Seizures and status epilepticus

Management— do this, in order

• Protect the patient from injury, but do not restrain the limbs and put nothing in the mouth — tongue-biting happens at seizure onset and cannot be prevented, while forcing objects between clenched teeth breaks teeth and lacerates the pharynx.
• Airway and oxygen first: apply a jaw thrust, suction the oropharynx, and give high-flow oxygen 15 L/min by reservoir mask; as soon as the convulsion ceases turn the patient semi-prone into the recovery position and keep watching the airway.
• Access and bloods in one procedure, with continuous ECG, oximetry, blood pressure and temperature — but do not let the search for a vein delay the first drug, because the intramuscular and buccal routes exist for exactly this.Doctor / Nurse
• Hypoglycaemia is corrected before anything else: adults 50% glucose 50–100 mL intravenously into a large vein followed by a flush (equivalent volumes of 25% or 10% glucose are acceptable and less sclerosant); children 10% glucose 2 mL/kg intravenously.Doctor / Nurse
• Thiamine 100 mg intramuscularly or intravenously before or with the glucose in anyone malnourished or with alcohol use disorder, since glucose alone can precipitate Wernicke's encephalopathy.Doctor / Nurse
• First-line benzodiazepine at 5 minutes, adult intravenous: lorazepam 4 mg IV given at 2 mg/min, repeated once after 10 minutes if the seizure continues, to a maximum of 8 mg in total.Doctor / Nurse
• Adult alternative: diazepam 10 mg IV at no more than 5 mg/min, repeated once (Kumar & Clark accept diazepam 10–20 mg IV repeated as required) — but lorazepam is preferred because its cerebral duration is longer and recurrence is less likely.Doctor / Nurse
• First-line benzodiazepine, child: lorazepam 0.1 mg/kg IV (maximum 4 mg), repeated once after 10 minutes.Doctor / Nurse
• No intravenous access: midazolam 10 mg IM into deltoid or anterolateral thigh, repeated once after 10 minutes, as effective as the intravenous route in the first instance; child midazolam 0.15–0.2 mg/kg IM (maximum 10 mg).Doctor / Nurse
• Buccal or rectal route: midazolam 10 mg buccally in an adult, half against each cheek (child 0.3 mg/kg buccally, maximum 10 mg); or diazepam 10 mg per rectum in an adult (child 0.5 mg/kg PR, maximum 10 mg).
• Two full benzodiazepine doses and no more — further doses add respiratory depression without efficacy because GABA-A receptors are internalised as the seizure continues; have bag-valve-mask, suction and airway equipment ready before the second dose.
• Second line by about 20 minutes, one drug at full weight-based dose: levetiracetam 60 mg/kg IV over 15 min, maximum 4500 mg, in 100 mL 0.9% sodium chloride (4000–4500 mg for a 70 kg adult) — the safest agent where invasive monitoring is unavailable; paediatric 40–60 mg/kg IV over 5–15 min, maximum 4500 mg.Doctor / Nurse
• Second-line alternatives: sodium valproate 20–40 mg/kg IV over 15 min, maximum 3000 mg (Kumar & Clark give 25 mg/kg); or phenytoin 15–20 mg/kg IV diluted to 10 mg/mL in 0.9% sodium chloride, never glucose, into a large vein at no more than 50 mg/min with continuous ECG — about 1 g over at least 20 minutes for a 70 kg adult, and 20 mg/kg over 20 min in a child.Doctor / Nurse
• Eclampsia — magnesium sulfate, not a benzodiazepine: 4–6 g intravenously over 4 minutes or until the seizure stops, with a further 2 g intravenously if seizures continue; definitive treatment is delivery.Doctor / Nurse
• Refractory status where anaesthesia is unavailable — phenobarbital: adults 10–20 mg/kg IV diluted 1 in 10 in water for injection at no more than 50–100 mg/min; children 20 mg/kg IV over 20 minutes; for drug-induced seizures give 15–20 mg/kg intravenously over no less than 30 minutes.Doctor / Nurse
• General anaesthesia for refractory status: midazolam 0.2 mg/kg loading then 0.05–0.2 mg/kg/hour, or propofol 2 mg/kg bolus repeated as needed then 5–10 mg/kg/hour, or a thiopental infusion, with intubation, ventilation and EEG titrated to burst suppression.Doctor / NurseNot available at your setup — Endotracheal intubation kit, Mechanical ventilator, ICU / HDU bed.
• Supportive care in parallel: treat hyperthermia by exposing the patient, spraying tepid water with high-volume fanning and using cooled intravenous fluid, and give 0.9% sodium chloride 500–1000 mL over the first hour in an adult to protect the kidney against rhabdomyolysis.Doctor / Nurse
• Correct what is correctable while the load runs: hypertonic saline for symptomatic hyponatraemia with a written rate plan, calcium gluconate for hypocalcaemia, magnesium for hypomagnesaemia, and empirical antibiotics and aciclovir before imaging and before lumbar puncture if meningitis or encephalitis is suspected.Doctor / NurseNot available at your setup — Serum electrolytes.