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Epilepsy - Management
How do I manage a person having a seizure including status epilepticus?

  • For people having a tonic–clonic seizure of less than 5 minutes' duration:
    • Look for an epilepsy identity card or jewelry.
    • Protect them from injury by:
      • Cushioning their head with your hands or soft material.
      • Removing harmful objects from nearby, or if this is not possible, moving the person away from immediate danger.
    • Do not restrain them or put anything in their mouth.
    • When the seizure stops, check their airway and place them in the recovery position.
    • Observe them until they have recovered.
    • Examine for, and manage, any injuries.
    • Arrange emergency admission if it is their first seizure.
  • For people having a tonic–clonic seizure lasting more than 5 minutes, or who have more than three seizures in an hour, in addition to the measures described above:
    • Treat with either:
      • Buccal midazolam, or
      • Rectal diazepam.
    • Call an ambulance for urgent hospital admission if seizures do not respond promptly to treatment with diazepam or midazolam. The aim is to ensure that people with persistent seizures arrive at the Accident and Emergency department within 30 minutes of the onset of the seizure.
    • Call an ambulance for urgent hospital admission if seizures do respond to treatment but:
      • Seizures were prolonged or recurrent before treatment was given, particularly if seizures had developed into status epilepticus. This is defined as a continuous seizure for 30 minutes or longer, or recurrent seizures without regaining consciousness lasting 30 minutes or longer.
      • There is a high risk of recurrence, such as a history of repeated seizures or status epilepticus.
      • There are difficulties monitoring the person's condition.
      • This is their first seizure.
  • For people having other types of seizures (simple partial, complex partial, absence, tonic, atonic, and myoclonic seizures):
    • Protect them from injury by removing harmful objects from nearby, or if this is not possible, moving them away from immediate danger.
    • Observe them until they have fully recovered.
    • Examine for, and manage, any injuries.
    • If symptoms persist, consider arranging admission or seeking specialist advice.
Basis for recommendation
  • The management of people having a seizure for less than 5 minutes is based on expert advice [Epilepsy Action, 2005a]. It is widely accepted that drug treatment for self-limiting, short duration seizures is unnecessary.
  • The treatment of people having prolonged or repeated seizures with rectal diazepam or buccal midazolam is based on evidence from five randomized controlled trials (RCTs) considered by the National Institute for Health and Clinical Excellence [NICE, 2004c].
    • Three RCTs (n = 275) found that rectal diazepam was effective at terminating prolonged and repeated seizures in adults and children in the community when compared with placebo.
    • One RCT (n = 42) found that rectal diazepam and buccal midazolam were similarly effective at controlling prolonged seizures in children with severe epilepsy.
    • One RCT (n = 44) found that intranasal midazolam was more effective than rectal diazepam at controlling acute seizures in children.
  • Admission criteria for people having prolonged or repeated seizures is based on expert opinion [NICE, 2004c].
  • The management of people having other types of seizures is based on expert opinion [Epilepsy Reseach UK, 2008].

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