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Seizures

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

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Your objective: explain the approach, recognize important warning signs, then test your recall.

Abbreviations explained
ACS
Acute coronary syndrome
OMI
Occlusion myocardial infarction
ECG
Electrocardiogram
PE
Pulmonary embolism
POCUS
Point-of-care ultrasound
QTc
QT interval corrected for heart rate
LBBB
Left bundle branch block
RBBB
Right bundle branch block
hs-cTn
High-sensitivity cardiac troponin
CTA
Computed tomography angiography
ICU
Intensive care unit
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The jobStop the seizure, find the reversible cause, decide if this is status.

  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.
  4. A patient who is not waking up may be in non-convulsive status.

A seizure lasting ≥5 minutes, or recurrent seizures without recovery, is status epilepticus — treat it as such.

Benzodiazepines first (AES 2016), then any of levetiracetam, valproate, or fosphenytoin at full ESETT doses. Glucose, pregnancy (eclampsia = magnesium), fever/meningitis, and sodium are the reversible checks that cannot wait.

Convulsive status epilepticus Critical

Key: ≥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 Critical

Key: Seizure in pregnancy or ≤6 weeks postpartum — magnesium sulfate, not a conventional AED as first-line; deliver.

Hypoglycemia / hyponatremia / isoniazid Critical

Key: Glucose every time. Severe hyponatremia: careful 3% saline. INH: pyridoxine in gram-for-gram equivalent.

ICH / SAH / CNS infection Critical

Key: First seizure with fever, headache, anticoagulation, or incomplete recovery — CT ± LP, antimicrobials if meningitis is possible.

Non-convulsive status epilepticus Critical

Key: Prolonged post-ictal state or coma with subtle twitching — EEG; treat empirically if high suspicion.

Eclampsia mimics / PRES / TTP Emergent

Key: Visual change, hypertension, thrombocytopenia — the seizure is the siren, not the diagnosis.

Alcohol withdrawal seizure Common

Key: Usually brief, within 48 h of stopping; still exclude other causes the first time. Benzodiazepines treat the withdrawal, not a new AED.

Unprovoked first seizure / known epilepsy breakthrough Common

Key: Back to baseline, normal exam: neuro follow-up. Breakthrough: levels, infection, missed doses, alcohol.

Tick what your patient has — the banner updates as you go.

Duration, recovery of consciousness, number of events, tongue bite, incontinence

Pregnancy / postpartum; fever, HIV, immunosuppression, travel

AED list and adherence; alcohol/benzodiazepine withdrawal; INH, tramadol, bupropion

Head trauma, anticoagulation, prior epilepsy, developmental history

Ongoing convulsive activity vs post-ictal vs unresponsive (non-convulsive)

Glucose, SpO₂, temperature; pupil and focal neuro findings

Meningismus, rash, trauma from the fall

Blood pressure (eclampsia, PRES, ICH)

Bedside

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

Labs

  • Na, Ca, Mg, glucose, CBC, renal/hepatic panels, AED levels if relevant
  • hCG; CK after prolonged convulsions; toxicology as indicated

Imaging / EEG

  • Non-contrast CT for first seizure with incomplete recovery, focal signs, trauma, anticoagulation, HIV, or age >40–50 without a clear provoked cause
  • LP when safe if CNS infection is possible; CT first only when indicated, and never delay empiric antimicrobials
  • EEG for suspected non-convulsive status
Medication safety reminder

Use this as a first-pass prompt; verify all medications, doses, concentrations, contraindications, weight, pregnancy status, and local protocols before administration.

Check indication, allergy, route, renal/hepatic risk, interactions, monitoring, and local formulary.

Discharge

  • Returned to baseline after a typical event in known epilepsy, or a first unprovoked seizure with a normal exam and no red flags — driving counselling, close neurology follow-up, safety-net advice.

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.

Use objective reassessment and the local pathway.

Before the next decision · reassess and hand over

Use these learning prompts with the presentation’s pathway. They are not discharge criteria.

  1. Reassess: compare symptoms, observations and examination with the initial assessment and response to treatment.
  2. Warning signs for Seizures:
    • 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. Reconsider: check unresolved findings and alternative explanations, including the pitfalls below.
  4. Escalate: communicate deterioration, uncertainty or needs beyond the current setting.
  5. Plan the transition: identify outstanding results, responsibility for follow-up, patient understanding and specific return advice.
Review this presentation’s disposition pathway →Practice a handover →

Clinical Pearls

  • Status starts at 5 minutes — do not wait for 20.
  • After benzos, ESETT: levetiracetam, valproate, and fosphenytoin are equivalent; pick one at a full dose and move on.
  • Eclampsia is magnesium and delivery, not phenytoin-first.
  • Glucose, sodium, pregnancy, and fever are the four checks that change the drug.

Pitfalls

  • Under-dosing benzodiazepines is the most common treatable error in status.
  • Valproate is contraindicated in pregnancy and in some mitochondrial disease — choose levetiracetam or fosphenytoin.
  • Do not start a daily AED after a single unprovoked seizure solely because it happened in the ED — shared decision with neurology (ILAE).
  • Psychogenic non-epileptic seizures occur (~10% in ESETT) — still treat until you are sure; then stop stacking AEDs.
  • A “post-ictal” patient who is not waking up may be in non-convulsive status.
PRACTICE REFRESHER

Rapid recall

Test your first action and the dangerous diagnoses before revealing the answer.

01 · First move

Before you scroll, what needs to happen first?

02 · Immediate threats

Name at least two diagnoses that cannot wait.

PRIVATE TO THIS DEVICE

Your learning note

Capture a weak point, a teaching pearl, or a question to take to your next shift.

Review schedule starts when marked reviewed
Altered Mental StatusComa & Depressed LOCPoisoning & OverdoseHeadache

Selected guidance · source check 2026-09-07. These 1 source links support selected teaching points, not a complete review of this topic. Check population, setting and local protocol before applying a recommendation.

  • Rosen’s Emergency Medicine, 10th ed. (2023) — seizures
  • AES 2016 evidence-based guideline for convulsive status epilepticus
  • ESETT (Kapur et al., NEJM 2019); RAMPART (Silbergleit et al., NEJM 2012)
  • ACOG / NICE eclampsia — magnesium sulfate
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