History/questionnaire:

Transient occurrence of signs or symptoms due to abnormal electrical activity in the brain with disturbance of consciousness, behaviour, emotion, motor function or sensation (seizure)?

Continuous seizure for 30 minutes or longer or recurrent seizures without regaining consciousness lasting 30 minutes or longer (status epilepticus)?

Differential diagnosis to epileptic seizure?

- Syncope?

- Cardiac arrhythmia?

- Panic attacks/hyperventilation?

- Non-epileptic attack disorders?

- Night terrors and breath holding attacks (in children 6 months - 5 years)?

Management: Tonic-clonic seizures ≥ 5 minutes, > 3 seizures an hour or status epilepticus?

- Airway opened and considered simple airway adjunct (eg nasopharyngeal airway (oropharyngeal adjunct often difficult?

- High flow oxygen (FiO2 100%)?

- Hypoglycaemia excluded?

- Protected from injury (cushioned head with hands or soft material, removed objects nearby or if not possible moved person away from immediate danger)?

- Looked for an epilepsy identity care or jewellery?

Anticonvulsant drug therapy?

Buccal midazolam: Repeat dose after 10 mins if required. Off license for < 3months +>18yrs:

1-2 months: 300mcg/kg (max. 2.5mg)

3-11 months: 2.5mg

1-4 years: 5mg

5-9 years: 7.5mg

≥ 10 years/adults: 10mg

Rectal diazepam: If preferred or if buccal midazolam not available Repeat dose after 10 minutes if required. Some preps off license <1 yr

1 month-1 year

2-11 years: 5-10mg

≥ 12 years/adults: 10-20mg

Elderly: 10mg

IV lorazepam: Slow IV through a large vein If IV access established + resuscitation facilities available

1 month-11 yrs: 100mcg/kg (max. 4mg)

≥ 12 years/adults: 4mg then observe

(Notes:

IV anticonvulsants lead to more rapid seizure cessation but this must be balanced by the time taken to establish IV access

Buccal, rectal, intranasal anticonvulsants lead to similar rates of seizure cessation as IV anticonvulsants - all are >90% effective

Moderate quality evidence that lorazepam is associated with less respiratory depression than diazepam

Adverse effects, including respiratory depression, were reported very infrequently

As long as a bag and mask to hand IV Lorazepam can be safely used in primary care)

Called ambulance and admitted as:

- Seizures do not respond promptly to treatment (people with persistent seizures should arrive at ED within 30 minutes of the onset of the seizure)?

Seizures respond to treatment but:

- Seizures were prolonged or recurrent before treatment, particularly if status epilepticus?

- High risk of recurrence (eg. history of repeated seizures/status)?

- Difficulty monitoring patient condition?

- First presentation seizure?

Tonic-clonic seizure lasting less than 5 minutes

Protected from injury (cushion head with hands or soft material; removed harmful objects from nearby or if not possible moved the person away from immediate danger)?

When the seizure stopped, checked airway and placed them in the recovery position?

Looked for an epilepsy identity card or jewellery?

Other types of seizures (eg focal, tonic, atonic, and myoclonic seizures)?

Protected them from injury as above and observe them until they have fully recovered?

If symptoms persisted, considered arranging admission or seeking specialist advice?

Resource(s):

CKS 2021

BNF