---

Seizure Management - Current Guidelines

Overview

1. Active/first unprovoked seizure (acute management and discharge decision)
2. Status epilepticus (emergency time-sensitive protocol)
3. Chronic epilepsy (antiseizure drug selection for long-term control)

---

1. First Unprovoked Seizure

Who to admit vs. discharge?

• Normal neurologic examination
• Normal mental status (post-ictal period resolved)
• Normal non-contrast head CT
• No acute or chronic medical comorbidities

Risk of recurrence

• Prior brain insult (stroke, trauma)
• Epileptiform abnormalities on EEG
• Significant abnormality on brain imaging
• Nocturnal onset seizure

At discharge

• Defer EEG and MRI to outpatient setting
• Driving prohibited until cleared (document per local law)
• Avoid swimming, heights, and hazardous machinery until cleared
• Neurologist follow-up arranged

---

2. Acute Seizure and Status Epilepticus - Emergency Management

Phase 1 - Active Seizure (0-5 minutes): Supportive Care

• Establish large-bore IV access
• Airway, breathing, circulation (ABCs)
• Oxygen, cardiac monitor, pulse oximetry, end-tidal capnography
• Point-of-care blood glucose - give IV glucose if hypoglycemia suspected (add thiamine if malnourished or alcoholism suspected)
• Patient protection (padded side rails, lateral positioning)
• Labs: glucose, BMP, Ca, Mg, lactate, toxicology screen, anticonvulsant levels, pregnancy test if appropriate
• Normal saline infusion (avoid glucose-containing fluids - incompatible with phenytoin)

Phase 2 - Established Status Epilepticus (5-10 min): Benzodiazepines

Phase 3 - Refractory Status Epilepticus (>30 minutes): Anesthetic Agents

• Intubate the patient
• Neuro-ICU admission + continuous EEG monitoring (mandatory after paralysis)
• Choose one of:

Special Situations

• Do not perform LP during active SE - wait until seizures are controlled
• Suspect CNS infection: start empiric antibiotics/antivirals immediately without waiting for LP
• Suspect toxic ingestion: GI decontamination as appropriate
• Non-convulsive SE (NCSE): suspect in comatose patients; continuous EEG monitoring (NCSE reported in 12-24% of post-cardiac arrest survivors)
• TBI prophylaxis: 7 days of levetiracetam 500 mg BID (adjusted for renal function) is preferred over phenytoin, which may worsen neurocognitive outcomes

---

3. Chronic Epilepsy - Antiseizure Drug Selection

Drug Selection by Seizure Type (Harrison's 22E)

Practical prescribing considerations

• Older drugs (phenytoin, valproate, carbamazepine, phenobarbital, ethosuximide) remain first-line globally due to comparable efficacy and lower cost
• Newer drugs (lamotrigine, levetiracetam, lacosamide) offer simpler dosing, fewer drug-drug interactions, and better tolerability - increasingly used as first-line monotherapy
• All antiseizure drugs carry common dose-related side effects: sedation, ataxia, dizziness, diplopia
• Monitor for idiosyncratic toxicity: rash (especially lamotrigine - risk of SJS), bone marrow suppression, hepatotoxicity
• Long-term use (especially in elderly) - monitor for osteoporosis
• Valproate: avoid in women of childbearing age (teratogenic) and liver disease
• Pregnancy: recent 2025 MONEAD study guidance recommends individualized ASM dose adjustments throughout pregnancy and postpartum

When to consider stopping treatment

• Seizure-free for 2-5 years (depending on syndrome and risk factors)
• Normal EEG and imaging
• Always taper slowly (abrupt cessation risks withdrawal seizures)

---

Summary Algorithm

Active seizure (any duration)
  → ABCs + IV access + glucose + monitoring
  
≥ 5 min OR established SE
  → Benzodiazepine (IV lorazepam or IM midazolam)
  → Simultaneous 2nd-line AED loading (fosphenytoin / levetiracetam / valproate)
  
Seizures persist > 20-30 min (refractory SE)
  → Intubate + ICU
  → Anesthetic infusion (midazolam / propofol / phenobarbital)
  → Continuous EEG monitoring

---

• Vignatelli L et al. Clinical practice guidelines on the management of status epilepticus in adults: A systematic review. Epilepsia. 2024. [PMID 38606469] - confirmed broad agreement on benzodiazepine-first protocol, noted gaps in refractory SE management across 15 international CPGs.
• MONEAD study (2025) - first evidence-based roadmap for antiseizure medication dose adjustment during pregnancy and postpartum.

Note: Drug doses should be verified against institutional protocols before administration. Consult neurology for new-onset epilepsy, refractory SE, or complex cases.

1. Mechanisms - how antibiotics work and why it matters for dosing (time-dependent vs concentration-dependent)
2. WHO AWaRe 2025 - the global framework: Access → Watch → Reserve
3. The 5 Rights - the pre-prescribing mental checklist every single time
4. Clinical decision process - 5-step method from syndrome identification to starting therapy
5. Common infections - CAP, UTI, SSTI, Sepsis, Meningitis, Intra-abdominal - with drugs and durations
6. The 48-72h review - the single most important stewardship habit
7. Duration - evidence that shorter is almost always better
8. IV to oral switch - stop keeping patients on IV unnecessarily
9. Special situations - allergy assessment, renal dosing, pregnancy, surgical prophylaxis
10. Common mistakes - the pitfalls every junior doctor makes
11. Local antibiogram - why knowing your hospital's data is non-negotiable
12. One-page checklist - to use at the bedside every day

---

IV Fluid Therapy - The Complete Junior Doctor's Guide

---

PART 1: THINK OF FLUIDS AS DRUGS

• An indication (why are you giving it?)
• A dose (how much?)
• A route and rate (how fast?)
• A duration (when do you stop?)
• Contraindications and side effects (fluids can kill)

Fluid overload is as dangerous as under-resuscitation. Both increase mortality. Your job is to give the right fluid, in the right amount, at the right time - and then stop.

---

PART 2: THE 4 INDICATIONS FOR IV FLUIDS

1. RESUSCITATION   → Restore perfusion in shock (emergency)
2. REPLACEMENT     → Replace ongoing measured losses (drains, NG, stomas, GI losses)
3. MAINTENANCE     → Cover daily physiological needs when patient cannot drink/eat
4. NUTRITION       → Fluid vehicle for feeding (TPN, drug diluents)

---

PART 3: THE FLUID FAMILIES - WHAT'S IN THE BAG

A. Crystalloids (the workhorses)

Isotonic Crystalloids (main clinical tools)

• NS has 154 mmol/L chloride vs plasma's 98-106 mmol/L - far too much chloride
• Large volumes cause hyperchloremic metabolic acidosis (non-anion gap, easy to miss)
• Associated with acute kidney injury (AKI) and higher rates of renal replacement therapy
• Exception: Use NS in TBI (balanced solutions may worsen cerebral edema), hyponatremia correction, and metabolic alkalosis

Hypotonic Crystalloids (maintenance and special use)

Common mistake: Using D5W or dextrose-saline for resuscitation. The glucose is rapidly metabolized, leaving only free water - which distributes into all body compartments and provides almost zero volume expansion. It is dangerous in hyponatremia.

Hypertonic Crystalloids (special use only)

B. Colloids (use cautiously)

Rule for interns: Avoid starches/HES entirely. They increase mortality in sepsis and cause AKI. The 2025 ESICM guidelines recommend crystalloids over albumin for most patients (except cirrhosis where albumin is preferred).

---

PART 4: THE 4 PHASES OF FLUID THERAPY (ROSE Framework)

Phase 1: RESUSCITATION (Salvage)     → Give fluid fast, immediately, 0-6 hours
Phase 2: OPTIMIZATION                → Small targeted challenges, reassess
Phase 3: STABILIZATION               → Maintenance only, no more boluses
Phase 4: EVACUATION (De-resuscitation) → Actively remove excess fluid (diuretics)

---

PART 5: RESUSCITATION - WHICH FLUID, HOW MUCH, HOW FAST

Step 1: Identify the type of shock

Critical rule: Do not give large fluid boluses to cardiogenic shock - it will worsen pulmonary edema and kill the patient. Vasopressors and inotropes are the priority.

Step 2: Choose your resuscitation fluid

Step 3: How much fluid to give?

Key shift in guidelines (2025-2026): The old "30 mL/kg always" rule is now qualified - use 30 mL/kg as a starting point but reassess frequently and stop if patient is not fluid responsive. Over-resuscitation is now recognized as harmful.

Step 4: Is the patient fluid responsive?

---

PART 6: MAINTENANCE FLUIDS - DAILY REQUIREMENTS

Daily fluid and electrolyte requirements (70 kg adult)

Standard maintenance fluid prescription (adult, normal renal function)

• 1L over 8h = 125 mL/h x 3 bags (1L each over 8h = 3L/24h)
• Each bag contains 0.18% NaCl + 4% dextrose + 20 mmol KCl

• Hyponatremia → Use more NS, restrict free water
• Hypernatremia → Use more free water (D5W or hypotonic saline)
• Hypokalemia → Add more KCl (max 40 mmol/L in peripheral line, max 10 mmol/h)
• Hyperkalemia → Remove KCl from fluids entirely

Warning about maintenance in elderly/cardiac patients: The standard 3L/day can cause fluid overload. In heart failure, renal failure, or elderly patients, restrict to 1-1.5L/day unless losses indicate more.

---

PART 7: REPLACEMENT FLUIDS - MATCH WHAT'S LOST

---

PART 8: SPECIAL CLINICAL SCENARIOS

Dehydration (simple, not shocked)

• Mild (dry mouth, dark urine): Encourage oral fluids if possible
• Moderate (postural dizziness, tachycardia): 500 mL-1L Hartmann's over 1-2h, reassess
• Severe (confused, HR >120, SBP <90): Treat as hypovolemic shock - see above

Diabetic Ketoacidosis (DKA)

Hypernatremia (dehydration / diabetes insipidus)

• Deficit = 0.6 x weight (kg) x [(Na/140) - 1]
• Replace slowly with D5W or 0.45% NS (no faster than 0.5-1 mmol/L per hour drop in Na)
• Correct too fast → cerebral edema → seizures

Hyponatremia

• Assess volume status first (hypovolemic vs euvolemic vs hypervolemic)
• Hypovolemic hyponatremia (e.g., vomiting + free water replacement): 0.9% NS
• SIADH (euvolemic hyponatremia): fluid restrict, treat cause
• Severe symptomatic (<120 + seizures/coma): 3% hypertonic saline 100 mL IV over 10 min (controlled, senior supervision)
• Never correct faster than 8-10 mmol/L in 24h → osmotic demyelination syndrome (central pontine myelinolysis)

Post-operative Fluid Management

• Minimise unnecessary IV fluids post-op ("drip and sip" approach)
• Most post-op patients can start sips within 4-6h
• Only use IV maintenance when genuinely unable to take orally
• Goal-directed fluid therapy (GDFT) in major surgery = reduced complications, faster recovery

---

PART 9: FLUID OVERLOAD - RECOGNIZE AND ACT

• Weight gain >1 kg/day (daily weights are the best tool)
• Peripheral pitting edema (ankles, sacrum)
• Pulmonary crackles / shortness of breath
• Rising creatinine (AKI from tissue edema)
• Abdominal distension / ascites
• Positive fluid balance (ins > outs over 24h)
• Worsening oxygenation / new requirement for oxygen

• Patient is haemodynamically stable (not shocked)
• Positive cumulative fluid balance >5-10%
• Signs of fluid overload as above
• Use: Furosemide 20-40 mg IV; target negative fluid balance 500 mL-1L/day

The 4 D's of Fluid Therapy (modern stewardship framework): Drug (indication) → Dose → Duration → De-escalation

---

PART 10: POTASSIUM - THE MOST DANGEROUS ELECTROLYTE

---

PART 11: MONITORING FLUID THERAPY - WHAT TO CHECK

Hourly/frequent:

• BP, HR, SpO2, RR
• Urine output: target ≥0.5 mL/kg/hour (normal = ~30-50 mL/h in adults)
• Urine output <0.5 mL/kg/h for >2h = oliguria → investigate

Every 4-8 hours (sick patients):

• Fluid balance (ins vs outs - document meticulously)
• Lactate (if sepsis/shock): target trend down; <2 mmol/L = adequate perfusion
• Blood glucose (DKA, TPN, high-dose dextrose)

Daily:

• Weight (most sensitive measure of fluid status)
• U&E, creatinine, electrolytes
• Reassess fluid strategy: still in resuscitation? Time to stop? Time to de-resuscitate?

---

PART 12: THE MENTAL CHECKLIST - USE IT EVERY TIME

Before prescribing any IV fluid:

✓ WHY am I giving this? (Resuscitation / Replacement / Maintenance / Nutrition)
✓ Is the patient in shock? What TYPE of shock?
✓ Which fluid matches the clinical scenario?
✓ Can they drink instead? (oral always preferred)
✓ What RATE and VOLUME? Document clearly.
✓ Reassessment time? (30 min for bolus; next check for maintenance)
✓ Stop criteria: when will I review and stop this fluid?
✓ Daily: check weight, fluid balance, electrolytes, urine output
✓ Am I adding to fluid overload?

---

Quick Summary Reference Card

---

• Surviving Sepsis Campaign 2026 - Crystalloids first-line; balanced crystalloids over 0.9% NS; up to 30 mL/kg initial resuscitation (SCCM.org)
• ESICM 2025 Fluid Guideline Part 1 (fluid type) - Balanced crystalloids preferred over isotonic saline for most critically ill patients; albumin for cirrhosis; isotonic saline for TBI
• ESICM 2025 Fluid Guideline Part 2 (volume) - Up to 30 mL/kg for sepsis with frequent reassessment; restrictive strategy for hemorrhagic shock (PMID 40163133)
• NICE NG253 (2025) - 250 mL boluses, up to 1000 mL; balanced crystalloid or 0.9% NS if not available
• Bailey & Love's Short Practice of Surgery, 28e - Fluid type selection, shock resuscitation
• Miller's Anesthesia, 10e - Fluid responsiveness, hyperchloremic acidosis, dynamic monitoring

Key takeaway for your career as MO: "Drip and sip" - get patients drinking as early as possible, use IV fluids only when genuinely needed, reassess the fluid balance every single day, and actively remove fluid when the patient no longer needs it. Fluid overload has become a recognized cause of morbidity and mortality, just like under-resuscitation.