1. If an adult has an uncomplicated seizure for the first time, they recover back to baseline with a normal neurological exam, and they have a normal MRI of the brain and EEG—to look at brain waves to make sure they don’t show evidence of seizure activity or a risk of seizures. If both scans are normal then we do not put patients on seizure medication. Two seizures in the same day may be counted as one seizure episode.
2. If the MRI of the brain is abnormal, showing recent injury or injury that happened some time ago, and it is a one-time seizure, we put patients on seizure medication. This is called lesional epilepsy. 
3. Once someone has a second seizure on a different day they are prescribed seizure medication, even if they have a normal MRI or EEG of the brain. 

Many people struggle with knowing when to call 911 when they have a seizure and end up calling with every seizure. They are usually sent home after the ER checks the blood level of their seizure medication and sees they are back to baseline, provided they have a normal CAT scan of the brain. This is usually the protocol of the ER when someone has a history of seizures. Emergency medicine physicians require additional reasons to admit someone that has a history of seizures other than a one-time seizure where the patient is normal afterwards without any complaints. First-time seizures are usually always admitted to the hospital from the ER because the cause can be anywhere from meningitis, to hemorrhagic stroke (bleeding in the brain), ischemic stroke (loss of blood to a part of the brain), drug overdose or other life-threatening medical conditions. Alcohol withdrawal-induced seizures are not helped by seizure medication. Also if you are placed on seizure medication be sure to go over the common long-term side effects with your doctor–remember the rare side effects are always mixed in. You may have a better chance of hitting the lottery than getting certain side effects to medications. However, remember someone wins the lottery every week but the majority never do. Always make sure the physician ordering the MRI has asked for an epilepsy protocol to be added to the MRI. That is a special protocol that does fine cuts through a part of the brain called the temporal lobes and other structures next to it to look for structural abnormalities such as a scar. If this is found it is considered temporal epilepsy and can be significantly helped or cured by surgery in up to 80% of cases. 

A little seizure vocabulary: ictal means seizure; the words are synonymous. Post-ictal means after the seizure and is the period where the seizure-related movement has stopped and the person either falls asleep or is very disoriented, confused and/or combative. The time of the seizure begins with the staring spell or abnormal movement and the clock stops when the movement stops. Don’t count the part where the person is disoriented but ask them orientation questions (year, month, city, or who you are if you know them). This must be differentiated from when someone does not have a seizure but passes out (syncope) and trembles for a while, then comes to and wonders what happened. This is not being disoriented but just waking up on the floor and not knowing how you got there. This is always confused by physicians and other people into thinking the person had a seizure when they simply fainted or passed out. Often it is because of heart problems, low blood sugar, or blood pressure issues. However, the list of reasons can be much longer. 

What to do when someone is having a seizure

Many seizure types—such as generalized absence seizures or complex partial seizures, which involve relatively brief episodes of unresponsiveness—don’t require any specific first-aid measures.

1. Stay calm
2. Prevent injury
During the seizure, you can exercise your common sense by ensuring there is nothing within reach that could harm the person if he/she struck it.
3. Pay attention to the length of the seizure
4. Make the person as comfortable as possible
5. Keep onlookers away
6. Do not hold the person down
If the person having a seizure thrashes around, there is no need for you to restrain them. Remember to consider your safety as well.
7. Do not put anything in the person’s mouth - Contrary to popular belief, a person having a seizure is incapable of swallowing their tongue so you can breathe easy knowing that you do not have to stick your fingers into their mouth if someone in this condition.
8. Do not give the person water, pills, or food until fully alert
9. If the seizure continues for longer than five minutes, call 911
10. Be sensitive and supportive, and ask others to do the same

Special situations

A seizure in water

If a seizure occurs in water, the person should be supported in the water with the head tilted so his face and so that their head remains above the surface. He/she should be removed from the water as quickly as possible with the head in this position. Once on dry land he should be examined, and if he is not breathing, artificial respiration should begin at once. Anyone who has a seizure in water should be taken to an emergency room for a careful medical check-up, even if he appears to be fully recovered afterwards. Heart or lung damage from ingestion of water is a possible hazard in such cases.

A seizure in an airplane

If the plane is not filled, and if the seat arms can be folded up, passengers to the left and/or right of the affected person may be reassigned to other seats so that the person having the seizure can be helped to lie across two or more seats with their head and body turned on one side. Once consciousness has fully returned, the person can be helped into a resting position in a single reclining seat. If there are no empty seats, the seat in which the person is sitting can be reclined, and once the rigidity phase has passed, he can be turned gently while in the seat so that he is leaning towards one side.

Pillows or blankets can be arranged so that the head doesn’t hit unpadded areas of the plane. However, care should be taken that the angle at which the person is sitting is such that his airway stays clear and breathing is unobstructed.

A seizure on a bus

Ease the person across a double or triple seat, turn him on his side, and follow the same steps as indicated above. There is no reason why a person who has fully recovered from a seizure cannot stay on the bus until he arrives at his destination, if he wishes to do so.

What to do and when to call 911 when you have a seizure

For adults, 911 is called for the following reasons:

1. It is the second seizure and the person does not return to normal, or it is a seizure that lasts for more than 5 minutes. This is considered status epilepticus (uncontrolled seizures that do not stop). Seizures usually last 2–3 minutes and no longer than 5 minutes.
2. The person does not have epilepsy or you don’t know if they have epilepsy. Look for an ID bracelet or ID card. 
3. The person is pregnant, has diabetes, is injured in some way, appears to be ill, or has had a seizure while in water deep enough to cover their head such as in a bathtub or swimming.  
4. The person experiences breathing difficultly or shows other abnormal physical signs of distress after the seizure is over. 

The Epilepsy Foundation of America has classes, information seminars, and educational materials to arm you with everything you need to know about seizures. Also remember that all states have different rules for physicians or ERs to report seizures and different restrictions on driving after a seizure so check your local DMV.