What is the immediate management for a seizure?

Immediate Management of Seizures

For an actively seizing patient, protect them from injury by helping them to the ground, placing them on their side in the recovery position, clearing the area around them, and staying with them—never restrain them or put anything in their mouth. 1

During the Active Seizure

Immediate Safety Measures

• Help the person to the ground to prevent fall-related injuries 1
• Place them on their side in the recovery position to reduce aspiration risk if vomiting occurs 1
• Clear the surrounding area of objects that could cause injury during seizure movements 1
• Stay with the person throughout the seizure and postictal period 1

Critical Actions to AVOID

• Do NOT restrain the person during seizure activity, as this can cause injury 1
• Do NOT put anything in their mouth—no objects, food, liquids, or oral medications 1
• Do NOT give oral medications during the seizure or when responsiveness is decreased afterward 1

When to Activate Emergency Medical Services

Mandatory EMS Activation Criteria

Activate 911 immediately for any of the following 1:

• First-time seizure (no prior seizure history)
• Seizure lasting >5 minutes (potential status epilepticus)
• Multiple seizures without return to baseline mental status between episodes
• Seizure occurring in water
• Seizure with traumatic injuries, difficulty breathing, or choking
• Seizure in an infant <6 months of age
• Seizure in a pregnant individual
• Patient does not return to baseline within 5-10 minutes after seizure stops

The rationale is that seizures lasting >5 minutes may not stop spontaneously and require emergency anticonvulsant medications 1. Most seizures are self-limited and resolve within 1-2 minutes 1.

Medical Management for Prolonged Seizures

Pharmacologic Intervention

• For seizures lasting >5 minutes, administer benzodiazepines as first-line therapy 2
• Lorazepam IV 4 mg given slowly (2 mg/min) is the recommended dose for adults ≥18 years 2
• If seizures continue after 10-15 minutes, an additional 4 mg IV dose may be given slowly 2
• Equipment for airway management must be immediately available before administering IV lorazepam, as respiratory depression is the most important risk 2

Critical Monitoring Requirements

• Start an IV infusion 2
• Monitor vital signs continuously 2
• Maintain an unobstructed airway 2
• Have artificial ventilation equipment available 2

Post-Seizure Assessment

Immediate Evaluation

• Check serum glucose and sodium levels—these are the only laboratory abnormalities that consistently alter acute management 3
• Obtain pregnancy test if patient has reached menarche 3
• Assess for return to baseline neurologic status 3

Indications for Emergent Head CT

Perform non-contrast head CT immediately if any of the following are present 3:

• New focal neurological deficits
• Persistent altered mental status
• Fever
• Recent trauma
• Persistent headache
• History of cancer or immunocompromised state
• Patients on anticoagulation
• Age >40 years
• Partial-onset seizures

When Lumbar Puncture is Needed

• Perform LP primarily when there is concern for meningitis or encephalitis 3
• Consider LP in immunocompromised patients (after head CT) 1, 3

Special Considerations

Febrile Seizures in Children

• Do NOT give antipyretics (acetaminophen, ibuprofen, paracetamol) to stop or prevent febrile seizures—they are ineffective for this purpose 1
• Fever treatment can help children feel better but will not prevent subsequent seizures 1

Post-Stroke Seizures

• Single self-limiting seizures within 24 hours of ischemic stroke should NOT be treated with long-term anticonvulsants 1
• New-onset seizures in stroke patients should be treated with short-acting medications (e.g., lorazepam IV) if not self-limiting 1
• Prophylactic anticonvulsants are NOT recommended in stroke patients and may cause harm with negative effects on neurological recovery 1

NPO Status After Multiple Seizures

• Keep patients NPO after seizures until swallowing screening is completed to prevent aspiration 4
• Swallowing assessment should be performed as soon as possible using validated tools 4
• Use alternative routes for medications (IV, rectal) while patient remains NPO 4

Disposition Decisions

Safe for Discharge

• Patients with first unprovoked seizure who have returned to clinical baseline in the ED do NOT require admission 3
• Low-risk patients (young, returned to baseline, normal neurologic exam, reliable follow-up) can have deferred outpatient MRI 3

Consider Admission If:

• Persistent abnormal neurologic examination 3
• Abnormal investigation results requiring inpatient management 3
• Patient has not returned to baseline 3

Common Pitfalls to Avoid

• Approximately 28-48% of suspected first seizures have alternative diagnoses (syncope, nonepileptic seizures, panic attacks)—careful history is essential 3
• Do not miss metabolic abnormalities like hypoglycemia or hyponatremia that may be causing the seizure 3
• Alcohol withdrawal seizures should be a diagnosis of exclusion, especially in first-time seizures—always search for symptomatic causes first 3
• Do not allow oral intake too early before proper swallowing assessment, as this can lead to aspiration pneumonia 4