What to do if an epileptic seizure lasts longer than 5 minutes?

Management of Seizures Lasting Longer Than 5 Minutes

Give rectal diazepam immediately for any seizure lasting longer than 5 minutes, as this represents status epilepticus requiring emergency anticonvulsant treatment. 1, 2

Why Immediate Treatment is Critical

Modern clinical guidelines have shifted to defining status epilepticus as any generalized convulsive seizure lasting 5 minutes or longer, rather than the traditional 20-minute threshold. 1 This change reflects evidence that:

• Seizures lasting >5 minutes are unlikely to stop spontaneously and require emergency medical intervention 1, 2
• Waiting another 5 minutes (option B) is inappropriate and increases risk of permanent neurological impairment from inadequately treated status epilepticus 3
• Status epilepticus is a potentially life-threatening condition with high risk of permanent neurological damage if treatment is delayed 3

Correct Home Management Protocol

Immediate Actions While Administering Medication

Ensure a safe environment (option A) while simultaneously preparing to give rectal diazepam (option C) - these are complementary, not mutually exclusive actions:

• Help the person to the ground to prevent fall-related injuries 2
• Place them on their side in the recovery position to reduce aspiration risk 2
• Clear the area of objects that could cause injury 2
• Stay with the person throughout the seizure 2

Rectal Diazepam Administration

Dosing for home administration:

• 0.5 mg/kg up to a maximum of 20 mg rectally 4
• This route is specifically recommended when IV access is unavailable, which is the typical home situation 4
• Rectal diazepam solution administered by trained caregivers is effective in stopping 81-87% of seizures within 10 minutes 5

Expected response:

• Seizures should cease within 2-5 minutes in most cases 6
• If seizures continue after 10-15 minutes, a second dose may be given 3, 6
• If seizures persist beyond 20 minutes despite two doses, activate EMS immediately 6

Why Other Options Are Incorrect

Option D (oral valproate) is dangerous and inappropriate:

• Never give oral medications during a seizure or when consciousness is impaired due to aspiration risk 2
• Oral anticonvulsants are maintenance medications, not acute seizure treatments 4
• Valproate has no role in acute seizure termination 4

Option B (waiting another 5 minutes) is harmful:

• Delays definitive treatment during a medical emergency 1
• Increases risk of progression to refractory status epilepticus 3
• The longer a seizure continues, the less likely it is to respond to treatment 7

When to Activate EMS

Call 911/EMS if: 2

• The seizure lasts >5 minutes (even while giving rectal diazepam) 1, 2
• This is a first-time seizure 2
• Multiple seizures occur without return to baseline between episodes 2
• The person doesn't return to baseline within 5-10 minutes after seizure stops 1
• Respiratory depression occurs (though rare with rectal diazepam) 5

Safety Considerations

Rectal diazepam is safe for home use:

• No clinically important respiratory depression in multiple studies 5, 8, 7
• Sedation occurs in approximately 9% of patients but is not dangerous 5
• Parents and caregivers can be trained to administer it safely and effectively 6, 7

Critical actions to avoid during seizures:

• Never restrain the person 2
• Never put anything in the mouth 2
• Never give oral medications or liquids 2