Seizures lasting for more than 30 minutes or repeated seizures without regaining consciousness between them.

The goal is to stop seizures within 20 minutes.

Consider eclampsia in pregnant patients and check the urine and BP: call a senior obstetrician—immediate delivery may be needed.

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Investigations

1. Initial bedside tests:

   • Random Blood Glucose
   • Pulse oximetry
   • ABG
   • Urea & Creatinine
   • Electrolytes
   • Ca²⁺
   • CBC
   • ECG

2. Additional investigations (once treatment has started):

   • Anticonvulsant levels
   • Toxicology screen
   • LP
   • Blood and urine cultures
   • EEG
   • CT brain
   • Carbon monoxide level
   • Cardiac monitoring

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Management

• Basic Life Support
• Open and secure the airway. Use adjuncts if necessary. Remove poorly fitting teeth if poorly fitting
• Oxygen, 100% + suction (as required)
• IV access and take blood tests
• Lorazepam 0.1 mg/kg (usually 4 mg) as a slow bolus into a large vein.
• If no response after 10–20 minutes, give a second dose.
• Warning Be cautious of respiratory arrest during the last part of the injection. Ensure full resuscitation equipment is available.
• Alternative Routes If IV access is difficult:
• Rectal Diazepam.
• Buccal Midazolam:
  • squirt half the volume between the lower gum and the cheek on each side
  • Adults and children over 10 years: 10 mg
  • Children 5–10 years: 7.5 mg
  • Children 1–5 years: 5 mg
• Thiamine 250mg IV over 30min if alcoholism or malnourishment suspected
• Glucose 50mL 50% IV, unless glucose known to be normal
• Treat acidosis if severe (contact ICU)
• Correct hypotension with fluids
• If fits continue
• Phenytoin Infusion: 15–18mg/kg IVI (roughly 1g if 60kg, and 1.5g if 80kg; max 2g) at a rate of 50mg/min (maximum rate).
• Maintenance dose: 100mg/6–8h (check levels).
• don’t put diazepam in same line: they don’t mix.
• do not use if bradycardiac or heart block.
• Warning: Monitor BP and ECG for potential hypotension or bradycardia.
• If fits continue
• General anesthesia (with e.g. propofol) and ventilation with continuous EEG monitoring in ICU.
• Continuous monitoring is critical, especially for respiratory function.

• Rule out pseudo-seizures if there are odd features (e.g., pelvic thrusts; resisting attempts to open lids and your attempts to do passive movements; arms and legs flailing around).
• Dexamethasone: 10mg IV if vasculitis/cerebral oedema (tumour) possible.
• After Seizures are Controlled Start oral anticonvulsants and identify potential causes (e.g., hypoglycemia, pregnancy, alcohol, CNS infections, or inadequate anticonvulsant dosing/compliance).

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