Fits — seizures

• Most seizures are brief and do not require drug treatment

• People with known epilepsy should have management plan in file notes

Ask

• How long has the person been fitting
• Whether they have had a fit before
• What happened before the fit
• What happened during the fit — could there be other injuries

Check

• DRS ABC

• Coma scale
• Head-to-toe exam with attention to
• sickness or injury that may have caused fit. Consider meningitis, head injury, stroke

Do

• Put in recovery position — Figure 2.14. Protect them from hurting themselves
• If pregnant — use wedge under hip to tilt to left side — see Fits in the second half of pregnancy
• If breathing obstructed or noisy — put in nasopharyngeal or oropharyngeal airway
• If they spit out airway or gag — leave in recovery position — Figure 2.14
• Give oxygen to target O₂ sats 94–98% OR if moderate/severe COPD — 88–92%

• Put in IV cannula or intraosseous needle
• If known epileptic — blood for serum drug levels. Note time of last dose on pathology form
• Check BGL and serum sodium level if available
• If BGL less than 4mmol/L — see Hypoglycaemia (low blood glucose)
• Prepare midazolam for 2 doses — Table 2.9
• Follow Flowchart 2.5
• Monitor closely at clinic for at least 4 hours after fit has stopped or as per patients management plan

Giving medicines

Midazolam

• Be ready to manage airway — midazolam depresses breathing

Buccal (cheek)

• Use undiluted liquid midazolam in syringe without needle
• Put end of syringe between cheek and teeth, on side closest to ground
• Give slowly until fitting stops or total dose given

Nasal (nose) with atomiser

• Check nostril is clear
• Use undiluted liquid midazolam in syringe without needle
• Connect atomiser to syringe — Figure 2.15, put tip into nostril — Figure 2.16
• Apply reasonable pressure on syringe plunger to deliver medicine as fine mist-like spray

IM

• Use undiluted liquid midazolam
• Full effect takes 5–10 minutes

IV/Intraosseous

• Mix 1mL ampoule midazolam (5mg) with 4mL normal saline to make 1mg/mL
• Give dose slowly over 2 minutes
  
• Giving too fast may cause respiratory depression (breathing to slow or stop)

Levetiracetam 

• Give levetiracetam IV — adult 40mg/kg/dose, child 40mg/kg/dose up to 3g — doses — over 5 minutes
• Mix measured dose with 100mL normal saline or glucose 5%

Valproate

• Do not use if child under 2 years or child with metabolic disease
• Can cause severe sedation or low BP
• Give valproate IV/intraosseous — adult 800mg, child 20mg/kg/dose up to 800mg — doses — over 15 minutes
• Mix with solvent provided to give 95mg/mL — 400mg + 4mL
• May also need ongoing infusion — medical consult
• Adult 1–2mg/kg/hour up to 2.5g/day, child 1.6mg/kg/hour up to 2.5mg/day — doses

Ongoing care in clinic

Ask 

• Ask people who saw fit exactly what happened
• If person usually takes medicine for fits — have any doses been missed
• Has person deliberately taken an overdose of medicine or child taken someone else's tablets — what kind, how much, when
• For females — are they pregnant or did they give birth in the last 3 weeks
• Has person been drinking a lot of alcohol or sniffing petrol recently
• Has person been unwell recently — infection, electrolyte disturbances
• Has person had a head injury recently
• How much sleep has the person had
• Other medical history, usual medicines and allergies

Check

• ECG
• If person goes home
• Someone responsible must stay with them all the time for next 12 hours
• Make sure carers know how to keep person safe and put them in recovery position — Figure 2.14 if they have another fit
• Talk with person about their medicines — are they taking them correctly
• Talk with person and their family or carer about things they shouldn't do — driving, swimming, sleeping too near the fire

Follow-up

Medical follow-up for people with known epilepsy or first fit