Seizures

Any person, 4 weeks to 15 years, 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	Protect the patient from injury by removing harmful objects Document seizure type and duration, including pre-hospital time

Airway

Assessment	Intervention
Patency of airway	Maintain airway patency Consider airway opening manoeuvres and positioning Recovery position, if indicated

Breathing

Assessment	Intervention
Respiratory rate and work of breathing Consider auscultation of chest (breath sounds) Oxygen saturation (SpO2)	Assist ventilation as clinically indicated Apply oxygen to maintain SpO2 over 93%

Seizure activity

Assessment	Intervention
Seizure activity less than 5 minutes	Continue to observe airway and breathing Place in recovery position post-seizure Continue close observation of A to G
Seizure activity over 5 minutes or of unknown duration or with known intracranial pathology, hypoxic injury, trauma or cardiorespiratory compromise	Continuous monitoring of SpO2 Apply oxygen Assist ventilation, if clinically indicated Check BGL. See glucose section Insert IV cannula, if trained and seizure activity over 5 minutes or of unknown duration If unable to obtain IV access, consider intraosseous, if trained
	Note: give a maximum of 2 doses of benzodiazepines in any seizure episode, inclusive of out of hospital treatment Select: IV access No IV access IV access Give midazolam 0.15 mg/kg IV, maximum single dose 10 mg. Repeat once after 5 minutes if seizure continues. Maximum total dose 20 mg No IV access Give: midazolam 0.15 mg/kg IM once only. Maximum dose 10 mg or midazolam 0.3 mg/kg intranasal/buccal, maximum single dose 10 mg. Repeat once after 5 minutes if seizure continues. Maximum total dose 20 mg Escalate as per local CERS protocol for second-line seizure management

Circulation

Assessment	Intervention
Perfusion (capillary refill, skin warmth and colour) Heart rate Blood pressure Cardiac rhythm	Assess circulation Attach cardiac monitoring: if seizure activity over 5 minutes or BP/HR 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 IVC, if trained and seizure activity over 5 minutes or of unknown duration 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, give sodium chloride 0.9% at 20 mL/kg IV/intraosseous bolus once only, maximum dose 1000 mL

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
Head-to-toe inspection, including posterior surfaces	Check and document any abnormalities Inspect for non-blanching rash and escalate immediately as per local CERS protocol

Fluids

Assessment	Intervention
Hydration status	Assess fluids, in and out. Document on fluid balance chart. Include gastrointestinal losses
Nausea and/or vomiting	If present, see nausea and/or vomiting section

Glucose

Assessment

Intervention

BGL

Measure BGL. See medication table for 40% glucose gel dosing If BGL between 2 mmol/L and 3 mmol/L and NOT symptomatic (Yellow Zone criteria): give quick-acting carbohydrate: Up to 12 months: milk feed and/or 40% glucose gel buccal 12 months and over: sugary soft drink or fruit juice or 40% glucose gel buccal reassess BGL in 15–30 minutes and repeat treatment until BGL over 3 mmol/L If BGL less than 2 mmol/L OR symptomatic (Red Zone criteria) OR unable to tolerate oral glucose: give 40% glucose gel buccally in incremental doses, as tolerated, while establishing IV access give 10% glucose, 2 mL/kg by slow IV injection once only if IV access delayed, give: Up to 25 kg: glucagon 0.5 mg IM, once only 25 kg and over: 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

• Consider possible underlying causes of seizure:
  • simple febrile seizure
  • known seizure disorder
  • head injury
  • infection, e.g. meningitis or sepsis
  • structural pathology, e.g. stroke or intracranial pathology
  • adherence to medications
  • intercurrent illness
  • drug or toxin overdose
  • hypoglycaemia
  • electrolyte disturbances.
• Refer to patient-specific seizure management plan for patients with a known seizure disorder, if available.
• Most acute seizures in children are brief and spontaneously resolve, only requiring observation and supportive care.
• Seizures of less than 5 minutes duration require observation and keeping the patient safe from injury.
• Antipyretics have not been shown to reduce the risk of further febrile seizures, but may help with symptomatic management of the primary illness.
• Respiratory and cardiovascular depression can be severe after the administration of midazolam. Close monitoring and treatment are required.
• Airway may require support for some time. Monitor respiratory rate and assess for signs of hypoventilation.

Interventions and diagnostics

Specific treatment

Post seizure care

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

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Analgesia

If pain score 1–6 (mild–moderate):

Give paracetamol 15 mg/kg orally once only, maximum dose 1000 mg

and/or ibuprofen, if 3 months and over, 10 mg/kg orally once only, maximum dose 400 mg

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

Consider non-pharmacological pain relief (appendix).

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Nausea and/or vomiting

If nausea and/or vomiting is present and over 6 months give:

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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.

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Pathology

• Urinalysis:
  • Patient who can void in the toilet: mid-stream urine
  • Patient who is not toilet trained: clean catch or catheter urine
  • If positive for nitrites and/or leucocytes send for MC&S. Keep sample refrigerated if transport delayed.
• Seriously unwell patient, prolonged seizure or less than 6 months: blood cultures, FBC, UEC, LFT, Ca/Mg/PO4, VBG, glucose
• On regular antiepileptic medications: discuss the need for drug levels with a medical or nurse practitioner

Medications

The patient’s weight is mandatory for calculating fluid and medication doses.

The Broselow Tape or APLS weight table (appendix) can be used only in circumstances where the patient cannot be weighed.

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