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Seizures, epilepsy and status epilepticus
A seizure lasting 5 minutes or more, or repeated seizures without regaining consciousness, is status epilepticus: a benzodiazepine at once (intravenous lorazepam or intramuscular midazolam), and if it does not stop — intravenous levetiracetam, fosphenytoin or valproate. After a first seizure, glucose and electrolytes, EEG and MRI are checked.
Why it matters in the exam
The question presents a first seizure in an adult, or a patient seizing in the emergency department for long minutes. In a first seizure a provoking cause is sought: hypoglycaemia, hyponatraemia, hypocalcaemia, alcohol or benzodiazepine withdrawal, drugs and infection. A first unprovoked seizure is usually not treated with drugs, unless the EEG shows epileptiform activity, the MRI shows a structural lesion or the seizure occurred in sleep. Epilepsy is defined by two unprovoked seizures 24 hours or more apart, or one seizure with a high risk of recurrence.
In choosing a drug: levetiracetam and lamotrigine suit most patients; valproate is avoided in women of childbearing age because of birth defects and developmental harm; ethosuximide suits absences, and carbamazepine may worsen them. Distinguishing from syncope: in syncope recovery is quick; in a seizure there is prolonged confusion afterwards, a bitten side of the tongue and sometimes incontinence. A seizure with forcefully closed eyes, pelvic thrusting and asynchronous movements suggests a psychogenic non-epileptic event — diagnosed by video-EEG. Driving is restricted after a seizure according to local law, and this must be explained to the patient.
Key points
- Status epilepticus: 5 minutes or more — a benzodiazepine at once.
- Second step: intravenous levetiracetam, fosphenytoin or valproate.
- First seizure: look for a provoking cause; EEG and MRI.
- Epilepsy: two unprovoked seizures 24 hours or more apart.
- Valproate not in childbearing age; ethosuximide for absences.
Summary table
| Situation | Finding | Action | Exam note |
|---|---|---|---|
| Status epilepticus | Seizure 5 minutes or more or repeated without consciousness | Intravenous lorazepam or intramuscular midazolam | Glucose at once |
| Second step | Continues after a benzodiazepine | Intravenous levetiracetam, fosphenytoin or valproate | Then anaesthesia and EEG |
| First seizure | Possible provoking cause | Glucose, sodium, calcium, alcohol, drugs; EEG and MRI | Usually no treatment |
| Epilepsy | Two seizures 24 hours or more apart | Levetiracetam or lamotrigine | Valproate not in childbearing age |
| Absences | A child with brief "staring" | Ethosuximide | Carbamazepine worsens |
| Psychogenic event | Closed eyes, pelvic thrusting | Video-EEG | Do not escalate drugs |
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Sources
- American Epilepsy Society Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults, 2016 — Timing and drug steps
- AAN/AES Guideline: Management of an Unprovoked First Seizure in Adults, 2015 — Recurrence risk and treatment
- Harrison's Principles of Internal Medicine, 21st edition (2022) — Seizures and Epilepsy
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.