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Critical Care / ICU · Ward Pathways · Locked — free with a referral
By Dr Javed Akhtar · Last reviewed 2 October 2026
Presentation Generalised tonic-clonic seizure ongoing at 7 minutes — treat the clock: benzodiazepine at 5 min, second-line loaded by 20 min, airway by 30–40 min.
Red flags Seizure >10 min Cyanosis, trauma, tongue bite with ongoing twitching Fever + neck stiffness (meningoencephalitis) Pregnancy — eclampsia until proven otherwise Differential diagnosis Hypoglycaemia, hyponatraemia Alcohol/benzodiazepine withdrawal Meningitis/encephalitis Non-epileptic attack disorder (diagnosis of exclusion — pelvis thrust, eyes closed) When to admit, call ICU or discharge Benzo: Lorazepam 0.1 mg/kg — full dose, may repeat once2nd line: LEV 60 mg/kg = fosphenytoin 20 mgPE/kg = valproate 40 mg/kgRefractory: Midazolam or propofol infusion + EEG after 30–40 minKey points ESETT: levetiracetam = fosphenytoin = valproate (~50% each) — pick what's fastest to hand Midazolam 10 mg IM is the best no-IV option (faster than hunting access) ~20% of convulsive status becomes non-convulsive — EEG everyone who doesn't wake up Never Underdose benzodiazepines for fear of respiratory depression — intubation beats ongoing seizures Skip second-line loading because convulsions stopped Paralyse without EEG — you blind yourself to ongoing seizures Common mistakes Diazepam PR delays while IV available Forgetting AED levels in known epileptics (subtherapeutic phenytoin) No cause found = no LP done Weaning infusion at 12 h → relapse Disposition and follow-up ICU until 24–48 h seizure-free; MRI + LP workup; neurology follow-up; driving advice per local law after any first seizure.
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