Acute Seizure (Including Status Epilepticus)
Updated UKMLA guide to acute seizure management, including first aid measures, status epilepticus, repeated seizures or cluster seizures, and prolonged seizure management.
First Aid Measures
- Time the seizure duration (start and finish)
- Protect the person from injury
- Cushion their head with a pillow
- Loosen tight clothing
- Remove harmful objects from nearby
- Only attempt to move the patient if they are in danger (e.g. near a busy road or hot cooker)
- When the seizure stops, check the airway and place them in the recovery position
- Stay with the patient until they have recovered
Do NOT restrain the person or put anything in their mouth
Call an ambulance if ANY of the following: [Ref]
- 1st seizure
- Seizure lasts longer than usual
- Unsure about seizure duration OR seizure lasted >5 min
- Patient did not regain full consciousness, or has several seizures without regaining consciousness
- Patient is seriously injured during the seizure
- Patient has difficulty breathing after the seizure
Patients with established epilepsy do NOT always need an ambulance or to go to the hospital every time they have a seizure. [Ref]
Status Epilepticus
Status epilepticus is defined as:
- Seizure that lasts 5 minutes or more, or
- Recurrent seizures without recovery in between
Adults Management
Manage as a medical emergency:
- A-E approach
- Secure the airway and give oxygen (if available) and assess cardiac and respiratory function
- Give immediate emergency treatment as detailed in the patient’s individualised emergency management plan if immediately available
General algorithm for those without an individualised emergency management plan:
If a 2nd line medication is being used, it should preferably be one that is different from those used by the patient routinely.
After an episode of convulsive status epilepticus, agree an emergency management plan with the person if they do not already have one and there is concern that status epilepticus may recur.
If a patient with unprovoked 1st seizure has ANY of the following, perform a CT head in the emergency department [Ref]
- New focal neurological deficit
- Persistent altered mental state
- Prolonged headache or fever
- Recent head trauma (consider need to image the cervical spine)
- History of immunosuppression, cancer, HIV or suspected HIV
- Anticoagulant use
- Previous stroke or neurological condition making assessment of deviation from
baseline uncertain - New seizure in patients over 65 years old
Do not carry out a CT scan for people with established epilepsy presenting at an emergency department after a typical seizure, unless there are other concerns such as: [Ref]
- New focal neurological deficit
- Persistent altered mental state beyond what is usual for the patient in the post-ictal phase
- Prolonged headache or fever
- Recent significant head trauma
- History of immunosuppression, cancer, HIV or suspected HIV
Management in Children
The management algorithm is largely the same as the adult one (see above), apart from the following:
- Rectal diazepam should be avoided
- For 2nd line medications, phenobarbital should be used instead of sodium valproate
Repeated Seizures or Cluster Seizures
Definition: 3 or more self-terminating seizures in 24 hours
Manage as a medical emergency:
- A-E approach
- Secure the airway and give oxygen (if available) and assess cardiac and respiratory function
- Give immediate emergency treatment as detailed in the patient’s individualised emergency management plan if immediately available
If the patient does NOT have an individualised emergency management plan → consider giving a benzodiazepine (e.g. clobazam or midazolam) immediately
Prolonged Seizures
Definition: seizure continuing for 2 minutes longer than the person’s usual seizure
Manage as a medical emergency:
- A-E approach
- Secure the airway and give oxygen (if available) and assess cardiac and respiratory function
- Give immediate emergency treatment as detailed in the patient’s individualised emergency management plan if immediately available
If the patient does NOT have an individualised emergency management plan → consider giving a benzodiazepine (e.g. clobazam or midazolam) immediately
Importantly, if the seizure continued for 5 minutes or more → follow the status epilepticus management algorithm