• Be aware that the first time you see a seizure it is quite terrifying and off-putting.
• The first thing to do is to look at your watch – they seem to go on forever when you see them, so it is important to get an objective measure of the time.
• There must be a Clinical Emergency Response call made for all generalised tonic-clonic seizures.
• Ensure the patient is safe – people having a seizure can injure themselves in various ways.
• They can fall off the bed – so bed rails need to be put up.
• Their tonic clonic movements can cause themselves injury – if they are hitting their head on the floor put a pillow underneath if you can, if you don’t have a pillow sit with your legs folded underneath their head.
• Never put anything in the patients mouth – patients usually bite their tongue on the first contraction.
• If practical, you can place a Hudson mask on the patient, otherwise wait until the seizure is complete.

Once the seizure is complete:

• Check the time.
• Place the patient in the recovery position and ensure the airway is patent.
• Usually the Clinical Emergency Response team will have arrived by this point.

After the seizure:

• Insert a cannula.
• Obtain a history of reason for admission, possible causes of seizure, and any previous seizures.
• Examine the patient for new focal neurology, check the vital signs and take a set of bloods.
  • Keep in mind that after the seizure, the patient may have a Todd’s paresis in the fitting limb.
  • Bloods: FBC, EUCs, LFTs (if known seizure disorder on anti-epileptics, can check drug levels too).
• Notify the neurology registrar on call and ask for advice (i.e. need for CTB with or without contrast).
  • They may ask you to describe the seizure as the type of seizure can influence the drugs that are prescribed.
    • How does it start? E.g. Head turns to one side, fitting of single arm before generalised seizure.
    • Where is it localised to? E.g. One limb, one side of body, whole body?
    • What is the character of the seizure? E.g. Tonic (stiffness) or tonic clonic (contraction and relaxation)?
• If duration is > 5 mins, call for ICU to assist.

• With recurrent seizures you get into the question of is this status epilepticus or not.
  • Most seizures terminate in 2 minutes, if a seizure continues for longer than 5 minutes we start to worry.
  • Status epilepticus by definition is ongoing seizures or recurrent seizures without recovery for 30 minutes, however if it is lasting more than 5 minutes we treat as it is status epilepticus.
  • Treatment – in consultation with the neurology registrar.
    • Call ICU – the management involves drugs that will often require the patient to be intubated and ventilated.
    • Diazepam 0.2 mg/kg given as IV infusion at a rate of 5 mg/min.
    • Check BSL.
    • Thiamine 100 mg IV.
    • Phenytoin 15-20 mg/kg given as IV infusion at a rate of 50 mg/min with constant ECG monitoring.
    • Check phenytoin level – even with a loading dose may still be quite sub-therapeutic.
    • May need to give more phenytoin in increments of 5 mg/kg.