Add a labelled seizure first-aid and emergency management image here.
Learning objectives
- Define a seizure, epilepsy, provoked seizure, unprovoked seizure, convulsive status epilepticus and non-convulsive status epilepticus.
- Recognise focal, generalised and unknown-onset seizures, including subtle presentations.
- Give safe first aid without restraining the patient or placing objects in the mouth.
- Perform an ABCDE assessment, check glucose and search for reversible causes.
- Describe emergency investigation, status epilepticus treatment, nursing care and disposition.
- Identify special risks in children, pregnancy, eclampsia, infection, trauma, poisoning and metabolic disease.
1. Definitions
A seizure is a transient occurrence of signs or symptoms caused by abnormal, excessive or synchronous neuronal activity in the brain. A seizure can cause motor movements, altered awareness, sensory symptoms, autonomic changes, behavioural symptoms or a combination.
Epilepsy is a disease of the brain with an enduring predisposition to generate epileptic seizures, diagnosed using accepted clinical criteria. A single seizure does not automatically mean epilepsy.
A provoked (acute symptomatic) seizure occurs in close temporal association with an acute insult such as hypoglycaemia, electrolyte disturbance, fever, meningitis, stroke, head injury, eclampsia or a toxic drug exposure. An unprovoked seizure occurs without an immediate precipitant and may be the first presentation of epilepsy or a structural brain lesion.
Status epilepticus is a seizure lasting long enough that it is unlikely to stop on its own, or recurrent seizures without recovery of consciousness between them. For practical emergency care, continuous convulsive activity for approximately five minutes, or repeated convulsions without recovery, should trigger status treatment and senior help. Non-convulsive status can present as persistent confusion, staring, subtle twitching or coma and requires EEG-supported specialist assessment.
| Term | Clinical meaning | Emergency concern |
|---|---|---|
| Focal seizure | Begins in a network of one hemisphere; awareness may be intact or impaired. | Progression to bilateral convulsion, focal lesion or stroke mimic. |
| Generalised seizure | Engages bilateral networks from onset, often with loss of awareness. | Hypoxia, aspiration, trauma and status epilepticus. |
| Postictal state | Temporary confusion, sleepiness, headache, weakness or aphasia after a seizure. | Do not assume all deficits are postictal; persistent focal deficit may be stroke. |
| Psychogenic non-epileptic seizure | Involuntary episodes without epileptic cortical discharges; real distress, not deliberate malingering. | Injury from inappropriate restraint or unnecessary medication; diagnose respectfully. |
2. Types and clinical features
Focal seizures
- Focal aware: the patient remains aware but may have unilateral jerking, tingling, an unusual smell or taste, visual distortion, déjà vu, fear, epigastric rising sensation or autonomic symptoms.
- Focal impaired awareness: staring, reduced responsiveness, lip smacking, chewing, picking at clothes or wandering; confusion follows.
- Focal-to-bilateral tonic-clonic: a focal warning or unilateral movement progresses to stiffening, rhythmic jerking and loss of consciousness.
Generalised tonic-clonic seizure
The patient may suddenly lose consciousness, fall, stiffen (tonic phase), then develop rhythmic jerking (clonic phase). Cyanosis, frothing, tongue injury, urinary incontinence and irregular breathing can occur. After the movements stop, breathing should improve; prolonged unresponsiveness, persistent cyanosis or repeated seizures is an emergency.
Other generalised patterns
- Absence: brief staring and interruption of activity, often many times daily, usually without a fall or postictal confusion.
- Myoclonic: sudden brief muscle jerks, commonly after waking; consciousness may be preserved.
- Atonic: sudden loss of tone and falls (“drop attacks”). Protect the head and consider injury.
- Tonic or clonic only: stiffening or rhythmic jerking without the full sequence.
3. Seizure first aid: Stay, Safe, Side
Stay: remain with the person, start a timer, observe and reassure.
Safe: remove hazards, cushion the head, loosen tight clothing, move furniture and protect privacy. Do not restrain the limbs.
Side: once jerking stops, place the patient in the recovery position; turn them to the side sooner if vomiting, secretions or impaired breathing are present.
- Call emergency help for a first seizure, a seizure lasting five minutes or longer, repeated seizures without recovery, injury, pregnancy, diabetes, water-related seizure, breathing difficulty or failure to return to usual consciousness.
- Do not put fingers, spoons, cloth, medicine, water or any object in the mouth. A person cannot swallow their tongue, but objects can obstruct the airway or break teeth.
- Do not give food, drink or oral tablets until fully awake and able to swallow.
- Do not attempt mouth-to-mouth during active convulsions. After the seizure, assess breathing and begin resuscitation if absent or abnormal according to BLS protocol.
- Record start and stop time, movements, eye/head deviation, colour, breathing, responsiveness, injuries, triggers and recovery. A witness video may help diagnosis if obtained safely and with consent.
4. Emergency assessment: ABCDE
| Step | Assessment | Actions |
|---|---|---|
| A – Airway | Secretions, vomit, tongue obstruction, jaw clenching, protective reflexes. | Position, suction, airway adjunct when appropriate; prepare expert airway support if protection fails. |
| B – Breathing | Rate, effort, chest movement, oxygen saturation, cyanosis and aspiration. | High-flow oxygen only for hypoxaemia or respiratory compromise; assist ventilation after convulsions if needed. |
| C – Circulation | Pulse, blood pressure, perfusion, temperature, ECG rhythm and IV access. | Monitor, obtain IV/IO access, draw blood, treat shock and dysrhythmia. |
| D – Disability | Glucose, GCS, pupils, focal signs, ongoing subtle seizure and postictal recovery. | Correct severe glucose abnormality, treat status promptly and repeat neurological observations. |
| E – Exposure | Trauma, fever, meningism, rash, pregnancy, medication patches, toxins and environmental exposure. | Prevent hypothermia, inspect injuries and look for the cause while preserving dignity. |
Check capillary glucose immediately. Hypoglycaemia can cause seizures and permanent brain injury; treat according to protocol and recheck. Measure temperature, attach cardiac and pulse-oximetry monitoring, obtain a 12-lead ECG and assess for pregnancy when relevant. Place the patient in a safe lateral position after active movements and protect the cervical spine when trauma is suspected.
5. Focused history
- Event chronology: what happened before, during and after; aura, fall, stiffening, jerking, eye deviation, vocalisation, colour change, incontinence, tongue injury and duration.
- Recovery: time to obey commands, persistent weakness, aphasia, headache, fever, confusion or recurrent seizure.
- Previous history: epilepsy, febrile seizures, stroke, head injury, tumour, meningitis, eclampsia, developmental disorder or family history.
- Medication: anti-seizure medicine, missed doses, recent changes, interactions, herbal preparations, insulin, anticoagulants and recreational drugs.
- Precipitants: sleep deprivation, alcohol withdrawal, infection, fever, fasting, dehydration, flashing lights, stress, metabolic disease and toxic exposure.
- Context: pregnancy/postpartum state, trauma, drowning, occupational hazards, baseline cognition, allergies, last meal and advance-care preferences.
6. Examination and differential diagnosis
Repeat the neurological examination after the postictal period. Assess orientation, speech, pupils, gaze, visual fields, facial symmetry, power, sensation, coordination, reflexes, gait when safe and signs of meningitis or raised intracranial pressure. Check for shoulder dislocation, facial injury, dental damage, burns, head trauma, petechiae and lateral tongue laceration.
| Possible mimic | Clues | Immediate check |
|---|---|---|
| Syncope | Brief loss of tone with rapid recovery; precipitating standing, pain or arrhythmia. | ECG, orthostatic context, glucose and cardiac history. |
| Hypoglycaemia | Sweating, tremor, confusion, seizure in a person using insulin or sulfonylurea. | Capillary glucose and prompt treatment. |
| Stroke/TIA | Persistent focal weakness, aphasia, neglect or visual loss. | Stroke pathway and urgent imaging; do not label as postictal without reassessment. |
| Psychogenic non-epileptic seizure | Variable asynchronous movements, prolonged fluctuating course, retained awareness in some episodes; features are not diagnostic alone. | Safety, calm communication and specialist review; avoid stigma. |
| Rigors or dystonia | Shivering with infection or medication-related abnormal postures. | Temperature, medication history and neurological assessment. |
7. Investigations
- Bedside tests: glucose immediately; temperature, oxygen saturation, ECG and pregnancy test when appropriate.
- Blood tests: electrolytes (especially sodium, calcium and magnesium), renal and liver function, full blood count, inflammatory markers, blood gas when critically ill, anticonvulsant level when available and toxicology guided by history.
- Brain imaging: urgent non-contrast CT for first seizure with trauma, persistent deficit, anticoagulation, fever, severe headache, reduced consciousness or suspected stroke/bleeding. MRI is preferred later for structural and epileptogenic lesions when stable.
- Lumbar puncture: consider for suspected meningitis or encephalitis after assessing for raised intracranial pressure and obtaining imaging when indicated; never delay antibiotics in a septic patient.
- EEG: urgent or continuous EEG is important for persistent altered consciousness, suspected non-convulsive status, unexplained coma or recurrent subtle events.
- Other: chest imaging, cultures, malaria or HIV testing and metabolic investigations according to local epidemiology and clinical findings.
8. Convulsive status epilepticus
Phase 1: immediate stabilisation
- Note the exact seizure start time and whether there was recovery between episodes.
- Protect airway and oxygenation, suction secretions, place monitoring and obtain IV or IO access without delaying treatment.
- Check glucose and correct severe hypoglycaemia. Consider thiamine before glucose in a severely malnourished or chronic alcohol-use patient according to local protocol.
- Draw blood, but never postpone the first anticonvulsant while waiting for results.
Phase 2: first-line benzodiazepine
For a convulsive seizure continuing beyond the emergency threshold, administer the locally approved benzodiazepine by the fastest reliable route, with oxygen, suction and ventilation equipment ready. If the seizure persists, repeat only according to the protocol and maximum limits. Watch for respiratory depression, hypotension and aspiration. Document drug, route, time and response.
Phase 3: second-line antiseizure medicine
If convulsions continue after appropriate benzodiazepine therapy, urgently administer a protocol-approved second-line agent such as levetiracetam, fosphenytoin/phenytoin or valproate, considering pregnancy, liver disease, cardiac conduction, drug interactions and local availability. The choice is specialist-led. Continue airway support and reassess whether the movements are epileptic.
Refractory status
Persistent seizures after first- and second-line treatment require anaesthesia/critical-care involvement, expert airway management, continuous EEG where available and an infusion anaesthetic or other specialist therapy. Search aggressively for infection, stroke, hypoglycaemia, electrolyte disturbance, toxin, withdrawal, eclampsia or autoimmune disease. Transfer to a monitored intensive-care setting.
9. Treat the cause
| Cause | Clues | Priority management |
|---|---|---|
| Hypoglycaemia | Diabetes, insulin, sweating, low bedside glucose. | Immediate protocol-based glucose and repeated measurement. |
| Hyponatraemia, hypocalcaemia or hypomagnesaemia | Vomiting, diuretics, renal disease, endocrine illness or prolonged illness. | Careful laboratory-guided correction; avoid rapid overcorrection. |
| Meningitis/encephalitis | Fever, headache, neck stiffness, rash, confusion or focal signs. | Sepsis pathway, cultures and empiric antimicrobials without avoidable delay; specialist imaging/LP. |
| Stroke or intracranial bleed | New persistent focal deficit, severe headache, anticoagulant use or trauma. | Urgent CT/CTA, stroke/neurosurgical pathway and reversal when indicated. |
| Drug/toxin or withdrawal | Access to medication, stimulant exposure, alcohol/benzodiazepine withdrawal. | Resuscitation, poison-centre advice, antidote when indicated and monitored care. |
| Eclampsia | Pregnancy or postpartum seizure with hypertension, headache or visual symptoms. | Obstetric emergency pathway, magnesium-based protocol, blood-pressure control and delivery planning. |
10. Care after a first or resolved seizure
- Observe until consciousness, breathing, vital signs and neurological function return to baseline or a senior clinician sets another plan.
- Maintain aspiration precautions, side positioning, oral suction as needed and nil by mouth until fully alert.
- Treat injuries, pain, fever and dehydration. Check for shoulder dislocation, fractures, head injury, dental trauma and burns.
- Do not automatically prescribe long-term anti-seizure medication after every first seizure; specialist risk assessment and the cause determine treatment.
- Arrange urgent neurology review for an unprovoked seizure, abnormal examination, structural lesion, recurrent events or uncertain diagnosis.
- Give safety advice: medication adherence, adequate sleep, avoiding alcohol/recreational drugs, bathing and swimming precautions, driving restrictions according to local law, work hazards and a family seizure plan.
11. Nursing and EMT responsibilities
- Prepare a seizure kit: oxygen, suction, bag-mask device, airway adjuncts, glucose meter, IV/IO equipment, prescribed emergency medicines and protective padding.
- Use calm, non-judgemental communication. Explain to relatives that movements cannot be stopped by restraint and that recovery can be slow.
- Record time, semiology, position, colour, breathing, triggers, medications, interventions, response and postictal observations.
- Repeat GCS, pupils, glucose, vital signs, respiratory status and focal neurological signs. Escalate failure to recover, new weakness, fever, hypoxia or recurrent seizure.
- Maintain a clear environment, protect the head, do not pull the tongue, do not force the jaw open and never leave a convulsing patient unattended.
- Use pressure-area care, safe transfers and fall precautions after a postictal episode. Avoid unnecessary restraints.
- Administer prescribed medicines using medication-safety checks, monitor respiratory depression and document exact times.
- Support family education and refer to epilepsy, mental-health, social-work and rehabilitation services when appropriate.
12. Special populations
- Children: consider febrile seizure, meningitis, metabolic disease, poisoning and non-accidental injury; use weight-based protocols and avoid overheating.
- Pregnancy/postpartum: a seizure is eclampsia until assessed otherwise. Protect airway, left lateral position, check blood pressure and glucose, and activate obstetric and critical-care teams.
- Older adults: consider stroke, tumour, medication toxicity, renal failure, hypoglycaemia and cardiac syncope; polypharmacy increases risk.
- Sickle-cell disease or HIV: consider stroke, infection, cerebral venous disease, opportunistic infection and medication interactions.
- Anticoagulation or trauma: lower the threshold for urgent CT; prevent secondary injury and involve neurosurgery if bleeding is suspected.
13. Applied scenarios
Scenario 1: first witnessed tonic-clonic seizure
A 22-year-old falls, stiffens and jerks for 90 seconds, then is sleepy. Clear hazards, time the event, protect the head, assess ABCDE and glucose, place side-lying after movements stop, check injury and obtain a focused history. Because it is a first seizure, arrange medical assessment and do not allow unsupervised discharge.
Scenario 2: convulsions for eight minutes
Call the resuscitation team, document the clock time, provide oxygen and suction, check glucose, obtain IV/IO access and administer the approved first-line medicine. If activity continues, escalate promptly to second-line therapy and critical care; never wait for spontaneous resolution.
Scenario 3: seizure with unilateral weakness
A patient has a seizure followed by aphasia and arm weakness that persists. Recheck glucose and airway, activate the stroke pathway and obtain urgent brain and vascular imaging. Persistent focal deficit must not be dismissed as a postictal state.
Scenario 4: postpartum seizure
A woman two days after delivery develops a seizure and severe headache. Place her laterally, protect airway, check glucose and blood pressure, call obstetric/critical-care teams and follow the local eclampsia magnesium and blood-pressure protocol while investigating haemorrhage, venous thrombosis and other causes.
14. Revision questions
- What is the practical time threshold for treating convulsive status epilepticus?
- List six actions that protect a patient during a tonic-clonic seizure.
- Why must glucose be checked immediately?
- When should a patient with a seizure receive urgent CT?
- Outline first-, second- and refractory-status treatment principles without relying on a single drug dose.
- Which features make a seizure in pregnancy an obstetric emergency?
Key takeaways
- Most brief seizures stop, but continuous or recurrent seizures without recovery are status epilepticus until proven otherwise.
- Stay with the patient, protect from injury, time the seizure and turn to the side; never restrain or put objects in the mouth.
- ABCDE, glucose, oxygenation, temperature, ECG and repeated neurological observations are the emergency foundation.
- Search for reversible causes, treat early under protocol and involve critical care when seizures persist.
- A first seizure, persistent focal deficit, pregnancy, injury, fever, poisoning or failure to recover needs urgent medical assessment.