A patient is fitting
Start the clock. Protect from injury, check the sugar, give a benzodiazepine at 5 minutes, again at 10, then call for help.
A 45-year-old woman, day 2 after a laparoscopic cholecystectomy, starts fitting. The nurse calls you at 2 minutes. She drinks heavily at home but "hasn't had a drink since admission". Yesterday's sodium was 128 mmol/L. She is on tramadol for pain. There is an IV cannula in her left hand.
What do you do at 5 minutes, at 15 minutes, and what might be the cause?
- Start the clockNote the time it started. Treat if still fitting at 5 minutes.
- Keep safeRecovery position when possible, nothing in the mouth, oxygen, suction ready.
- Check sugarTreat if below 4 mmol/L (72 mg/dL).
- Benzodiazepine at 5 minutesLorazepam IV, or buccal midazolam or rectal diazepam if no IV access.
- Repeat once after 5–10 minutesTwo doses in total, including any given before.
- Still fitting after 2 dosesSecond-line drug now. Call the senior and anaesthetist.
- Pregnant or postpartumMagnesium sulfate for eclampsia.
- After the fitRecovery position, observations, GCS, find the cause.
- Fitting 5 minutes or more
- Second benzodiazepine needed
- Not waking up after the fit
- First fit, head injury or on anticoagulants
- Pregnant or recently delivered
- Fever or neck stiffness
- Hypoglycaemia
- Eclampsia
- Low sodium, calcium or magnesium
- Alcohol or benzodiazepine withdrawal
- Missed antiepileptics
- Meningitis or encephalitis
- Stroke or bleed
- Drug toxicity (tramadol, ciprofloxacin, isoniazid, tricyclics)
- Non-epileptic attacks
| Treat | Fit lasting 5 minutes or more, or repeated fits without recovery |
| Lorazepam | 0.1 mg/kg IV (usually 4 mg), may repeat once |
| Diazepam | 10 mg IV, or 10–20 mg rectally |
| Buccal midazolam | 10 mg (5 mg if elderly or under 50 kg) |
| Levetiracetam | 60 mg/kg IV over 10 minutes (maximum 4.5 g) |
| Phenytoin | 20 mg/kg IV, no faster than 50 mg/minute, with ECG monitoring |
| Sodium valproate | 40 mg/kg IV over 10 minutes (maximum 3 g), avoid in women of child-bearing age and liver disease |
| Eclampsia | Magnesium sulfate 4 g IV over 5–15 minutes, then 1 g/hour |
Check every dose against a current drug reference and your hospital protocol.
On this page
On the phone
- How long has it been going on? Ask someone to note the time.
- Is there IV access? Known epilepsy? Is there a rescue plan in the notes?
- Tell the nurse: turn on the side, nothing in the mouth, oxygen, suction ready, check the sugar, get lorazepam or midazolam ready.
When you arrive
- Airway: recovery position, suction, oxygen by mask. Don't force anything between the teeth. A nasopharyngeal airway can help.
- Sugar.
- Watch the fit: generalised or focal? Eyes open or tightly shut? Head moving side to side?
- Look for causes: head injury, fever, neck stiffness, pregnancy, drug chart (missed antiepileptics, tramadol, ciprofloxacin, isoniazid, withdrawal of alcohol or benzodiazepines).
The timeline
- 0 minTime it, keep safe, oxygen, sugar, IV access
- 5 minFirst benzodiazepine (lorazepam IV or buccal midazolam)
- 10–15 minSecond benzodiazepine dose (the last one)
- 20 minSecond-line drug: levetiracetam, phenytoin or valproate
- 30–40 minStill fitting: anaesthetist, intubation and anaesthesia, ICU
Two doses of benzodiazepine, then move to a second-line drug. A third benzodiazepine stops the breathing, not the fit.
Causes to look for
| Cause | Clue | Action |
|---|---|---|
| Missed antiepileptics | Known epilepsy, nil by mouth, vomiting | Restart (IV if needed); check levels |
| Low sugar | Insulin or sulfonylurea, liver failure, alcohol | Dextrose (and thiamine first if alcohol) |
| Eclampsia | Pregnant over 20 weeks or postpartum, high BP | Magnesium sulfate, obstetrics |
| Low sodium | Recent bloods, thiazides, hypotonic fluids | 3% saline if severe; see hyponatraemia |
| Low calcium or magnesium | Thyroid surgery, PPIs, alcohol | IV replacement |
| Alcohol withdrawal | Heavy drinking, 6–72 hours after the last drink, tremor | Benzodiazepine, thiamine |
| Benzodiazepine withdrawal | Long-term use stopped suddenly | Restart |
| Drugs | Tramadol, ciprofloxacin, isoniazid, tricyclics, bupropion | Stop; treat toxicity |
| Meningitis or encephalitis | Fever, neck stiffness, confusion | Antibiotics, aciclovir |
| Stroke, bleed, tumour | Focal signs, persistent drowsiness | CT head |
| Head injury | Fall, bruises | CT head |
Is it really a fit?
| Feature | Epileptic seizure | Syncope with jerks | Non-epileptic attack |
|---|---|---|---|
| Onset | Sudden, may have aura | Standing, warm, lightheaded | Often gradual, emotional trigger |
| Eyes | Open | Open | Often tightly shut, resists opening |
| Movements | Rhythmic, synchronous | A few brief jerks | Side-to-side head, pelvic thrusting, waxing and waning |
| Duration | Usually under 2–3 minutes | Seconds | Often long |
| Recovery | Confused, drowsy for minutes to hours | Quick | Variable, may cry |
| Tongue bite | Side of the tongue | Rare | Tip, if any |
Treat as a seizure if unsure. Never assume a non-epileptic attack without senior assessment.
Treatment
After the fit stops
- Recovery positionObservations every 15 minutes, GCS until back to normal.
- BloodsGlucose, sodium, calcium, magnesium, CBC, CRP, LFTs, antiepileptic levels if relevant, CK.
- Restart missed antiepilepticsIV if not able to swallow.
- First fit in hospitalNeurological examination, CT head, look for infection, ECG.
- Tell the family and documentWhat it looked like, timings, drugs, cause, plan.
Common mistakes
- Not timing the fit.
- Giving a third or fourth benzodiazepine instead of a second-line drug.
- Forgetting to check sugar.
- Missing eclampsia in a postpartum woman.
- Giving phenytoin too fast or without ECG monitoring.
- Using valproate in a woman of child-bearing age when another option exists.
- Missing alcohol withdrawal on day 2–3 of admission.
Frequently asked questions
When should a benzodiazepine be given in a seizure?
If the fit lasts 5 minutes or longer, or fits repeat without recovery in between.
What if there is no IV access?
Give buccal midazolam 10 mg or rectal diazepam 10–20 mg.
How many doses of benzodiazepine can be given?
Two in total, including any given before arrival. Then move to a second-line drug such as levetiracetam.
What should be done after a first seizure in hospital?
Check sugar and electrolytes, examine for focal signs, CT head, look for infection and drug causes, and get a neurology opinion.
Test yourself
Exam-style questions on this guide, from our two question banks. Choose an answer to see why each option is right or wrong.
1. A ward patient has been fitting for 5 minutes. IV access is in place. What is the first drug?
Answer: IV lorazepam 4 mg. A benzodiazepine is first-line at 5 minutes; repeat once if still fitting.
- Oral diazepam: Not in a fitting patient.
- IV haloperidol: Not an antiepileptic.
- Wait 10 more minutes: Treat at 5 minutes.
- IV phenytoin: Second-line.
2. A fitting patient has had two doses of benzodiazepine. What next?
Answer: IV levetiracetam. After two benzodiazepine doses, give levetiracetam, phenytoin or valproate.
- Oral carbamazepine: Too slow.
- Paracetamol: No.
- Observation: Fitting must be stopped.
- A third dose of lorazepam: Not recommended.
3. A woman fits 10 days after delivery with BP 170/110. Which drug is essential?
Answer: Magnesium sulfate. Postpartum eclampsia is treated with magnesium sulfate and BP control.
- Levetiracetam: Not for eclampsia.
- Carbamazepine: No.
- Phenytoin alone: Magnesium is superior for eclampsia.
- Lorazepam alone: Doesn't treat eclampsia.
4. A 20-month-old had a 3-minute generalised seizure with fever from otitis media, and is now fully recovered and playing. Parents ask about the future. What is correct?
Answer: Low epilepsy risk; no prophylaxis. Simple febrile seizure: 6 months–5 years, generalised, < 15 minutes, single in 24 hours, full recovery. Recurrence ~30%; epilepsy risk only slightly higher than baseline (~1–2%). No investigations needed beyond finding the fever source; no prophylactic antiepileptics; antipyretics improve comfort but don’t prevent seizures. Teach first aid; buccal midazolam if prolonged. Complex seizures (focal, > 15 min, recurrent within 24 h) need further assessment; exclude meningitis.
- Start daily valproate: Prophylactic anticonvulsants are not indicated.
- Needs EEG and MRI urgently: A simple febrile seizure does not need EEG or MRI.
- Paracetamol prevents recurrence: Antipyretics do not prevent recurrence.
5. A term neonate born after prolonged labour with low Apgars has seizures at 12 hours. Glucose and calcium are normal. What is first-line anticonvulsant?
Answer: Phenobarbital. Neonatal seizures: commonest cause is hypoxic-ischaemic encephalopathy (first 24 h); also hypoglycaemia, hypocalcaemia, hypomagnesaemia, sepsis/meningitis, intracranial haemorrhage, inborn errors, drug withdrawal. Check glucose, calcium, magnesium, sodium, infection screen. First-line: phenobarbital (WHO 20 mg/kg IV); then phenytoin, levetiracetam, midazolam. Treat cause; therapeutic hypothermia for moderate–severe HIE where available.
- Phenytoin first-line: Phenytoin is second-line.
- Diazepam infusion: Diazepam infusion is not preferred in neonates.
- Carbamazepine: Carbamazepine is not used acutely.
6. Benzodiazepines, barbiturates and some anticonvulsants work by enhancing which neurotransmitter?
Answer: GABA. GABA is the main inhibitory neurotransmitter of the brain. Benzodiazepines increase the frequency of GABA-A chloride channel opening; barbiturates increase its duration. More chloride enters neurons, which become harder to excite. Flumazenil reverses benzodiazepines.
- Glutamate: The main excitatory transmitter; blocked by drugs like ketamine and memantine.
- Dopamine: Affected by antipsychotics and Parkinson's drugs.
- Acetylcholine: Affected by anticholinesterases and antimuscarinics.
- Serotonin: Affected by SSRIs and triptans.
7. Which benzodiazepine forms long-acting active metabolites?
Answer: Diazepam. Diazepam is metabolised in the liver to active metabolites such as desmethyldiazepam, which have very long half-lives, so effects last days and accumulate in the elderly and in liver disease. Lorazepam, oxazepam and temazepam are directly glucuronidated with no active metabolites, so they are safer in liver disease.
- Lorazepam: No active metabolites.
- Oxazepam: No active metabolites.
- Temazepam: No active metabolites.
- Midazolam: Short-acting; minor metabolites.
References and dose sources
- Lorazepam dosing: Drugs.com: Lorazepam dosage (see also our lorazepam dose page)
- Midazolam dosing: Drugs.com: Midazolam dosage (see also our midazolam dose page)
- Diazepam dosing: Drugs.com: Diazepam dosage (see also our diazepam dose page)
- Levetiracetam dosing: Drugs.com: Levetiracetam dosage (see also our levetiracetam dose page)
- Phenytoin dosing: Drugs.com: Phenytoin dosage (see also our phenytoin dose page)
- Sodium valproate dosing: Drugs.com: Valproic acid dosage (see also our sodium valproate dose page)
- Dextrose (glucose) dosing: Drugs.com: Dextrose dosage (see also our dextrose (glucose) dose page)
- Thiamine (vitamin B1) dosing: Drugs.com: Thiamine dosage (see also our thiamine (vitamin b1) dose page)
- Magnesium sulfate dosing: Drugs.com: Magnesium sulfate dosage (see also our magnesium sulfate dose page)
International guidance is linked where it reflects good practice. Where your hospital’s protocol differs, follow your hospital.