers rather than baths. If they are going to be near water, let people know [ahead of time]. Climbing up high on a ladder or a roof is probably not a good idea for them. Other dangerous activities include bikes, skateboards, and horseback riding. You have to really think about those things.

She mentioned epilepsy-safe pillows. I don't know how many people are using them, and the jury's still out as to how well those work. The bigger point that it brings up with me is that some patients die in their sleep. They have a seizure in their sleep, and if they are face-down in bed, they can asphyxiate.

Williams: It was helpful to be reminded of these things because we get so fixated on the medical management that sometimes we forget about the life part — what happens after the patient leaves the office.

Watto: The final primary care point is basic counseling, such as telling patients that sleep can be a trigger. They need to take care of their sleep and watch their alcohol intake. Run through the patient's medication list to see if they are on any drugs that lower the seizure threshold. There are a lot of them.

Williams: Even some antibiotics, if I'm not mistaken.

Watto: Yes, and tramadol, bupropion — some of our favorites.

Williams: The drugs that toxicologists love.

Watto: If this sounds like something you're interested in and you want to hear a lot more about seizures from a really fantastic expert, then click on #257 Carpe Diem: Seizure Basics for Primary Care to hear our full audio interview with Dr Sarah Dawit.

And you can also join our mailing list and get a PDF copy of our show notes every week.

Thank you for watching.

The Curbsiders are a national network of students, residents, and clinician educators from across the country, representing 15 different institutions. They "curbside" experts to deconstruct various topics in the world of medicine to provide listeners with clinical pearls, practice-changing knowledge, and bad puns. Learn more about their contributors and follow them on Twitter.

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