Seizures and status epilepticus

Manage now— do this, in order

• Protect from injury but never restrain the limbs and put nothing in the mouth — restraint causes fractures, and objects between the teeth break teeth and lacerate the pharynx. Jaw thrust, suction the oropharynx, high-flow oxygen 15 L/min by reservoir mask; recovery position once the convulsion ceases.
• Correct hypoglycaemia before anything else: adults 50% glucose 50-100 mL IV into a large vein with a flush (25% or 10% equivalents are less sclerosant); children 10% glucose 2 mL/kg IV. Give thiamine 100 mg IM/IV before or with the glucose in anyone malnourished or with alcohol use disorder.Doctor / Nurse
• First-line benzodiazepine at 5 minutes: lorazepam 4 mg IV at 2 mg/min, repeated once after 10 minutes, max 8 mg total (child 0.1 mg/kg IV, max 4 mg); or diazepam 10 mg IV at no more than 5 mg/min, repeated once. Do not let the search for a vein delay the drug.Doctor / Nurse
• Two full benzodiazepine doses and no more — a third adds respiratory depression without efficacy, because GABA-A receptors are internalised as the seizure continues. Never under-dose either: half doses at intervals are the commonest reason a treatable seizure becomes refractory. 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 minutes, max 4500 mg, in 100 mL 0.9% sodium chloride (child 40-60 mg/kg, max 4500 mg) — the safest agent where monitoring is limited; or sodium valproate 20-40 mg/kg IV over 15 minutes, max 3000 mg; or phenytoin 15-20 mg/kg IV diluted to 10 mg/mL in 0.9% sodium chloride — never glucose — at no more than 50 mg/min with continuous ECG (child 20 mg/kg over 20 minutes).Doctor / Nurse
• Avoid sodium valproate in women and girls of childbearing potential, in liver disease, pancreatitis, suspected mitochondrial disease and children under 2 years, where it causes fatal hepatotoxicity. Do not load phenytoin blindly in a patient already taking it — choose another agent and send a level.
• Eclampsia — magnesium sulfate, not a benzodiazepine: 4-6 g IV over 4 minutes or until the seizure stops, with a further 2 g IV if seizures continue; definitive treatment is delivery.Doctor / Nurse
• Refractory status: phenobarbital where anaesthesia is unavailable — adults 10-20 mg/kg IV diluted 1 in 10 at no more than 50-100 mg/min, children 20 mg/kg IV over 20 minutes — but never a full 20 mg/kg load without ventilatory support, as it may cause respiratory arrest. Definitive: general anaesthesia (midazolam 0.2 mg/kg then 0.05-0.2 mg/kg/h, or propofol 2 mg/kg bolus then 5-10 mg/kg/h) with intubation, ventilation and EEG titrated to burst suppression.Doctor / NurseNot available at your setup — Endotracheal intubation kit, Mechanical ventilator.
• In parallel: cool hyperthermia by exposing, spraying tepid water with high-volume fanning and cooled IV fluid; give 0.9% sodium chloride 500-1000 mL over the first hour in an adult to protect the kidney against rhabdomyolysis; correct sodium (hypertonic saline for symptomatic hyponatraemia — never too fast), calcium and magnesium; and give empirical antibiotics and aciclovir before imaging and before lumbar puncture if meningitis or encephalitis is suspected.Doctor / Nurse