Fits (Seizures)

ABCs

note seizure onset time
airway, breathing, circulation; do not put anything in mouth
left lateral (recovery) position
monitor + oxygen; secure IV access
vitals + RBS immediately
labs: CBC, VBG, RFT, Ca²⁺, Mg²⁺, AED levels (if known epilepsy)
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)

status & can’t-miss

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)

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

0–5 minobserve	most seizures self-limited; observe; 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); repeat once after 3–5 min if ongoing; no IV → IM midazolam 10 mg; call for help; prepare escalation
> 20 minstatus epilepticus	call Neurology + ICU; 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; ICU admission likely. Refractory → anesthesia/intubation (Advanced: Mechanical Ventilation); treat cause (glucose, Na); eclampsia → MgSO₄ 4 g IV then 1 g/h

treat reversible causes immediately

hypoglycemia → IV glucose (see ABCs above)
severe hyponatremia → 3% NaCl 150 mL IV over 20 min; recheck Na; repeat 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
eclampsia → MgSO₄ (see ABCs above)

after seizure resolution

monitor GCS closely
no recovery within 20–30 min → suspect non-convulsive status; arrange EEG; escalate to senior/ICU/Neurology

first seizure workup

imaging: CT brain non-contrast for all first seizures (hemorrhage, mass, stroke). MRI brain outpatient if CT normal and no clear metabolic trigger
LP: if meningitis/encephalitis suspected (fever, meningism, immunosuppressed); after CT excludes mass effect
EEG: not usually needed acutely unless non-convulsive status suspected; arrange outpatient for 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
disposition: admit if status, recurrent seizures, new focal deficit, known intracranial lesion, or no cause identified. Single provoked seizure with full recovery → brief observation, discharge with Neurology follow-up
advise patient: no driving, swimming alone, or working at heights until specialist review

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 Sep 2026file complaint/fits-seizures