Management of seizures and status epilepticus

Management of seizures and status epilepticus

Questions from healthcare professionals

Q: Can touch or contact trigger a seizure, even when the patient is asleep? If a patient is having seizures with increased frequency, what are the possible issues around management?

A: As far as we are aware, reflex seizures such as you describe can occur during sleep. If the frequency of someone's seizures is increasing, that would be a cause for concern. Re-evaluation of the situation, including seizures history and management, with a epilepsy specialist would be advisable.
January 2012

Q: Are there any guidelines on how long should you monitor a client with learning difficulties following a tonic clonic seizure, and how often should you check a client during the night if they have a history of nocturnal seizures (to reduce the risk of SUDEP)?

A: This depends on the individual client: each individual should have an treatment and care plan, which is individualised and drawn up specifically for them. This would depend on what their seizures are usually like for them, and how they normally recover from their seizures. This would then also allow for any changes in the seizure type, pattern or recovery to be easily identified.
For clients at high risk of SUDEP, it may be more appropriate to consider a monitoring device for nocturnal seizures, rather than relying on just checking on them in the night. You can find details of companies that produce seizure monitoring devices and alarms on our website
April 2011

Q: There are several different versions of buccal midazolam available, some are maleates and some hydrochlorides. Have there been any studies comparing the efficacy of the maleate and hydrochloride? Is it appropriate for patients to be switched between different versions of midazolam?

A: We are not aware of any studies that compare the efficacy of the two different versions, however each has its positives and negatives. For example, the hydrochloride has a license for IV use to treat status but the maleate is, at present, unlicensed. Conversely, the hydrochloride is more acidic and less viscous than the maleate, which can make administration more challenging. When initiating treatment with either version, it is important that the individual’s reaction to it is monitored to ensure their recovery. As with any epilepsy treatment, it is appropriate to ensure that the same version of drug is dispensed with each prescription, to help ensure a consistent response for the patient.
January 2011

Q: We are comparing emergency medication protocols and there seems to be some difference in opinion between different agencies. Has there been any research comparing the use of buccal midazolam and rectal diazepam?

A: Buccal midazolam efficacy has been compared to that of rectal diazepam in the following study: Scott R et al.   Buccal midazolam and rectal diazepam for treatment of prolonged seizures in childhood and adolescence: a randomised trial. Lancet. 1999 Feb 20;353(9153):623-6. For further information on either drug, you may like to contact the manufacturers directly.
October 2010

Q: Are there any guidelines or protocols about when emergency medication prescriptions should be initiated and when it should be stopped being prescribed? What are the first aid guidelines for someone who has been seizure free for many years but who starts having seizures again?

A: Emergency medication (sometimes referred to as 'rescue medication') is usually initially prescribed when an individual has had an episode of status. Within the community this usually refers to seizures that are prolonged (that last longer than 5 minutes) or that happen in clusters where the individual does not recover in between. After an individual experiences status once (and has a 'history of status') it is often appropriate to consider starting a prescription for emergency medication. This should be accompanied by the development of a protocol for administration for that given individual, and the parents/family/care givers should be offered information and support to give the emergency medication.

We are not aware of any guidelines on stopping a prescription for emergency medication after a period of seizure freedom (either on or off medication). One would have to assume that there was a good reason for starting the prescription, and the individual patient factors around why stopping the prescription is being considered should be reviewed. This decision would therefore need to be made on an individual basis, in discussion with the healthcare professional making/reviewing the prescription, and the individual and care-givers as appropriate.

If the decision is made to stop prescribing emergency medication, it may be worth considering a protocol in event of a further seizure, in terms of starting treatment again. If further seizures happen following stopping the prescription, the standard seizure management would apply, unless there were any other individual patient factors that would suggest seizures for that individual should be managed in a different way.

Find out more with our information on types of epileptic seizures and what to do.
You can also read the Joint Epilepsy Council's publications about protocols for emergency medication.
For more information, find out about Epilepsy Society's booklets on emergency medications.
July 2010

Q: Is there ever a case for prescribing emergency medication on a 'just in case' basis for a client with no history of status?

A: Generally, emergency medication (sometimes referred to as 'rescue medication') is usually prescribed when an individual has had an episode of status. Within the community, this usually refers to seizures that are prolonged (that last longer than 5 minutes) or that happen in clusters where the individual does not recover in between. After an individual experiences status once (and has a 'history of status'), it is often appropriate to consider starting a prescription for emergency medication.
Although emergency medications are not usually prescribed unless reactively following an episode of status, there may be individual patient factors that lead to a prescription being considered. In this case, it is appropriate to discuss the situation with the individual's epilepsy specialist.
July 2010

Q: I manage a team of support workers who provide non-care support to clients living in the community. The support provided is to help people live independently, for example budgeting skills and accessing other services. To ensure the support provided is relevant, a comprehensive risk assessment is conducted with the clients. We have a number of clients with epilepsy. What are the correct ways to manage seizures, and what risk management should we consider?

A: There are many types of seizures, and the correct action to take depends on what seizure the person has and how it affects them. While some individuals have specific requests about how to manage their seizures, our website gives general seizure management and first aid guidelines for seizures.

When considering appropriate risk assessments for an individual with epilepsy, it is important to consider the risks of epilepsy and seizures in general, the risks associated with that individual's seizures specifically and the risk associated with the particular activity. For ideas about what to consider for an individual's risk assessment, you may like to read our information on risk. For ideas about what to record about an individual's seizures, to help with completing a risk assessment, you may like to read our information on recording seizures. 
July 2010

Q: I work in a Special Care Dentistry Department where we see patients with epilepsy. We stock Buccal Midazolam in our emergency kits in line with the Resuscitation Council advice for dentists. Are there any written guidelines or training resources about giving buccal midazolam? Also, what are the guidelines about nasal administration of midazolam for the treatment of status?

A: Written guidelines about using buccal midazolam, including sample protocols, are available from the Joint Epilepsy Council (www.jointepilepsycouncil.org.uk). A training DVD should be available soon, from the manufacturers of buccal midazolam maleate Special Products (www.specialproducts.biz)

The NICE clinical guidelines on the treatment and management of epilepsy (Clinical Guideline 20, www.nice.org.uk) covers the treatment of status with rectal diazepam and buccal midazolam. There are some research papers on the use of midazolam by nasal administration. Look online at www.ncbi.nlm.nih.gov
July 2009

Q:Is Midazolam available as a nasal spray to treat status epilepticus?

A: Although buccal preparations of midazolam are sometimes used nasally to treat status, we are not aware of a specific nasal spray version of midazolam currently available.
March 2009

Q: When placing an individual in the recovery position after a seizure do they have to be in the left lateral position? Also do they have to be on their left side when being administered rectal diazepam?

A: Generally, making sure someone is on their side in the recovery position may be more important than to specify which side, as debris and fluids are able to run out either side of the mouth. For administering rectal diazepam, the left lateral position may often be suggested, as this follows the curve of the rectum. However, using either side may have equal effect, and the individual being on their side may again be more important. 
July 2008

Q: What are the guidelines for managing seizures, and at what stage should help be called for someone having a seizure?

A: There is information about managing seizures on this website under 'first aid'. This provides basic first aid and seizure management instructions. It also includes information on when to call for help if a seizure is prolonged or results in injury. Wherever possible, knowing about the individual's history and details about their seizures can help to give individualised care for their seizures. 
May 2008

Q: Question: What are the guidelines for administering buccal midazolam and how often doses can be repeated?

A: You can find out about the guidelines for buccal midazolam on the website of the Joint Epilepsy Council  under Resources: Publications: A guideline on training standards for the administration of buccal midazolam. 
April 2008

Q: How is status epilepticus managed?

A: For information on the management of status epilepticus, please see our articles section. There are two useful  papers: Treatment of tonic-clonic status epilepticus and Treatment of non-convulsive status epilepticus.
March 2008

Q: When is status life-threatening?

A: Convulsive status epilepticus is potentially life-threatening and requires emergency treatment. For more information about the treatment of status see the chapters Treatment of tonic-clonic status epilepticus and Treatment of non-convulsive status epilepticus in our articles section.
February 2008

Q: How soon after administering rectal diazepam should you call an ambulance if the seizure continues?

A: Each case is individual, and each person should have their own individualised protocol for when to give diazepam, in what dose, when to repeat the dose (if appropriate) and when to call for an ambulance. This is usually developed by the neurologist, alongside the individual and their family or carers.

For more information on developing a protocol for rectal diazepam, you might like to look on the Joint Epilepsy Council website for the publication 'A guideline on training standards for the administration of rectal diazepam' under the resources section.
December 2007

Q: Would you recommend Oxygen for use in someone who is post-ictally cyanosed? If so what rate would you give it?

A: If cyanosed, yes. The rate may depend on individual cases but usually at least 5L/min.
November 2007

Q: I have someone on my caseload at the moment and their parents have asked me about what rescue medication their adult son should be getting. They are aware of the possibilities of rectal diazepam or buccal midazolam, but don't know which to ask their GP to prescribe?

A: We’re not able to answer patient-specific questions, so are not able to comment on this particular case. However, according to NICE guidelines, treatments for epilepsy should be prescribed by a neurologist rather than by a GP. A decision regarding rescue medication would be best made through discussion with the person’s neurologist. Training about how to administer the medication, and a protocol, would be needed for both rectal diazepam and buccal midazolam.
July 2007

Q: Can the loading dose of phenytoin be increased upto 30mg/kg in refractory status epilepticus?

A: No, it should be no more than 18-20mg/kg.
January 2007

Q: Is it normal to do base line observations such as blood pressure after someone has had a seizure?

A: This isn’t normal practice, but it is good practice to check that the person is safe and has started breathing again after a seizure is over.
January 2007

Q: I am looking for guidelines on when to prescibe rectal valium (i.e. after one or two tonic clonic seizures) as it is sometimes inappropriately prescribed to children having only one short seizure.

A: There are no written specific guidelines that we are aware of. However we agree that it is probably over-prescribed, and as people require training to administer it, this is where there can be problems. In general, practice should be that in children with epilepsy, it is prescribed to be given outside hospital only if there is a history of a prolonged seizure or clusters previously requiring emergency treatment. In principle, the first dose of a benzodiazepine for a prolonged seizure should be given by medical or paramedical staff. If the child has not had a prolonged seizure before (>5mins) then this is out of the ordinary and medical help should be called. Therefore children with only a history of self-limiting short seizures should not be prescribed emergency medication.
July 2006

Q: What is the law concerning the administration of rectal diazepam while in the community?

A: There are no legal requirements, however there are guidelines published by the Joint Epilepsy Council, which should be followed. Staff who administer rectal diazepam must have been trained and this training must be current. Regular updates are essential. Epilepsy Society offers training in the administration of rectal diazepam.
May 2006

Q: Can the loading dose of phenytoin given in complex partial status epilepticus worsen seizures?

A: A loading dose of phenytoin is not recommended treatment for non-convulsive status epilepticus. However it would not be likely to worsen seizures.
March 2006

Q: Is there ever any indication for 1:1000 adrenaline to be given by doctors during a tonic clonic seizure or status epilepticus?

A: There is no indication for this.
February 2006

Q: What is the difference between Hypnoval and Epistatus for use as rescue medications in epilepsy?

A: Hypnoval is a hydrochloride (and should not be used buccally). Epistatus is a maleate (can be used). There is more information in the UKMiCentral website occasional report on buccal midazolam.
February 2006

Q: Is there an approved training course for the administration of Midazolam. Do you have guidelines available for its use.

A: We’re not aware of any approved training courses for the administration of Midazolam. NSE has not produced guidelines for its use as it is still unlicensed. However the Joint Epilepsy Council has produced a guideline on training standards for the administration of the drug. The guideline ‘has been developed for those who deliver training in the administration of rectal diazepam, as well as for those who wish to purchase such training’. More details are available on the Joint Epilepsy Council website under Resources – publications.
October 2005

Q: What are the effects of a complex partial seizure carrying on for hours?

A: There is no clear answer to this question. There is some experimental evidence that prolonged non-convulsive status could cause brain damage. However it is not yet clear whether this happens in reality.
May 2005

Q: Breathing is affected during tonic-clonic seizures and in the postictal phase. Why is this, and what is the management?

A: In tonic-clonic seizures, air is forced out of the lungs during the tonic phase of the seizure, and then muscle activity during the clonic phase causes irregular breathing. In the post-ictal phase there may still be some ongoing seizure activity that may affect a person’s breathing. To help breathing return to normal after the seizure, the person should be placed on their side in the recovery position. For information about what first aid to give during the seizure itself, and when a seizure is considered a medical emergency, see the first aid page on this website.
October 2004

Q: What observations need to be carried out on a young adult during a seizure?

A: Observers can provide vital information for the GP or neurologist, about what has happened during a seizure. This information can be helpful in making a diagnosis of epilepsy and in identifying the type of seizure. Observations include what the person was doing before, during and after the seizure. Other information can also be recorded - more details are given on the first aid page of this website.
March 2004

Q: How do you support a person in a wheelchair during a seizure and how would you get them out of the wheelchair during a seizure if they required rectal diazepam?

A: The usual first aid guidelines apply to a person having a seizure in a wheelchair, for example loosening clothing and cushioning the head to prevent injury. In terms of administration of rectal diazepam, it is not possible to be prescriptive as it is a matter of judgement in each individual situation. Status epilepticus is an emergency situation and therefore one would act as appropriately as possible and do the best one can, remembering that emergency treatment does need to be given in order to stop the seizure.
February 2004

Q: Is there an upper limit for phenytoin loading dose during status epilepticus management, as I have read in some texts that it shouldn't exceed 1g?

A: This is correct, 1g should be the maximum dose for IV loading.
February 2004

Q: It has been my training and understanding that when timing a seizure the beginning is determined when the child goes into their non alert state and the end of the seizure is determined by a return to a level of consciousness which is manifested by their response to person, place, time. Is this correct?

A: When timing the length of a seizure, it is useful to time the various stages. For example in a generalised seizure, the first stage is when convulsive movements are occurring. The second stage is when the convulsions have stopped and the patient is responding to touch and verbal questions but is still confused. The third stage is full recovery, when the patient is fully orientated. Each of these stages can be timed and recorded to provide maximum information about the seizure.
January 2004

Please note: Epilepsy Society is unable to provide a medical opinion on specific cases. Responses contain information relating to the general principles of investigation and management. Answers are not, and should not be assumed to be, direct medical advice.