Resus council guideline 2021.

Definition (convulsive) – seizure lasting more than 5 minutes. Used to be 30 minutes! Unlikely to terminate spontaneously after 5 minutes. Evidence that the longer it lasts, the hard it is to treat.

Use existing seizure management plan, if there is one!

Buccal midazolam (0.3-0.5mg/kg depending on age) and IM/IO lorazepam 0.1mg/kg – max 2 doses of benzo’s, including any home/prehospital doses.

If no response to first dose after 5 minutes, go for IV lorazepam and prepare next step.

2nd line should then be within 15 minutes of start of seizure – Levetiracetam, phenytoin, phenobarb.

Phenytoin needs to go slowly (over 20 mins – risk of brady/asystole) cf levetiracetam (over 5 mins). Call anaesthetist.

After 5 mins, either try alternative or go for intubation and deep sedation: RSI with thiopental, or propofol +/- rocuronium. Ketamine and midaz given as alternatives as no evidence for 3rd line agent!

Meanwhile – check glucose, sodium, calcium/Mg (if sepsis). Temperature control.

Beware CNS haemorrhage (trauma?), raised intracranial pressure, meningitis, encephalitis.

[no rectal medicines mentioned but paraldehyde worked pretty well back in the day]