Management of tonic-clonic seizure lasting more than 5 minutes

In addition to the measures taken in the acute management of tonic-clonic seizures, patients who have prolonged (lasting 5 minutes or more) or repeated (three or more in an hour) convulsive seizures should be treated with:

• buccal midazolam - as first-line treatment
• rectal diazepam - if preferred or if buccal midazolam is not available (1)

Notes:

• Acutely, during a tonic-clonic seizure:
  • there should be clear space around the patient
  • place some support under the person’s head and neck (a cushion a folded coat or support the head with another person hand)
  • loosen any tight neckwear, belts etc. and also remove any spectacles
  • place the patient in the recovery position and aid general recovery once the seizure has taken its course; wipe away any excess mucus and check their airways and breathing. Ensure that the patient cannot hurt themselves
  • seizure duration should be timed
  • bystanders should not
    • move the patient except in circumstances where he or she is in danger of further injury e.g. from fire or traffic
    • place anything in the mouth or give anything by mouth
    • restrict the movement of the patient or lift the patient (2)
  • emergency treatment should be sought in cases where
    • a single seizure persists for longer than 5 minutes or 2 minutes longer than what is normal for that person
    • the person does not regain consciousness
    • there are multiple seizures (three or more seizures in an hour)
    • an injury has occurred to the person
    • the person may have inhaled water
    • breathing difficulties continue
    • it’s the persons first seizure (2,3)

Reference:

• (1) National Clinical Guideline Centre (NCGC) 2012. The epilepsies: the diagnosis and management of the epilepsies in adults and children in primary and secondary care.
• (2) Epilepsy Action 2005. The role of primary care in epilepsy management 2.
• (3) Epilepsy Research UK. What to do when someone has seizures