Fits (Seizures)

at the bedside

airway, breathing, circulation; nothing in the mouth; recovery position; oxygen, cardiac monitor, IV access; full vitals and glucose
note the onset time and duration → time every dose from it
hypoglycemia → IV glucose 150–200 mL of 10% or 75–100 mL of 20% over 10–15 min; D50W 50 mL only if 10/20% unavailable
BP > 180/110 → consider hypertensive encephalopathy / eclampsia / PRES
pregnancy: pregnant or postpartum seizure → treat as eclampsia until proven otherwise (MgSO₄ first, not benzodiazepines)

escalate now if

status epilepticus → seizure > 5 min or ≥ 2 seizures without full recovery → benzodiazepine now
pregnant or postpartum → eclampsia, magnesium not benzodiazepine
fever, meningism, new focal deficit or head injury → CT then LP; meningitis → antibiotics now
not waking 20–30 min after the seizure → non-convulsive status

seizure causes → 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
status epilepticus → seizure > 5 min or repeated seizures without recovery → treat
non-convulsive status → not waking 20–30 min after, subtle twitching, eye deviation → EEG, neurology

history
- known epilepsy or AED non-adherence
- alcohol or benzodiazepine withdrawal
- stress, fatigue, exertion, sleep deprivation
- pregnancy or postpartum (eclampsia)
- head trauma, immunosuppression, recent neurosurgery
- aura → epigastric rising, déjà vu, visual/olfactory/gustatory hallucination (supports seizure over syncope)
features supporting seizure
- tongue biting, incontinence, post-ictal confusion
- triggers → urination/defecation (reflex syncope vs seizure)
examination
- assess for injuries
- neurological exam → new focal deficits
- vitals (fever, hypertension)

glucose, VBG → hypoglycemia, lactate and acidosis after the seizure → venous blood gas
RFT, Ca, Mg, CBC → sodium, calcium and magnesium are the fixable causes → sodium
antiepileptic levels → known epilepsy: missed doses are the usual trigger
ECG → QT, arrhythmia; convulsive syncope looks like a seizure; β-hCG → women of reproductive age
CT head, LP, EEG → by indication, first seizure workup; fever or meningism → cultures first

0–5 min → protect, time it, no drug; most seizures stop on their own
5–20 min → benzodiazepine, call for help
- lorazepam 0.1 mg/kg IV, max 4 mg per dose
- or diazepam 0.15–0.2 mg/kg IV, max 10 mg per dose
- no IV access → midazolam 10 mg IM
- still seizing at 3–5 min → repeat once
> 20 min, status epilepticus → neurology and ICU now; second-line drug
- levetiracetam 60 mg/kg IV, max 4.5 g
- or valproate 40 mg/kg IV
- or fosphenytoin 20 mg PE/kg IV
- refractory → anesthesia and intubation → mechanical ventilation
eclampsia (pregnant or postpartum) → magnesium sulfate 4 g IV over 15–20 min, then 1 g/h infusion; obstetrics now; benzodiazepines are not first line

treat reversible causes immediately

hypoglycemia → IV glucose (see ABCs above)
severe hyponatremia → 3% NaCl 150 mL IV over 20 min; repeat the Na; repeat the dose once if seizure persists; goal: raise Na by 5 mmol/L; max 10 mmol/L in 24 h. Full protocol: sodium
hypocalcemia, hypomagnesemia → replace IV; see respective lab pages for doses

after seizure resolution

monitor GCS closely
no recovery within 20–30 min → suspect non-convulsive status; arrange EEG; neurology and ICU

first seizure workup

CT head, non-contrast, after stabilisation, for every first seizure; with contrast if tumour or abscess is suspected (cancer, immunosuppression); MRI epilepsy protocol when the CT is normal and there is no metabolic trigger, a neurology decision
LP → if meningitis/encephalitis suspected (fever, meningism, immunosuppressed); after CT excludes mass effect
EEG → not usually needed acutely unless non-convulsive status suspected; the treating team arranges it for a first unprovoked seizure
AED decision → single provoked seizure (metabolic, drug-related, alcohol withdrawal) usually needs no long-term AED, correct the precipitant; first unprovoked seizure: AED start is a Neurology decision
monitored bed and neurology → status, recurrent seizures, new focal deficit, known intracranial lesion, or no cause found

hand over → seizure times and drugs given, cause found, next dose due, escalation trigger

source	type
ILAE 2015 · Definition and classification of status epilepticus	consensus definition
ESETT 2019 (NEJM) · Levetiracetam vs fosphenytoin vs valproate for established status	RCT

Verify indication, dose, allergies, interactions, renal/hepatic function and local protocols before prescribing.

free the on-call checklist covers the whole shift on one printable page.

studying for the IM exam? IM Rapid Review covers seizures and status in the same format. see the sample chapter.

reviewed Jun 2026updated Oct 2026file complaint/fits-seizures