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FOCUSED SHIFT VIEW

Seizures

Stop the seizure, find the reversible cause, decide if this is status.

Open full pathway
Educational first-pass aid. Reassess the patient, confirm doses and use local protocols.

1 · First minutes

  1. ≥5 min continuous, or recurrent without recovery, is status — treat it as such.
  2. Benzodiazepines first (adequate dose). Then levetiracetam, valproate, or fosphenytoin at full ESETT doses.
  3. Reversible checks that cannot wait: glucose, pregnancy (magnesium), fever/meningitis, sodium.

2 · Escalate now if

  • Seizure ≥5 minutes or no return to baseline
  • Pregnancy or recent postpartum
  • Fever, meningismus, or immunocompromise
  • Focal deficit, trauma, or anticoagulation
  • Status not responding to a benzodiazepine
  • Infantile spasm or neonatal seizure (different pathway)

3 · Immediate workup

  • Glucose immediately; airway and pulse oximetry
  • ECG (QT, ischemia, TCA); core temperature

4 · Don’t miss

  • Convulsive status epilepticus
    ≥5 min continuous or ≥2 seizures without recovery. IM midazolam or IV lorazepam first (AES 2016 / RAMPART). Then levetiracetam 60 mg/kg (max 4.5 g), valproate 40 mg/kg (max 3 g), or fosphenytoin 20 mg PE/kg — ESETT 2019 showed equivalent efficacy (~47%).
  • Eclampsia
    Seizure in pregnancy or ≤6 weeks postpartum — magnesium sulfate, not a conventional AED as first-line; deliver.
  • Hypoglycemia / hyponatremia / isoniazid
    Glucose every time. Severe hyponatremia: careful 3% saline. INH: pyridoxine in gram-for-gram equivalent.
  • ICH / SAH / CNS infection
    First seizure with fever, headache, anticoagulation, or incomplete recovery — CT ± LP, antimicrobials if meningitis is possible.
  • Non-convulsive status epilepticus
    Prolonged post-ictal state or coma with subtle twitching — EEG; treat empirically if high suspicion.

5 · Disposition lane

Admit

Prolonged post-ictal state, first seizure with an unclear workup, withdrawal with ongoing risk, infection under treatment, social/safety concerns.

ICU / RSI / EEG

Established or refractory status, eclampsia, ICH, need for airway protection or continuous EEG.