Seizure ⚡️
Emergency management of seizures and status epilepticus. Midazolam (buccal/intranasal), benzodiazepines, antiepileptics, and neurology referral for on-call doctors.
🧠 Differential
- Epileptic seizure (known epilepsy?)
- Alcohol withdrawal (DTs)
- Metabolic: Na, Ca, glucose, urea
- Structural: tumour, bleed, infection
- Non-epileptic: pseudoseizure
📞 Immediate Actions
- A–E assessment
- Protect airway & patient (side position, clear surroundings)
- Check vitals, oxygenate, consider suction
- IV access, bedside glucose
- Urgent bloods: U&E, glucose, calcium, toxicology, LFTs
- ECG
🚑 Ongoing Seizure (Status Epilepticus)
- Defined as seizure >5 min or recurrent seizures without recovery
- Initial rescue therapy: Midazolam 5mg intranasal or buccal if no IV access
- 3 minutes later: Midazolam 5mg intranasal or buccal again if still seizing
- 2 minutes later: Lorazepam 2mg IV slowly over 2 mins
- 2 minutes later: Lorazepam 2mg IV again if still seizing
- 2 minutes later: Levetiracetam 60mg/kg IV (max 4500mg) over 10 minutes
- If still seizing: proceed to RSI with Propofol or Phenobarbital and ICU support
- Throughout: ensure airway protection, cardiac monitoring, glucose and electrolytes
🔍 Post-Ictal Workup
- CT Brain if first seizure or focal neurology
- Consider LP if infection suspected
- Drug/alcohol screen if relevant
- Collateral history from witnesses
⚠️ Red Flags
- GCS < 8 after seizure
- Prolonged post-ictal state >30–60min
- Focal neurology or trauma signs
- Multiple seizures or status epilepticus
📋 Plan
- Seizure terminated → Neuro Obs 1-hrly until GCS 15
- Antiepileptic drug (AED) restart if known epilepsy
- Neurology referral for new seizures
- Driving advice: no driving for minimum 6 months
Related NICE guidance
NICENICE NG217 — Epilepsies in children, young people and adults
Full guidance on nice.org.uk. BetterCall is not endorsed by NICE.
Note Template
Ready-to-use clinical note structure
🕒 08 / 10 / 2026 — 16:07 ATRP re: seizure Patient: [age] [sex] Admission Dx: [reason for admission] PMHx: [epilepsy, brain injury, metabolic disorders] 🧾 Hx: • Type and duration of seizure • Witnessed activity and post-ictal state • Previous seizure history and medications • Triggers: infection, non-compliance, alcohol 🩺 Exam: • ABCDE assessment • Vitals: HR __ BP __ RR __ Temp __ SpO₂ __ • Neurological exam: GCS, focal deficits • Signs of trauma or tongue biting 📋 Impression: Likely seizure type: [generalised / focal / status epilepticus] 📌 Plan: • Ensure airway patency and oxygenation • Check glucose and correct hypoglycaemia • IV/IM benzodiazepines if active seizure • Bloods: electrolytes, anticonvulsant levels • Neuroimaging if first seizure or focal signs • Review and optimise anti-epileptic drugs • Monitor for recurrence and escalate if needed 👤 [Your Name], [Role] IMC: _______
Educational reference only. Medical disclaimer