31 August 2026Chapter 1: A few symptoms and syndromesPDF page 22Source update: October 2024
Generalised seizures and convulsive status epilepticus
Clinical guide to generalised seizures, status epilepticus, immediate safety steps, and urgent causes to consider.
This guide supports clinical education and care navigation. It does not replace bedside judgement, emergency care, specialist advice, or local treatment protocol.
Seek urgent care
- A seizure lasting 5 minutes or more, repeated seizures, or failure to fully recover between episodes.
- Seizure with fever, stiff neck, head injury, pregnancy, low blood sugar risk, severe malaria risk, poisoning, or altered consciousness.
- Any first seizure, seizure in an infant, breathing difficulty, blue lips, injury, or persistent confusion.
Clinical definition
Generalised tonic-clonic seizures are bilateral involuntary movements caused by abnormal brain activity and associated with impaired or lost consciousness.
Most seizures stop within 5 minutes. Convulsive status epilepticus is present when a seizure lasts longer than 5 minutes, or when two or more seizures occur within 5 minutes without full recovery of baseline consciousness between them.
Status epilepticus is time-critical. The longer it continues, the harder it is to stop and the higher the risk of hypoxia, aspiration, permanent brain injury, and death.
In pregnancy and the postpartum period, seizures may represent eclampsia and need obstetric emergency management.
Clinical features
- During the tonic phase, muscles contract and respiratory muscles may be involved. During the clonic phase, rhythmic jerking of the limbs occurs.
- Loss of consciousness is typical. Urinary incontinence, breathing difficulty, cyanosis, tongue injury, or traumatic injury may occur.
- The postictal phase may include fatigue, confusion, headache, memory loss, and temporary focal deficits. Recovery is usually within 30 to 60 minutes; delayed recovery needs urgent review.
- Look for fever, neck stiffness, rash, trauma, poisoning, pregnancy, diabetes medicine use, alcohol use, malnutrition, malaria exposure, and known epilepsy.
First aid during a seizure
- Note the start time and call for help.
- Protect the patient from falls and injury, loosen tight clothing, and do not restrain the limbs forcefully.
- Maintain the airway and place the patient in the recovery position when possible to reduce aspiration risk.
- Do not put fingers, spoons, tablets, liquids, or other objects in the mouth.
- Check capillary blood glucose immediately when available. If glucose cannot be measured quickly and hypoglycaemia is possible, treat empirically.
- Give oxygen when available, especially if cyanosis, respiratory difficulty, prolonged seizure, pregnancy, or severe illness is present.
- If the seizure stops within 5 minutes, proceed to postictal assessment and search for the cause.
Febrile seizures
Febrile seizures are common in children 6 months to 5 years with fever, usually from a viral respiratory or gastrointestinal infection, when there is no evidence of central nervous system infection, metabolic disturbance, or previous afebrile seizure.
- Antipyretics may improve comfort but do not prevent febrile convulsions.
- If a seizure lasts more than 5 minutes or recurs within 5 minutes, treat as status epilepticus.
| Type | Clinical definition | Management direction |
|---|---|---|
| Simple febrile seizure | Single generalised seizure, no focal signs, less than 15 minutes, and no recurrence within 24 hours. | If it stops within 5 minutes, antiseizure medicine is not required. Observe until full neurological recovery, treat discomfort from fever, and give clear return precautions. |
| Complex febrile seizure | Focal features, duration over 15 minutes, or more than one seizure within 24 hours. | Assess carefully for CNS infection, metabolic disease, severe malaria, and other serious causes. Escalate if prolonged, recurrent, or recovery is delayed. |
Status epilepticus precautions
- Antiseizure medicines can cause respiratory depression, bradycardia, and hypotension, especially in children and older adults.
- Before giving antiseizure medicine, have bag-mask ventilation equipment and fluid replacement ready.
- Monitor respiratory rate, oxygen saturation, heart rate, and blood pressure at least every 15 minutes until stable.
- Never give antiseizure medicines by rapid IV injection. Slow or stop administration if respiratory rate, heart rate, or blood pressure falls.
- Do not give more than two benzodiazepine doses for the same episode before moving to second-line treatment.
First-line antiseizure treatment
Benzodiazepines are first-line treatment for convulsive status epilepticus. Route depends on setting, access, available formulation, and staff skill.
- For patients 65 years and over, reduce IV diazepam dose and do not exceed 10 mg per rectal dose.
- Buccal midazolam is placed between gum and cheek; intranasal midazolam is atomised into one or both nostrils; rectal diazepam is delivered using an appropriate syringe or short tube according to volume.
- If seizures recur 6 hours or more after stopping, restart from first-line treatment. If recurrence is within 6 hours, continue from the last effective step.
| Setting | Preferred route options | Escalation |
|---|---|---|
| Pre-hospital or no IV/IO access | Midazolam buccal or intranasal using 5 mg/ml solution; midazolam IM using 1 mg/ml solution; or diazepam rectal using 5 mg/ml solution. | Repeat the same dose once after 5 minutes if seizures continue, then refer urgently for second-line treatment. |
| Hospital with IV/IO access | Diazepam 5 mg/ml by slow IV injection over 3 to 5 minutes. | If one benzodiazepine dose was already given before arrival, give one more. If two doses were already given, start second-line treatment. |
| Age or weight | Midazolam buccal/intranasal 5 mg/ml | Midazolam IM 1 mg/ml | Diazepam rectal 5 mg/ml | Diazepam slow IV 5 mg/ml |
|---|---|---|---|---|
| 1 to under 4 months; 3 to under 6 kg | 0.25 ml | 0.6 ml | 0.4 ml | 0.25 ml |
| 4 to under 12 months; 6 to under 10 kg | 0.4 ml | 1.2 ml | 0.7 ml | 0.4 ml |
| 1 to under 3 years; 10 to under 15 kg | 0.6 ml | 2 ml | 1.2 ml | 0.6 ml |
| 3 to under 5 years; 15 to under 20 kg | 1 ml | 3 ml | 1.5 ml | 1 ml |
| 5 to under 9 years; 20 to under 30 kg | 1.2 ml | 4 ml | 2 ml | 1.2 ml |
| 9 to under 12 years; 30 to under 40 kg | 2 ml | 6 ml | 2 ml | 2 ml |
| 12 years and over or adults; 40 kg and over | 2 ml | 10 ml | 2 to 4 ml | 2 ml |
Second-line antiseizure treatment
Second-line antiseizure medicine is indicated in children when seizures continue 5 minutes after the second benzodiazepine dose. In adults, give second-line treatment even if seizures stop after benzodiazepine unless a reversible cause such as hypoglycaemia or electrolyte disturbance is rapidly corrected.
- Levetiracetam can be used broadly but needs caution in renal impairment or heart disorders.
- Valproate is contraindicated in children under 2 years and hepatic disease, and should be avoided in women or girls who are or may become pregnant unless no safer lifesaving option exists.
- Phenobarbital can worsen respiratory depression and requires caution in respiratory, renal, hepatic, paediatric, and older-adult risk groups.
- Phenytoin requires cardiac monitoring where possible and caution in bradycardia, AV block, heart failure, rhythm disorders, hypotension, and hepatic impairment.
- If seizures persist after one second-line medicine, change to another appropriate second-line medicine. If seizures persist or recur within 6 hours despite two second-line medicines, transfer to intensive care for refractory status epilepticus.
| Patient group | First choice | Second choice | Third choice |
|---|---|---|---|
| Children 1 month to under 2 years | Levetiracetam | Phenobarbital | Phenytoin |
| Girls 10 years and over and women | Levetiracetam or valproic acid only when safer options are unavailable and risk is justified | Phenobarbital | Phenytoin |
| Girls 2 to under 10 years | Levetiracetam or valproic acid | Phenobarbital | Phenytoin |
| Boys 2 years and over and men | Levetiracetam or valproic acid | Phenobarbital | Phenytoin |
| Medicine | Loading direction | Maintenance direction |
|---|---|---|
| Levetiracetam | Children: 40 mg/kg up to 3 g over 10 minutes; repeat half-dose if needed without exceeding 60 mg/kg or 4.5 g. Adults: 60 mg/kg up to 4.5 g over 15 minutes. | Children: start 12 hours later, age-based 7 to 10 mg/kg every 12 hours orally. Adults: 1 to 1.5 g every 12 hours orally. |
| Phenobarbital | Children: 20 mg/kg up to 1 g over 20 minutes; repeat 10 mg/kg if needed. Adults: 15 mg/kg up to 1 g over 15 minutes. | Children: once-daily oral maintenance by age. Adults: 60 to 180 mg once daily orally. |
| Phenytoin | 20 mg/kg up to 2 g by IV infusion with 0.9% sodium chloride only; use slower rates in older adults or cardiac disease. | Children: 2.5 mg/kg every 12 hours orally. Adults: 3 to 4 mg/kg once daily orally. |
| Valproic acid | Children 2 years and over: 20 mg/kg up to 1.5 g over 5 minutes; may repeat once. Adults: 40 mg/kg up to 3 g over 10 minutes. | Children: 5 to 7.5 mg/kg twice daily orally after 6 to 8 hours. Adults: 1 g twice daily orally after 12 hours. |
Maintenance treatment
- Maintenance antiseizure therapy is considered after loading treatment, unless the seizure cause is rapidly reversible and corrected.
- In children, maintenance is indicated after second-line treatment, three or more seizures in 24 hours, persistent focal signs or impaired consciousness beyond the expected postictal phase, traumatic brain injury within 24 hours, or known/presumed epilepsy.
- In adults, maintenance treatment is indicated for most patients after status epilepticus unless a reversible cause is promptly corrected.
- If seizures do not recur, continue maintenance treatment for 48 to 72 hours then reassess. For head trauma, continue seizure prophylaxis for 7 days. For epilepsy, start or resume long-term treatment.
Postictal management and investigations
- Record the seizure stop time, keep the patient in recovery position, and maintain the airway.
- Give oxygen when available, especially after antiseizure medicines, and target oxygen saturation above 94%.
- Monitor vital signs and oxygen saturation every 15 minutes until stable, then hourly. Monitor respiratory rate closely after benzodiazepines or phenobarbital; monitor heart rate, blood pressure, and ECG if available after phenytoin.
- Observe for recurrent seizures and delayed recovery. Failure to return to baseline within 30 to 60 minutes should trigger urgent reassessment.
- Investigations depend on presentation and resources: capillary glucose, malaria rapid diagnostic test in endemic areas, lumbar puncture and CSF culture when indicated, full blood count, electrolytes, creatinine, liver enzymes, coagulation tests, and blood culture.
Causes and differential diagnosis
- Febrile seizures in young children, usually with viral respiratory or gastrointestinal illness.
- CNS infection: meningitis, encephalitis, severe malaria, neurocysticercosis, trypanosomiasis, cerebral toxoplasmosis, or cryptococcal meningitis.
- Metabolic problems: hypoglycaemia, hyponatraemia, hypocalcaemia, renal failure, liver failure, or other electrolyte disturbance.
- Toxic causes: psychoactive drugs, alcohol, methanol, medicines, neurotoxic pesticides, venoms, and carbon monoxide.
- Withdrawal from CNS depressants such as alcohol, opioids, benzodiazepines, and barbiturates.
- Epilepsy: first presentation, missed doses, treatment interruption, ineffective regimen, or abrupt stopping of antiseizure medicines.
- Structural or systemic disease: head trauma, CNS tumour, stroke, sepsis, hypertensive encephalopathy, or hypoxic encephalopathy.
Complications, prevention, and referral
- Complications include aspiration, hypoxia, traumatic injury, rhabdomyolysis, hyperthermia, recurrent seizures, respiratory depression from treatment, hypotension, bradycardia, permanent neurological injury, and death.
- Prevention depends on treating fever and infections, preventing malaria, avoiding abrupt withdrawal from alcohol or sedatives, ensuring adherence to epilepsy treatment, safe diabetes care, correcting metabolic abnormalities, and injury prevention.
- Refer or admit urgently for status epilepticus, recurrent seizures, first seizure, pregnancy or postpartum seizure, persistent altered mental status, focal deficit, suspected CNS infection, severe malaria, poisoning, trauma, hypoglycaemia not rapidly corrected, or need for second-line/maintenance antiseizure treatment.
- Handover should include timing, number of seizures, recovery between episodes, medicines and doses already given, glucose result and treatment, oxygen and ventilation support, suspected cause, pregnancy status, injuries, and investigation results.
Medicines in this guide
Diazepam injectableBenzodiazepine option for first-line treatment of convulsive status epilepticus when IV/rectal administration is used.Diazepam oralOral benzodiazepine monograph for non-emergency indications and safety precautions.Midazolam injectableBenzodiazepine used by buccal, intranasal, or IM routes in seizure emergencies depending on formulation and setting.Levetiracetam injectableSecond-line antiseizure loading medicine for status epilepticus.Levetiracetam oralMaintenance antiseizure option after stabilisation when indicated.Phenobarbital injectableSecond-line antiseizure option requiring respiratory monitoring.Phenytoin injectableSecond-line option requiring careful cardiac and infusion monitoring.Valproic acid injectableSecond-line option with major restrictions in pregnancy, possible pregnancy, liver disease, and young children.Glucose 50% injectableAdult emergency treatment for severe hypoglycaemia; children require 10% glucose.Thiamine injectableGive with glucose when vitamin B1 deficiency is suspected, especially alcohol-related seizures.
Source
MSF Clinical guidelines - Diagnosis and treatment manual (December 2024)
This page is a paraphrased clinician-oriented guide derived from the source topic on PDF page 22. Medicine-specific details should be checked against local protocol and the linked drug-information pages.