A practical Foundation doctor guide to acute seizure management on the ward, including:
- ABCDE
- glucose
- first-line benzodiazepines
- escalation
- post-seizure care and key investigations
Acute Seizure on the Ward: What Should You Do?
You are bleeped to a ward because a patient is actively fitting.
This is one of the situations where a structured response matters.
Your priorities are to keep the patient safe, assess ABCDE, correct reversible causes, start appropriate treatment if the seizure does not stop promptly, and escalate early.
The key timing point: Most seizures self-terminate within around 2 minutes. If the seizure is continuing, aim to start antiseizure treatment no later than 5 minutes from onset.
1. Go to the bedside and call for help early
Do not manage an ongoing seizure from the desk. Go immediately and establish:
- How long has the seizure been going on?
- Is it still ongoing now?
- Is this a first seizure, or is there a known seizure disorder?
- Has the patient fully recovered between events, or are they having repeated seizures?
- What is the current airway, oxygenation and haemodynamic status?
If there are any adverse features, escalate immediately: airway obstruction, hypoxia, hypotension or fever.
Foundation doctor tip: Start management but always contact a senior. If the patient is acutely unwell or you are worried, call for help and get the crash trolley.
2. Start with ABCDE and basic seizure first aid
- A — Airway — Check that the airway is patent. If convulsing, do not put anything in the mouth. Once it is safe, position and suction as required.
- B — Breathing — Give high-flow oxygen if needed (for example 15 L/min via a non-rebreather mask as part of immediate management). Check respiratory effort and saturations.
- C — Circulation — Attach monitoring if available, obtain a full set of observations and secure IV access.
- D — Disability — Check GCS when possible and check capillary blood glucose early. Ongoing fitting and recurrent seizures are themselves a neurological emergency.
- E — Exposure — Look for clues such as fever, trauma, head injury, alcohol misuse or evidence of infection.
Basic seizure first-aid principles still apply:
- protect the patient from injury
- do not restrain them
- do not put anything in their mouth
- loosen tight clothing around the neck if relevant
- place them in the recovery position once convulsions stop and if it is safe to do so. NHS: What to do if someone has a seizure
3. Check capillary glucose early
A bedside glucose is one of the fastest reversible causes to identify. Check capillary glucose in all patients.
If BM is below 4.0 mmol/L, correct it promptly:
- 100 mL of 20% glucose IV over 15 minutes, or
- 200 mL of 10% glucose IV over 15 minutes
Correcting hypoglycaemia does not replace the need for ABCDE and escalation if the patient remains unwell.
4. If the seizure is still going at 5 minutes, give first-line medication
A prolonged ongoing convulsive seizure should be treated as a medical emergency. Choose one of the following first-line options if the seizure has not self-terminated within 5 minutes:
| Option | Dose / comment |
|---|---|
| Midazolam (buccal) | 10 mg buccal |
| Diazepam (per rectum) | 10 mg PR |
| Lorazepam (intravenous) | 4 mg IV if access is available; preferred if IV access is present (e.g. 0.1 mg/kg up to a maximum of 4 mg). |
BNF also supports lorazepam and midazolam as first-line options in status epilepticus. BNF: Status epilepticus
5. If the seizure is still going at 10 minutes, escalate and repeat benzodiazepine treatment
If the seizure is persisting beyond 10 minutes, call a senior and give lorazepam 4 mg IV (or repeat it as directed in the pathway if already given as step 1).
At this point you should be thinking of established convulsive status epilepticus and making sure senior help is already on the way.
6. If the seizure is still going at 15 minutes, this becomes senior-led management
This stage is only to be initiated by a senior. If the seizure is persisting beyond 15 minutes, the next step is escalation to second-line antiseizure medication. NICE NG217: Treating status epilepticus
| Second-line option | Dose |
|---|---|
| Phenytoin IV | 20 mg/kg IV, maximum dose 2 g, rate 50 mg/min. Monitor BP and ECG. |
| Levetiracetam IV | 60 mg/kg IV, maximum dose 4.5 g, diluted in 100 mL sodium chloride 0.9%, given over 10 minutes. |
| Valproate IV | 40 mg/kg IV, maximum dose 3 g, diluted in 100 mL sodium chloride 0.9%, given over 5 minutes. |
7. If the seizure persists, escalate to critical care
Ongoing seizures after second-line treatment need escalation to critical care for airway support, continuous monitoring and advanced treatment in refractory status epilepticus.
8. Adjunctive treatments: think about the cause
- Suspected alcohol misuse: consider Pabrinex IV and assess with CIWA-Ar where relevant.
- Suspected cerebral oedema (for example vasculitis or cerebral tumour): dexamethasone 10 mg IV after discussion with a senior and CT head evidence of cerebral oedema.
Do not forget that seizure management is not only about stopping the fit. You also need to identify and start treating the underlying cause.
9. Post-seizure management is just as important
Once the seizure has stopped, continue a structured review rather than simply leaving the bedside:
- repeat ABCDE
- monitor observations and GCS
- check whether the patient is waking as expected
- look for tongue bite, head injury or other trauma
- document timing, treatments and response
| Investigation / review | What to consider |
|---|---|
| ABG | pH, pO₂ and lactate. |
| Bloods | FBC, U&Es, magnesium, calcium, LFTs and CRP. |
| Additional blood tests | Coagulation if potential intracranial bleeding; toxicology screen if relevant; anticonvulsant levels if the patient is already taking these; cultures if infection is suspected; repeat glucose if diabetic or hypoglycaemia is a concern. |
| Other investigations | Consider lumbar puncture, CT head and EEG as clinically appropriate. |
| Medication review | Review medicines that lower seizure threshold (for example quinolones). Check BNF for more detail. |
| Seizure prophylaxis | Senior advice on ongoing prophylaxis may be needed (for example levetiracetam). Consider prescribing a step-1 PRN rescue medicine if recurrent seizures are a concern. |
10. A practical FY1 approach at the bedside
- Note the time or ask exactly when the seizure started.
- Call for help early and ask for the crash trolley if the patient looks unwell.
- Start ABCDE and basic seizure first aid.
- Check capillary glucose and correct hypoglycaemia if present.
- If the seizure continues beyond 5 minutes, give first-line treatment.
- If the seizure persists beyond 10 minutes, escalate and give the next step of treatment.
- If the seizure persists beyond 15 minutes, ensure senior-led second-line treatment and critical-care escalation.
- Once the seizure stops, investigate why it happened and document everything clearly.
11. When should the FY1 escalate immediately?
- This is a first seizure or there is no clear history available.
- The seizure is prolonged or recurrent.
- There is airway compromise, hypoxia or hypotension.
- The patient is febrile or you suspect CNS infection.
- The patient has head injury, trauma or possible intracranial bleeding.
- There is persistent reduced GCS after the seizure.
- You suspect status epilepticus.
- You are worried.
The Foundation doctor seizure rule
TIME THE SEIZURE → ABCDE → CALL FOR HELP → CHECK GLUCOSE → GIVE FIRST-LINE TREATMENT BY 5 MINUTES IF ONGOING → ESCALATE AT 10 MINUTES → SENIOR-LED SECOND-LINE TREATMENT AT 15 MINUTES → POST-SEIZURE REVIEW AND INVESTIGATE THE CAUSE
The key message
In an acute seizure, time matters. Keep the patient safe, treat reversible causes, start appropriate medication promptly if the seizure continues, and escalate early rather than late.
Educational note: This article is intended as an educational guide for Foundation doctors. For individual patients, follow current NICE/BNF guidance and your NHS organisation’s status epilepticus and emergency-care pathways, and seek senior advice when appropriate.
