Synopsis
Recognise and terminate prolonged seizures promptly, protect airway and dignity, identify reversible precipitants in line with goals, provide reliable non-oral rescue and maintenance routes, and prevent recurrent medication and supply failure.
- Time every event and describe onset, awareness, movement, eye and head deviation, colour, injury, duration and recovery; video can help with consent.
- First-line seizure aid is safety: cushion the head, remove hazards, do not restrain limbs or put anything in the mouth, and use recovery position afterward.
- Treat a convulsive seizure at 5 minutes with the prescribed rescue route and call emergency help according to the individual plan.
- In the community, adult buccal midazolam 10 mg is a common first rescue; rectal diazepam 10 mg is an alternative when authorised and acceptable.
- In hospital, intravenous lorazepam is first-line when access and resuscitation support are available; do not delay rescue while repeatedly attempting difficult access.
- Check glucose immediately and correct reversible electrolyte, infection, hypoxia, medicine, withdrawal and intracranial causes in line with goals.
- If swallowing fails, specialist options include subcutaneous midazolam infusion or off-label subcutaneous levetiracetam with pharmacy-supported compatibility and conversion.
- Levetiracetam is commonly used for tumour-related seizures because interaction burden is low, but dose follows renal function and mood or behavioural effects need review.
- The gold-standard plan states seizure threshold, first and repeat rescue, maximum doses, emergency call, airway support, maintenance route and what differs if admission is not wanted.
Key red flags
A first seizure, focal onset, new weakness, severe headache, trauma or anticoagulation requires urgent intracranial assessment when treatment is appropriate.
A convulsion lasting 5 minutes or serial seizures without recovery requires immediate rescue and status pathway activation.
Persistent impaired awareness with subtle twitching, eye deviation or automatisms may be non-convulsive status and needs urgent neurological review.
Hypoglycaemia, hyponatraemia, hypercalcaemia, uraemia, hepatic failure, infection or hypoxia can precipitate seizures and requires targeted correction.
Abrupt withdrawal of benzodiazepine, alcohol, gabapentinoid or antiseizure medicine can cause recurrent seizures and must be identified.
Midazolam and opioid combinations can depress breathing; record every dose, observe ventilation and have a clear maximum and escalation step.
Valproate is hazardous in significant hepatic disease, while levetiracetam requires renal adjustment and behavioural adverse-effect review.
Convulsion lasting 5 minutes or recurrent seizures without recovery requires immediate benzodiazepine and escalation.
Investigation priorities
Document trigger, focal onset, awareness, movements, colour, injury, timed duration, rescue response and postictal recovery.
Management branches
A convulsive seizure reaches 5 minutes or recurs without recovery.
- Call emergency help, protect airway and patient, give oxygen as indicated, check glucose and administer authorised buccal, rectal or intravenous benzodiazepine without delay.
- Time and record the dose, repeat only under the current status protocol and prepare airway support because cumulative benzodiazepine and opioid can depress ventilation.
- If seizure continues, progress promptly to second-line intravenous antiseizure treatment and critical-care or goal-concordant palliative escalation rather than repeating first-line indefinitely.