Include in assessment

• Capillary glucose
• Venous blood gas (to measure lactate and acidosis) and venous bloods including FBC, LFTs, U&Es, Ca²⁺, PO₄^3-, Mg²⁺ (look for electrolyte abnormalities), antiepileptic drug levels (if taking), clotting
• ECG (look for prolonged QT interval)
• Urine toxicology screen (if relevant)
• Further investigations (if cause unknown):
  • CT/MRI brain (look for any focal lesions or bleed)
  • Electroencephalogram (EEG)
  • Lumbar puncture (if meningitis / encephalitis suspected)

Initial ABCDE approach

• Airway
  • Recovery position
  • Maintain airway with jaw-thrust ± suction as required
  • Consider nasopharyngeal airway if airway concerns (not oropharyngeal airway due to trismus)
• Breathing
  • 15L oxygen via non-rebreather mask
• Circulation
  • Secure IV access
  • Attach monitoring (pulse oximetry, blood pressure, cardiac monitor)
• Disability
  • Check capillary glucose
• Everything else
  • Full examination

Pharmacological seizure management

If seizure ongoing, within:

• 10 minutes: 4mg lorazepam IV OR 10mg diazepam PR
• 20 minutes: repeat above
• 30 minutes: phenytoin 20mg/kg IV (max. 2g; at 50mg/minute with cardiac monitoring) or levetiracetam (Keppra) 40mg/kg IV (max. 4.5g; over 10 minutes)
• 60 minutes: general anaesthesia in intensive care unit

Plus:

• If hypoglycaemia: 50ml 50% glucose IV 
• If any suggestion of alcohol dependence: Pabrinex I+II 2 pairs IV
• Treatment for any obvious causes

After patient has recovered consciousness

• Post-ictal period may last a few hours
• Find cause
  • Full history
  • Multi-system examination (including full neurological exam)
  • Complete any outstanding investigations above
• Treat cause
• Refer to medical team/neurology or seizure clinic
• Give driving advice and instruct patient to inform DVLA

Questions

Try an OSCE station

1. Status epilepticus
2. Find more here