Fits (Seizures)

ABCs
  • Airway, Breathing, Circulation
  • Place patient in left lateral position
  • Attach monitor + oxygen
  • Vitals + RBS immediately
  • Send labs
    • CBC
    • VBG
    • RFT
    • Ca²⁺, Mg²⁺
    • AED levels (if known epilepsy)
  • If hypoglycemia → Give D50W 50 mL IV STAT
  • If BP > 180/110 → consider hypertensive encephalopathy
HPI & examination
  • History
    • Known epilepsy or AED non-adherence
    • Alcohol or benzodiazepine withdrawal
    • Recent stress, fatigue, exertion
    • Prodrome: palpitations, nausea, vomiting, sweating
    • Features supporting seizure:
      • Tongue biting
      • Incontinence
      • Post-ictal confusion
    • Triggering events: Urination / defecation (reflex syncope vs seizure)
  • Examination
    • Assess for injuries
    • Full neurological exam → look for new focal deficits
    • Check vitals immediately (esp. fever, hypertension)

Differential diagnosis
  • Seizures
    • Epilepsy
    • Stroke / hemorrhage / trauma
    • Metabolic: Hypoglycemia
    • Hypoxia
    • Withdrawal: Alcohol / benzodiazepines
    • Infection
    • Eclampsia
    • PRES
    • Tumor
    • Medication non-adherence
  • Mimics
    • Syncope
    • TIA
    • Migraine
    • PNES
    • Dystonia
    • Myoclonus
    • Tremor
Management
  • Timing-Based Seizure Management
    • 0–5 minutes
      • Most seizures are self-limited
      • Observe closely
      • No medications unless prolonged
    • 5–20 minutes
      • Give: IV Diazepam 5 mg OR
      • Lorazepam 1–2 mg STAT
      • May repeat after 3–5 minutes if ongoing
      • Call for help and prepare escalation
    • >20 minutes (Status Epilepticus)
      • Urgent: Call Neurology + ICU
      • Load with: Levetiracetam (Keppra) OR
      • Valproate (Depakine) (after senior discussion)
      • Likely ICU admission
  • After Seizure Resolution
    • Monitor GCS closely
    • If no recovery within 20–30 minutes: Suspect non-convulsive status epilepticus
    • Arrange EEG
    • Escalate to senior / ICU / Neurology
  • Escalation Criteria
    • Status epilepticus: Seizure >5 min OR ≥2 seizures without full recovery
    • Concern for: CNS infection, Intracranial mass, Stroke
    • Persistent altered mental status

related · hypoglycemia · sodium · calcium · magnesium · altered mental status

Studying for R1? The IM Rapid Review covers this in the same format — see the sample chapter.

Last reviewed · May 2026

MOC