Seizures and Status Epilepticus: Emergency Recognition and Management

Learning objectives

• Differentiate focal, generalized, unknown-onset and non-convulsive seizures.
• Provide safe first aid without restraining the patient or placing objects in the mouth.
• Recognise status epilepticus and use a staged ABCDE and medication pathway.
• Identify metabolic, structural, toxic, infectious, pregnancy-related and medication-related causes.
• Plan postictal care, investigations, nursing observation, referral and discharge education.

Definitions and seizure types

A seizure is a transient occurrence of signs and symptoms caused by abnormal excessive or synchronous neuronal activity. Epilepsy is a neurological disorder with a predisposition to recurrent unprovoked seizures. A convulsive seizure may involve tonic stiffening followed by rhythmic clonic jerking, while focal seizures may cause a single-limb jerk, sensory symptoms, behavioural arrest, automatisms or impaired awareness. Some seizures are non-convulsive and present as staring, subtle twitching, aphasia or unexplained reduced consciousness.

Status epilepticus should be treated when a convulsive seizure lasts about five minutes or longer, or when seizures recur without recovery of consciousness. The longer it continues, the less likely it is to stop spontaneously and the harder it is to control. Use the patient’s emergency seizure plan when available, but do not delay ABCDE or emergency treatment.

First aid at the scene

1. Stay calm, note the start time and call for help. Protect the patient from traffic, fire, water, sharp objects and falls.
2. Place something soft under the head, loosen tight clothing around the neck and remove glasses.
3. Do not restrain movements, force the mouth open, insert fingers/objects, give food or drink, or attempt mouth-to-mouth while the seizure is active.
4. When jerking stops, place the patient in the recovery position if breathing adequately; suction secretions only when trained and needed.
5. Check breathing, colour and responsiveness. Start CPR if the patient is unresponsive and not breathing normally after the seizure.
6. Call emergency services for a first seizure, a seizure lasting five minutes or more, repeated seizures without recovery, injury, pregnancy, diabetes, breathing difficulty or water-related onset.

Triage and immediate ABCDE

History and examination after the seizure

• Witness description: onset, eye/head deviation, stiffening, jerking, colour change, vocalisation, incontinence, tongue bite and duration.
• Recovery: time to obey commands, persistent confusion, focal weakness, headache or amnesia.
• Previous seizures, epilepsy care plan, adherence, recent medicine change, withdrawal from alcohol/benzodiazepines and access to rescue medicine.
• Triggers: sleep deprivation, fever, infection, hypoglycaemia, dehydration, flashing lights, stimulant use and missed doses.
• Pregnancy/postpartum status, eclampsia symptoms, recent head injury, stroke symptoms, cancer, HIV/TB, renal/liver disease and family history.
• Examine for meningism, focal neurological signs, trauma, fever, rash, toxidromes, pregnancy hypertension and lateral tongue injury.

Status epilepticus pathway

1. 0–5 minutes: ABCDE, protect from injury, time the seizure, check glucose, oxygenate if hypoxaemic, establish IV/IO access and prepare medicines.
2. At about 5 minutes: give a benzodiazepine through the locally approved route and dose; use the patient’s prescribed rescue medicine if available. Monitor breathing continuously.
3. After the first dose: reassess airway, ventilation, pulse, BP and seizure activity. If ongoing, repeat only according to protocol and do not exceed safe cumulative dosing.
4. Established status: call anaesthesia/critical care and give a second-line antiseizure medicine such as levetiracetam, fosphenytoin/phenytoin, valproate or phenobarbital according to local resources and contraindications.
5. Refractory status: prepare intubation, continuous anaesthetic infusion, EEG where available and ICU transfer. Search actively for a structural, infectious, toxic or metabolic cause.
6. After clinical cessation: persistent coma may represent non-convulsive status; obtain urgent senior/neurology assessment and EEG if available.

Medication safety

Search for reversible causes

Investigations

• Bedside glucose immediately; repeat after correction.
• FBC, electrolytes including sodium/calcium/magnesium, renal/liver function, blood gas and pregnancy test when relevant.
• ECG and continuous cardiac monitoring after repeated seizures or sedative/antiseizure medicine.
• Drug levels when a therapeutic medicine may be subtherapeutic or toxic.
• Blood cultures and infection testing for fever, sepsis or immunosuppression.
• Urgent neuroimaging for first seizure, trauma, focal signs, persistent reduced consciousness, anticoagulant use, malignancy, severe headache or suspected stroke.
• Lumbar puncture only after imaging/safety assessment when meningitis or encephalitis remains possible.
• EEG for suspected non-convulsive status, unexplained coma or recurrent subtle events.

Special emergencies

• Eclampsia: treat any seizure in pregnancy/postpartum with an eclampsia pathway until proven otherwise; magnesium, BP control, airway and urgent obstetric care are priorities.
• Febrile seizure: protect the child, treat fever for comfort, evaluate the source and arrange medical review after a first or atypical episode.
• Hypoglycaemic seizure: check glucose, give immediate glucose by a safe route and reassess consciousness and repeat level.
• Seizure with trauma: maintain cervical-spine precautions where indicated, control bleeding and assess for intracranial injury.
• Psychogenic nonepileptic events: protect from harm, avoid unnecessary repeated sedatives, seek specialist assessment and communicate respectfully; never assume this diagnosis before excluding life threats.
• Alcohol/benzodiazepine withdrawal: monitor autonomic instability, treat seizures and involve addiction/medical services.

Postictal care

• Place in recovery position if breathing and protect the airway; continue monitoring until baseline or a clear cause is identified.
• Repeat GCS, pupils, glucose, vital signs and focused neurological examination; document recovery time.
• Assess for aspiration, tongue injury, head injury, shoulder dislocation, burns, rhabdomyolysis and pregnancy complications.
• Provide calm reassurance, reduce stimulation and avoid arguing about events the patient cannot recall.
• Do not give oral medication, food or drink until alert and swallowing safely.
• Escalate persistent confusion, new focal deficit, fever, severe headache, recurrent seizure, respiratory depression or abnormal vital signs.

Nursing interventions and monitoring

• Time each seizure and record motor, eye, colour, breathing and recovery features; a witness video may help if obtained safely.
• Maintain suction, oxygen, bag-mask equipment, IV/IO access and emergency medicines at the bedside.
• After benzodiazepines or second-line medicines, monitor respiratory rate, SpO₂, BP, ECG, level of consciousness and infusion reactions.
• Use seizure precautions, padded rails where appropriate, low bed, fall prevention and pressure-area care.
• Measure temperature, urine output and fluid balance; monitor for hyperthermia, acidosis, renal injury and rhabdomyolysis in prolonged seizures.
• Communicate drug doses, seizure times, last-known-well/recovery time, glucose and response in SBAR handover.

Discharge, prevention and education

• Explain the likely cause, medicine plan, adherence, sleep, alcohol/drug triggers and safety precautions.
• Provide a written seizure action plan: when to time the seizure, when to use prescribed rescue medicine and when to call emergency services.
• Advise against driving, swimming alone, heights, open fires and dangerous machinery until cleared under local law and specialist advice.
• Arrange first-seizure/neurology follow-up, EEG or imaging as indicated; do not discharge unexplained high-risk cases without a safe plan.
• Teach family to use recovery position and never restrain or put objects in the mouth.
• Discuss pregnancy, contraception, medication interactions and folic-acid planning with the clinician.

Clinical scenarios

Common errors to avoid

• Failing to time the seizure or waiting too long to treat status epilepticus.
• Putting a spoon, fingers or medication into the mouth of a convulsing patient.
• Restraining movements or leaving the patient alone.
• Giving repeated sedatives without airway, breathing and BP monitoring.
• Calling persistent coma “postictal” without considering non-convulsive status, hypoglycaemia, stroke, poisoning or infection.
• Discharging a first seizure without injury assessment, cause evaluation and follow-up.
• Assuming every seizure in pregnancy is epilepsy rather than eclampsia.

Revision questions

1. What is status epilepticus and why does treatment become more urgent with time?
2. List safe first-aid actions and actions that must never be performed during a seizure.
3. What are the ABCDE priorities during convulsive status?
4. Which reversible causes should be considered after a first seizure?
5. Why can a patient remain unconscious after visible jerking has stopped?
6. What monitoring is required after benzodiazepine or second-line antiseizure medicine?
7. Write a discharge education plan for a person with a first unprovoked seizure.

Key takeaways

• Protect, time, oxygenate and check glucose before focusing on the label.
• Status epilepticus is a medical emergency; benzodiazepines are first-line, followed by monitored second-line therapy when needed.
• Search for infection, metabolic, structural, toxic, pregnancy-related and medication causes.
• Persistent coma after convulsions may be non-convulsive status or another neurological emergency.
• Monitoring, airway readiness, respectful first aid and a written seizure plan prevent avoidable harm.

References for further study

• WHO mhGAP: Epilepsy and seizures evidence centre
• WHO: Antiseizure medicines for established status epilepticus
• Resuscitation Council UK: Paediatric life support and seizures
• NHS: What to do if someone has a seizure
• International League Against Epilepsy: Guidelines and reports