Seizures and Status Epilepticus
Description General Measures Medicine Treatment Referral ICD-10 code: G41.0-2/G41.8-9 For description and general measures of seizures, See: Seizures . DESCRIPTION This is a medical emergency and has the potential for causing high mortality. Status epilepticus is a series of seizures following one another lasting >30 minutes with no intervening periods of recovery of consciousness. The
ICD-10 code: G41.0-2/G41.8-9
For description and general measures of seizures, See: Seizures.
DESCRIPTION
This is a medical emergency and has the potential for causing high mortality. Status epilepticus is a series of seizures following one another lasting >30 minutes with no intervening periods of recovery of consciousness. The seizure may be generalised or partial, convulsive or non-convulsive.
Do not wait for established status epilepticus to terminate convulsions. Convulsions lasting > 5 minutes should be terminated.
GENERAL MEASURES
- Place the patient in a lateral (recovery) position.
- Do not place anything (spoon or spatula, etc.) in the patient's mouth.
- Do not try to open the patient’s mouth.
- Maintain airway.
- Assist respiration and give high flow oxygen.
- Prepare for intubation if sufficiently skilled in the procedure and relevant rescue devices are available.
- Check blood glucose (exclude hypoglycaemia).
- Monitor vital signs every 15 minutes.
- Establish an IV line.
MEDICINE TREATMENT
Children < 12 years of age
- Midazolam, buccal, 0.5 mg/kg/dose. See: Dosing table.
- Use midazolam for injection 5 mg in 1 mL undiluted.
- Draw up the required volume in a 5 mL syringe.
- Remove needle then administer midazolam into the buccal cavity (between gum and cheeks).
- If seizures persist for > 5 minutes, repeat the dose and refer urgently.
Note:
Buccal midazolam should not be used in infants < 6 months of age.
OR
- Midazolam, IM:
- Child > 13 kg: midazolam, IM, 5 mg, repeat once after 5-10 minutes if still fitting.
OR
- Diazepam, rectal, 0.5 mg/kg/dose as a single dose. See: Dosing table.
- Use diazepam for injection 10mg in 2 mL undiluted.
- Draw up the required volume in a 2 mL syringe.
- Remove needle then insert the whole barrel of the lubricated syringe into the rectum and inject the contents.
- Remove syringe and hold buttocks together to minimise leakage.
- Maximum dose: 10 mg in 1 hour.
- May be repeated after 10 minutes if convulsions continue.
- Expect a response within 1–5 minutes.
CAUTION
Benzodiazepines, can cause respiratory depression. Monitor closely for respiratory depression. If this occurs, assist ventilation with bag-valve mask (1 breath every 3–5 seconds) and refer urgently.
If no response after two consecutive doses of either midazolam or diazepam, and if the convulsion has lasted more than 20 minutes:
ADD
- Phenobarbital, oral, crushed and given by nasogastric tube, 20 mg/kg as a single dose. See: Dosing table.
Adults
- Midazolam, IM, 10 mg, immediately.
- Repeat once after 5–10 minutes if still fitting
OR
- Midazolam, buccal, 10 mg using the parenteral formulation.
- Repeat once after 5–10 minutes if still fitting.
OR
- Diazepam, slow IV, 10 mg.
- Administer at a rate not exceeding 5mg/minute.
- Repeat within 5 minutes if needed.
- Maximum dose: 20 mg within 1 hour.
- Expect a response within 1–5 minutes.
CAUTION
Benzodiazepines can cause respiratory depression. Monitor closely for respiratory depression. If this occurs, assist ventilation with bag-valve mask (1 breath every 3-5 seconds) and refer urgently.
Avoid diazepam IM since absorption is slow and erratic.
Do not mix diazepam with other medicines in same syringe.
REFERRAL
Urgent
Seizures that cannot be controlled.
Non-urgent
All patients once stabilised.
Note:
Clinical notes describing medication administered, time, dose, and route of administration should accompany patients.
Standard Treatment Guidelines and Essential Medicines List for South Africa, Primary Healthcare, 2020-4_Version 1.1_October 2024
Chapter 21: Emergencies and Injuries