Seizures

Acute management of prolonged seizure

According to Therapeutic Guidelines, immediate treatment is indicated if

1. A seizure lasts longer than 5 minutes, or

2. Seizures recur without full recovery of consciousness between events

First-line pharmacological treatment

Midazolam is recommended as first-line benzodiazepine treatment

• Adults

  • ≥40 kg: 10 mg IM

  • <40 kg: 5 mg IM

  • Alternative routes: IV (10 mg over 2 minutes), intranasal, or buccal

• Paediatric dose

  • 0.2 mg/kg IV, IM, buccal, or intranasal

If the seizure continues beyond 5 minutes after the first dose of midazolam

• Repeat midazolam (one additional dose), or

• Proceed to second-line agents

  • IV phenytoin/fosphenytoin

  • IV valproate

  • IV levetiracetam

Key considerations during acute seizure

• Check blood glucose early: Hypoglycaemia must be corrected promptly

• Ensure a safe environment: Position the patient to avoid injury, loosen tight clothing, protect the airway, and do not place objects in their mouth

Non-pharmacological and long-term management

Driving restrictions

In Australia, driving regulations for patients with seizure are enforced through the Austroads guidelines, also reflected in RACGP recommendations. Generally

• Private vehicle licence: No driving for 6 months if a patient has had a seizure

• Commercial licence: No driving for 5 years

Always advise patients to inform the local driving authority if they experience any seizure activity

Lifestyle modifications

• Alcohol: Limit to a maximum of 2 standard drinks per day (though individual advice may vary based on overall risk)

• Substances: Avoid illicit drugs and caution with sedating medications (e.g. antihistamines)

• Sleep hygiene: Encourage regular sleep patterns and adequate rest

• Swimming/bathing: Recommend supervised swimming; advise showering rather than bathing if alone, to reduce the risk of drowning in case of a seizure

• Stress reduction: Relaxation therapies, mindfulness, and other stress-management techniques

• Family/household education: Train family members or housemates in seizure first aid

• Occupational considerations: Advise to notify their employer if safety at work could be compromised

Contraception and pregnancy planning

• Contraceptive choices: Depot medroxyprogesterone injection or levonorgestrel intrauterine device (Mirena) may be preferable when avoiding interactions with enzyme-inducing antiepileptics

• Pre-pregnancy planning: Women with epilepsy should seek preconception counselling, as certain antiepileptic drugs carry teratogenic risks

Referral and further investigations

• EEG (electroencephalogram): Often indicated in new-onset suspected epilepsy or if the clinical picture is unclear

• Neuroimaging: Urgent imaging (CT or MRI) if

  • Seizure has a focal onset

  • Abnormal neurological examination

  • First seizure occurs in a patient over 25 years of age (to exclude intracranial pathology)

• Neurologist referral: If recurrent seizures, diagnostic uncertainty, or concern for complex comorbidities

Seizure – first episode

When encountering a first seizure in general practice, consider the broad range of differentials and always exclude correctable metabolic or structural causes

Differential diagnosis

• Seizure-related

  • First presentation of epilepsy

  • Psychogenic non-epileptic seizure (PNES)

• Syncope

  • Cardiac: Arrhythmias, structural heart disease

  • Vasovagal (common faint)

  • Postural (orthostatic) hypotension

• Neurological

  • Intracranial bleed (subarachnoid, intracerebral)

  • CNS infection (meningitis, encephalitis)

  • Tumour

  • Stroke or transient ischaemic attack

  • Basilar migraine

  • Narcolepsy (rare mimic)

• Metabolic

  • Hypoglycaemia

  • Hypo/hypernatraemia

  • Hypo/hyperkalaemia

  • Hypomagnesaemia

• Other

  • Drug/alcohol intoxication or withdrawal

  • Hyperventilation attack

  • Conversion disorder

Investigations for first seizure

• Serum electrolytes, including magnesium

• Blood glucose (capillary and serum)

• Full blood count, renal function, liver function tests

• Possibly toxicology screen if clinical suspicion

History and examination

Key historical features

• Prior similar events or childhood seizures

• Event description: Witness accounts, urinary incontinence, tongue biting

• Triggers: Emotional stress, sleep deprivation, flashing lights

• Precipitating factors: Palpitations (cardiac cause), substance use, recent head trauma

• Associated symptoms: Headaches, confusion, focal neurological signs

• Family history: Seizures or epilepsy

• Psychosocial: Anxiety, recent stressors, history of psychological trauma (may point to PNES)

Examination findings

• General: Look for track marks (IV drug use), smell of alcohol

• Vital signs: Fever (possible infection), arrhythmias

• Neurological: Pupil abnormalities, meningism, focal deficits

• Tongue laceration: Suggestive of a generalised convulsive event

• Integument: Injuries consistent with a fall or convulsion