While walking her dog, one of my patients witnessed a stranger having a generalized seizure. Someone called 911 and the man was transported to the hospital. My patient was shaken by the incident and wonders what she could have done to help. What should bystanders be taught to do in such a situation?-C.M., MO.

Wendi P. Rank, MSN, RN, CNRN, replies: For a bystander without a medical background, witnessing a seizure can be frightening.1 As nurses, we have the knowledge and opportunity to educate the public about seizures and their initial emergency management.2 Public education is especially important when someone at risk for seizure is likely to be present.3,4 For example, if a high-school student has a diagnosed seizure disorder, the student's teachers and school personnel who interact with the student would benefit from bystander education on seizure first aid.

All bystander education should include a thorough discussion of seizure identification, types of seizures, and recognition of life-threatening situations during a seizure. The CDC and the Epilepsy Foundation provide materials and courses for instructing various groups in the lay public (see Resources for bystander education).3,4

Bystanders should know that supporting airway, breathing, and circulation are the first priorities.5 However, they should be informed that breathing may be restricted in the tonic phase, making the victim appear apneic. This is normal and rescue breathing is typically not needed as the tonic phase usually lasts only about 15 seconds. If breathing does not resume in the clonic phase, emergency intervention and rescue breathing are indicated.2,3

Also inform bystanders that most epileptic seizures are not life-threatening.2 However, seizures can have many causes besides epilepsy, and some of these are life-threatening. Because a bystander who encounters a stranger experiencing a seizure will not know the person's seizure or health history, the bystander should call 911 to ensure appropriate evaluation and treatment (see Calling 911).

Any bystander can initiate simple seizure first aid. The Epilepsy Foundation advocates for "Stay, Safe, Side" as a mnemonic for bystanders.3

Stay. Teach bystanders to ease the person to the ground, if necessary, and protect the head. They should remain with the person for the duration of the seizure and the postictal phase. Instruct them to be calm, check for medical identification jewelry, and time the seizure. Many people with seizure disorders have emergency information on their cell phone.

Safe. Teach bystanders to keep the victim safe by removing him or her from any potentially hazardous situations, such as water or traffic. Disperse any crowds but ask for another person to remain in the event the bystander requires additional assistance.

Side. Teach bystanders to turn an unresponsive victim on the side to clear any secretions. Loosen tight clothing. Tell bystanders not to place anything in the victim's mouth or try to hold the victim down. If possible, they should remove furniture and other objects that pose an injury risk. They should not let the person eat or drink until fully alert.3

In the immediate period after the seizure, the person can have impaired consciousness or be confused. The bystander should calmly explain what happened using simple language.

Educating the community about seizures has been shown to decrease the public's apprehension of witnessing a seizure, as well as decrease the stigma that often surrounds people with epilepsy. The nurse can play an important role in this education.

Calling 911

Teach bystanders who encounter someone experiencing a seizure to recognize circumstances that require activation of emergency medical services (EMS). The CDC and the Epilepsy Foundation recommend emergency intervention if the seizure is known to be a first seizure or the seizure history is not known; the victim is pregnant, sick, or injured; the seizure lasts longer than 5 minutes or is recurrent; or the victim has difficulty breathing.3,4

The American Heart Association's basic life support (BLS) algorithm for approaching an unresponsive victim provides a framework for the initial approach.5 The first thing a bystander should do is evaluate the safety of the situation. Bystanders should be taught to approach the victim only if the situation appears safe. Bystander education should also cover these points:

* If circumstances warrant EMS activation, teach bystanders to support airway, breathing, and circulation until emergency responders arrive. In emergency seizure situations, the victim may require rescue breathing and/or chest compressions. Bystanders trained in BLS are qualified to provide these interventions until emergency transport arrives.5

* Educate bystanders about status epilepticus, which is a medical emergency. Status epilepticus can be presumed if a seizure lasts longer than 5 minutes or the seizures are recurrent without recovery time between events.2

* If trauma is involved, bystanders should not move the victim due to the risk of spinal cord injury.

Resources for bystander education

* Centers for Disease Control and Prevention: Seizure first aidhttp://www.cdc.gov/epilepsy/about/first-aid.htm

* EndEpilepsy: Seizure first aid starts with using your brainhttps://endepilepsy.org/wp-content/uploads/2019/01/SeizureSafetyPoster.pdf

* Epilepsy Foundationhttp://www.epilepsy.com

REFERENCES