Fits (Seizures)
ABCs
- airway, breathing, circulation
- place patient in the left lateral position
- attach monitor + oxygen
- vitals + RBS immediately
- send labs: CBC, VBG, RFT, Ca²⁺, Mg²⁺, AED levels (if known epilepsy)
- if hypoglycemia → D50W 50 mL IV STAT
- if BP > 180/110 → consider hypertensive encephalopathy
red flags
status & can’t-miss
- status epilepticus: seizure > 5 min or ≥ 2 seizures without full recovery
- concern for CNS infection, intracranial mass, stroke
- persistent altered mental status
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 (especially fever, hypertension)
differentials
- 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
management (by time)
| 0–5 minobserve | most seizures are self-limited; observe closely; no medications unless prolonged |
| 5–20 minbenzodiazepine | IV lorazepam 0.1 mg/kg (max 4 mg/dose) or IV diazepam 0.15–0.2 mg/kg (max 10 mg/dose); may repeat once after 3–5 min if ongoing; no IV access → IM midazolam 10 mg; call for help, prepare escalation |
| > 20 minstatus epilepticus | urgent → call Neurology + ICU; load second-line by ~20 min if still seizing: levetiracetam 60 mg/kg (max 4.5 g), valproate 40 mg/kg, or fosphenytoin 20 mg PE/kg; likely ICU admission. refractory → anaesthesia / intubation; treat the cause (glucose, Na); eclampsia → MgSO₄ 4 g IV then 1 g/h |
after seizure resolution
- monitor GCS closely
- if no recovery within 20–30 min → suspect non-convulsive status epilepticus, arrange EEG, escalate to senior / ICU / Neurology
studying for the IM exam? the IM Rapid Review covers seizures and status in the same format. see the sample chapter.
Last reviewed · June 2026