Seizures are a serious and sometimes life threatening condition that you need to be able to recognise and manage in an acute setting. This guide gives an overview of the recognition and immediate management of seizures (using an ABCDE approach).
Is the patient able to talk? (if so the airway is patent)
Place the patient in the recovery position if possible (to reduce risk of airway compromise).
Noisy breathing suggests airway compromise
- Perform the head tilt, chin lift maneuver.
- If noisy breathing persists try a jaw thrust.
- If airway still appears compromised use an airway adjunct (e.g. oropharyngeal airway).
- Use suction to clear airway secretions – also ensure any loose fitting dentures are removed.
- An anaesthetist should be contacted as soon as possible to enable advanced airway management.
Give high flow oxygen via a non-rebreather mask.
Assess the patient
Oxygen saturation – aim to keep 94-98%
Air entry – auscultate to assess air entry
Respiratory rate – may be reduced by anticonvulsive agents – e.g. Lorazepam
Chest X-ray – to evaluate possibility of aspiration
Assess the patient
BP / Pulse– if hypotensive resuscitate with IV fluids (always consider pre-eclampsia in women with hypertension.)
Capillary refill time – central – should be <2 seconds
Gain IV access and take bloods
Gain IV access
Take blood samples – FBC / U&Es / Calcium / Magnesium / LFT / Glucose / Coagulation / Toxicology (including antiepileptic drug level is already on treatment)
First line treatment²
Benzodiazepine – multiple options and routes (consult local guidance)
- Lorazepam (IV) is often used as a first line therapy (0.1 mg/kg (usually a 4 mg bolus, repeated once after 10−20 minutes; rate not critical).²
- Failure to respond to first line treatment requires input from critical care.
- Give usual AED medication if already on treatment.
Second line (should be instituted by anaesthetist / critical care)²
Phenytoin infusion – requires BP and ECG monitoring
Dexamethasone – if vasculitis or cerebral oedema (tumour) possible
Other treatments to consider²
Administer glucose (50 ml of 50% solution) and/or intravenous thiamine (250 mg) as high potency intravenous Pabrinex if any suggestion of alcohol abuse or impaired nutrition².
Arterial blood gas (ABG):
- Assessment of oxygenation
- pH – acidosis would suggest the need for urgent critical care input
- Lactate – again raised levels would support the need for critical care input
Assess GCS – continue to reassess GCS – if <8 anaesthetic support for the airway is required
Check blood glucose – hypoglycaemia may be the underlying cause or contributing to a reduced GCS
Assess pupils – may give clues as to a cause for seizure – drug overdose / intracerebral pathology
Expose patient’s entire body looking for:
- Rash – meningococcal septicaemia
- Hidden sources of sepsis – i.e. infected leg ulcer
- Other secondary injuries – may have trauma secondary to seizure
It is essential to continually reassess ABCDE and treat issues as you encounter them. This allows continual reassessment of the response to treatment and early recognition of deterioration.
If the patient does not respond to treatment, or deteriorates, critical care input should be involved as soon as possible.
1. Oxford handbook of Clinical Medicine – management of status epilepticus – p809