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What should i do first when patient come to me with seizure

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What should i do first when patient come to me with seizure

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Quick answer

First: protect the patient and assess ABCs.
  1. Call for help / activate emergency response.
  2. Keep them safe: lay them on the floor or bed if possible, remove nearby hazards, cushion the head, loosen tight neck clothing.
  3. Position: turn them onto their side as soon as safely possible to maintain the airway and allow secretions to drain.
  4. Assess airway, breathing, circulation and give oxygen/suction if available and needed.
  5. Time the seizure and observe features: onset, movements, eye/head deviation, color change, trauma, incontinence.
  6. Do not restrain them, put anything in their mouth, or give food, drink, or oral medicines during or immediately after the seizure.
  7. Once safe, check capillary blood glucose promptly and correct hypoglycemia per protocol.
  8. If seizure lasts 5 minutes or more, recurs without recovery, or the patient has respiratory compromise, treat as status epilepticus using your local emergency protocol, typically with a benzodiazepine, and arrange urgent transfer.
After it stops, continue lateral positioning, reassess vitals and neurologic status, look for injury or cause, and do not leave the patient alone until they recover.

What is the step-by-step adult status epilepticus protocol?

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Searching the Web

adult convulsive status epilepticus guideline benzodiazepine second line dosing 2025

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"Status Epilepticus"[MeSH Terms] AND treatment

Reading Web Page

https://www.nice.org.uk/guidance/ng217/chapter/7-Treating-st…

Adult convulsive status epilepticus protocol

Treat as status epilepticus if a generalized convulsive seizure lasts 5 minutes or longer, or recurrent seizures occur without recovery of consciousness. This is an emergency. Use this alongside local ED/ICU and medication policies.

0-5 minutes: immediate resuscitation and preparation

  1. Call for senior/emergency help. Bring airway equipment and prepare for rapid sequence intubation if deterioration is likely.
  2. Protect from injury and place in lateral position if feasible. Do not restrain or place objects in the mouth.
  3. ABCDE assessment
    • Airway: suction secretions, consider airway adjunct.
    • Breathing: high-flow oxygen, pulse oximetry, capnography if available.
    • Circulation: cardiac monitor, BP, two IV lines if possible.
  4. Check capillary glucose immediately.
    • If hypoglycemic: give IV dextrose per local protocol.
    • Give thiamine first or with glucose if malnutrition or alcohol dependence is likely, but do not delay glucose for a hypoglycemic patient.
  5. Send urgent tests: CBC, electrolytes including calcium and magnesium, renal/liver function, glucose, antiseizure-medication concentration when relevant, blood gas, pregnancy test where applicable, toxicology when indicated.
  6. Look for reversible causes: missed antiseizure medication, hypoglycemia, alcohol/drug withdrawal or intoxication, infection/meningitis, stroke, head trauma, eclampsia, metabolic disturbance.

5-10 minutes: first-line benzodiazepine

Give one adequate dose promptly. If convulsions continue after 5-10 minutes, give one repeat dose only.
Preferred if IV access is available
  • Lorazepam IV: 0.1 mg/kg, maximum 4 mg, administered slowly.
    Repeat once after 5 minutes if ongoing convulsions.
If IV access is not immediately available
  • Midazolam IM: 10 mg for adults over 40 kg.
    Alternative routes, depending on local protocol: intranasal or buccal midazolam.
  • Diazepam IV: 0.15-0.2 mg/kg, maximum 10 mg; repeat once if needed. Rectal diazepam may be used in prehospital/community settings where appropriate.
Monitor closely for respiratory depression and hypotension. Be ready to assist ventilation. The current NICE pathway calls for immediate emergency treatment, a second benzodiazepine dose if seizures persist 5-10 minutes after the first, and escalation after two doses. NICE status epilepticus guidance

10-30 minutes: second-line loading antiseizure medication

Do not wait excessively after benzodiazepines. Give one full IV loading dose of one of the following while continuing ABC support:
OptionTypical adult loading doseKey cautions
Levetiracetam IV60 mg/kg, max 4.5 g, over about 10 minOften simplest choice; few acute drug interactions. Adjust maintenance dosing later in renal impairment.
Valproate IV40 mg/kg, max 3 g, over about 10 minAvoid or seek specialist advice in pregnancy, significant hepatic disease, mitochondrial disease, hyperammonemia, or severe thrombocytopenia.
Fosphenytoin IV20 mg phenytoin equivalents (PE)/kg, max 1.5 g PE; max rate 150 mg PE/minContinuous ECG/BP monitoring. Caution with conduction disease, bradycardia, hypotension.
Phenytoin IV if fosphenytoin unavailable20 mg/kg, max 1.5 g, no faster than 50 mg/minECG/BP monitoring; extravasation and hypotension risk.
Levetiracetam, phenytoin/fosphenytoin, and valproate are accepted second-line choices. The best option depends on contraindications, access, cause, and local availability. If the first second-line drug fails, involve neurology/critical care urgently and consider another appropriate second-line agent rather than repeating benzodiazepines indefinitely.

30-60 minutes: refractory status epilepticus

Refractory status epilepticus means seizures continue after an adequate benzodiazepine plus an appropriately loaded second-line antiseizure medicine.
  1. Move to ICU / resuscitation setting and involve neurology plus anaesthesia/critical care.
  2. Intubate and ventilate if airway protection, oxygenation, ventilation, or ongoing anesthetic infusion requires it.
  3. Start continuous EEG as soon as possible. Motor activity may stop while electrographic seizures continue.
  4. Give continuous IV anesthetic therapy according to local ICU protocol, commonly:
    • Midazolam infusion
    • Propofol infusion if hemodynamically suitable
    • Thiopental/pentobarbital in selected cases
    • Ketamine may be considered in specialist management of refractory or super-refractory cases.
  5. Continue and optimize longer-acting antiseizure drugs so anesthetic infusions can later be weaned.
  6. Treat the cause in parallel: antibiotics/acyclovir for suspected CNS infection, magnesium for eclampsia, antidotal/toxicology treatment, stroke pathway, correction of electrolytes, etc.
A recent systematic review of continuous IV anesthetics concerns refractory status management, not a replacement for the early benzodiazepine then second-line sequence: Au et al., 2024, PMID 38466294.

After visible convulsions stop

  • Continue airway, breathing, circulation and neurological observations.
  • If the patient does not return toward baseline, urgently obtain EEG or continuous EEG to exclude non-convulsive status epilepticus.
  • Obtain CT head urgently if there is head injury, focal neurological deficit, persistent depressed consciousness, anticoagulant use, concern for hemorrhage/stroke, malignancy, or first seizure with concerning features.
  • Consider lumbar puncture after imaging when CNS infection or encephalitis is suspected.
  • Document seizure timing, drugs, doses, response, possible cause, and baseline function.

Practical rule

At 5 minutes: benzodiazepine.
After two adequate benzodiazepine doses: load levetiracetam, valproate, or fosphenytoin/phenytoin.
If still seizing: ICU, intubation when indicated, continuous EEG, anesthetic infusion, and urgent cause-directed treatment.

Which reference book you use for surgery in respect to answer questions

For the adult status epilepticus answer, I did not use a surgery reference book. It is primarily an emergency medicine, neurology, and critical-care topic.
I used:
I also attempted to search the medical textbook library, but it did not return usable results, so I did not cite or rely on a specific surgery textbook. I would not claim a surgical reference unless I had actually retrieved it.
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