Seizures

Any person, 16 years and over, presenting with seizure-like activity or is in a post-ictal state.

History prompts, signs and symptoms

These are not exhaustive lists. Maintain an open mind and be aware of cognitive bias.

Red flags

Recognise: identify indicators of actual or potential clinical severity and risk of deterioration.

Respond: carefully consider alternative ECAT protocol. Escalate as per clinical reasoning and local CERS protocol, and continue treatment.

Clinical assessment and specified intervention (A to G)

If the patient has any Yellow or Red Zone observations or additional criteria (as per the relevant NSW Standard Emergency Observation Chart), refer and escalate as per local CERS protocol and continue treatment.

Position

Assessment	Intervention
General appearance/first impressions	Recovery position if post-ictal Protect from injury by removing harmful objects Document seizure type, specific features and duration, including pre-hospital time

Airway

Assessment	Intervention
Patency of airway	Maintain airway patency Consider airway opening manoeuvres and positioning

Breathing

Assessment	Intervention
Respiratory rate and effort Auscultate chest (breath sounds) Oxygen saturation (SpO2)	Assist ventilation, as clinically indicated If actively seizing, apply oxygen Consider oxygen if dyspnoeic, titrate oxygen to maintain SpO2 over 93% Patients at risk of hypercapnia, maintain SpO2 at 88–92%

Seizure duration

Assessment

Intervention

Seizure lasting over 3 minutes duration or of unknown duration

Check BGL – see glucose section A maximum of 2 doses of benzodiazepines should be given in any seizure episode, inclusive of ambulance treatment Select: IV access No IV access IV access Give: 16–65 years: midazolam 5 mg IV. If seizure continues, repeat once after 5 minutes. Maximum dose 10 mg 65 years and over: midazolam 2.5 mg IV. If seizure continues, repeat once after 5 minutes. Maximum dose 5 mg No IV access Give: 16–65 years: midazolam 5 mg IM. If seizure continues, repeat once after 5 minutes. Maximum dose 10 mg 65 years and over: midazolam 2.5 mg IM. If seizure continues, repeat once after 5 minutes. Maximum dose 5 mg or all age groups: midazolam 5 mg buccal/intranasal. If seizure continues, repeat once after 10 minutes. Maximum dose 10 mg Escalate as per local CERS protocol for second-line seizure management

Circulation

Assessment	Intervention
Perfusion (capillary refill, skin warmth and colour) Pulse Blood pressure Cardiac rhythm	Assess circulation Attach cardiac monitor and complete 12 lead ECG if BP/HR are within the Yellow or Red Zones, or where clinically relevant, e.g. irregular pulse, palpitations, syncope, shock, respiratory compromise, cardiac history or clinical concern
IVC and/or pathology	Insert IV cannula, if trained If unable to obtain IV access, consider intraosseous, if trained See pathology section
Signs of shock: tachycardia and CRT 3 seconds and over and/or abnormal skin perfusion and/or hypotension	If signs of shock present and/or SBP less than 90 mmHg, give 250 mL of sodium chloride 0.9% IV/intraosseous bolus Repeat every 10 minutes (up to 1000 mL) until SBP over 90 mmHg or signs of shock have resolved

Disability

Assessment	Intervention
GCS, pupillary response and limb strength	Obtain baseline and repeat assessment, as clinically indicated
Pain	Assess pain. If indicated, give early analgesia as per analgesia section then resume A to G assessment

Exposure

Assessment	Intervention
Temperature	Measure temperature
Skin inspection, including posterior surfaces	Check and document any abnormalities

Fluids

Assessment	Intervention
Hydration status: last ate, drank, bowels opened, passed urine or vomited	Commence fluid balance chart, as required
NBM	Consider clear fluids or NBM based on red flags and clinical severity
Nausea and/or vomiting	If present, see nausea and/or vomiting section

Glucose

Assessment

Intervention

BGL

Measure BGL If BGL less than 4 mmol/L with NO decrease in level of consciousness (Yellow Zone criteria): give quick-acting carbohydrate: sugary soft drink, fruit juice or 40% glucose gel, up to 15 g, buccal reassess BGL in 15–30 minutes and repeat treatment until BGL over 4 mmol/L If BGL less than 4 mmol/L WITH a decrease in level of consciousness (Red Zone criteria) OR the patient is unable to tolerate oral intake: give 40% glucose gel, up to 15 g, buccally in incremental doses, as tolerated, while establishing IV access give 10% glucose 200 mL by IV infusion over 15 minutes, once only if delay in IV access, give glucagon 1 mg IM, once only reassess BGL in 15 minutes If the patient is unconscious or peri-arrest: give 50% glucose 50 mL by slow IV injection, once only. Use with caution as extravasation can cause necrosis if delay in IV access, give glucagon 1 mg IM, once only reassess BGL in 15 minutes Once stabilised, give patient long-acting carbohydrate and continue to check BGL hourly, or as clinically indicated

Focused assessment

Complete a neurological focused assessment.

Precautions and notes

• The main goals of seizure management in the emergency department are to terminate the seizure, ensure airway protection, manage the post-ictal phase and prevent further seizures.
• Airway may require support for some time. Monitor respiratory rate and assess for signs of hypoventilation.

Interventions and diagnostics

Specific treatment

Post seizure care

• Place patient in recovery position and maintain airway.
• Reorientate to surroundings and monitor for further seizures.
• Continuous monitoring of neurological status until fully recovered.
• Allow the patient to rest or sleep to recover.
• Provide reassurance and comfort.

Alcohol or opioid use

• Commence appropriate alcohol withdrawal scale and/or opioid withdrawal scale in patients with a history of alcohol and other drug use.

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Analgesia

If pain score 1–6 (mild–moderate), give:

• paracetamol 1000 mg orally once only
• and/or ibuprofen 400 mg orally once only.

If severe pain present, give analgesia and escalate as per local CERS protocol.

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Nausea and/or vomiting

If nausea and/or vomiting is present, give:

• ondansetron 4 mg orally or IV/IM. If symptoms persist after 60 minutes, repeat once, maximum dose 8 mg

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Thiamine

If patient is experiencing alcohol withdrawal, or is at high risk of thiamine deficiency (e.g. those who drink large amounts of alcohol or who are severely malnourished), then:

• monitor using alcohol withdrawal scale
• give thiamine 300 mg IV/IM once only

If hypoglycaemic: thiamine should be given before glucose, or as soon as possible. Glucose can further deplete thiamine stores and precipitate Wernicke encephalopathy.

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Radiology

Radiology will depend on the working diagnosis. It needs to be requested by a medical or nurse practitioner. If there is concern for urgent radiology, escalate as per local CERS protocol.

Pathology

• FBC, UEC, LFT, Ca/Mg/PO4
• Patients on antiepileptic medications: discuss the need for drug levels with medical or nurse practitioner

Medications

The shaded sections in this protocol are only to be used by registered nurses who have completed the required education.

Medications with contraindications or requiring dose adjustment are marked:

• ^H for patients with known hepatic impairment
• ^R for patients with known renal impairment.

Escalate to medical or nurse practitioner.

Evidence informed	Information was drawn from evidence-based guidelines and a review of latest available research. For more information, see the development process.
Collaboration	This protocol was developed by the ECAT Working Group, led by the Agency for Clinical Innovation. The group involved expert medical, nursing and allied health representatives from local health districts across NSW. Consensus was reached on all recommendations included within this protocol.
Currency	Due for review: Jan 2026. Based on a regular review cycle.
Feedback	Email ACI-ECIs@health.nsw.gov.au