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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
  • Circualtion
    • Secure IV access
    • Attach monitoring (pulse oximetry, blood pressure, cardiac monitor)
  • Disability
    • Check capillary glucose
  • Everything else 
    • Full examination

Include in assessment

  • Capillary glucose
  • Venous blood gas (to measure lactate and acidosis) and venous bloods including FBC, LFTs, U&Es, Ca2+, PO43-, 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)

Pharmacological seizure management

If seizure onions, 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


  • 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