WHO estimates that around 50 million people have epilepsy, and that nearly 80% live in low- and middle-income countries, where up to three-quarters may not receive the treatment they need. Seizures also happen with fever in children, low blood sugar, head injury, meningitis, malaria, eclampsia, alcohol withdrawal and other conditions. Every nurse should know what to do.
During a tonic-clonic seizure
- Note the time the seizure started.
- Stay with the person and call for help.
- Protect from injury: move hard or sharp objects away, cushion the head.
- Do not restrain movements.
- Do not put anything in the mouth: not a spoon, finger or cloth. People cannot swallow their tongue.
- Loosen tight clothing around the neck.
- Give oxygen if available and check blood glucose as soon as possible.
- When the jerking stops, turn them into the recovery position.
- Observe and record: what happened before, how it started, which parts of the body moved, colour, breathing, duration, incontinence, tongue biting, and recovery.
When to treat as an emergency
Most seizures stop on their own within 2–3 minutes. Give emergency medication and call for help if:
- A seizure lasts 5 minutes or more.
- Seizures follow one another without full recovery in between.
- It is the person’s first seizure, they are injured, pregnant, have diabetes, or have breathing difficulties.
Status epilepticus is a seizure lasting 5 minutes or more, or repeated seizures without recovery. It is a medical emergency: the longer it lasts, the harder it is to stop and the greater the risk of brain damage and death.
Emergency treatment (as prescribed or per protocol)
- First-line: a benzodiazepine at 5 minutes. Options include buccal or intranasal midazolam, rectal diazepam, or IV lorazepam or diazepam if IV access exists. A second dose may be given once if the seizure continues, per protocol.
- Second-line: if seizures continue, IV levetiracetam, phenytoin or sodium valproate, given by trained staff with monitoring.
- Third-line: anaesthesia and ventilation in critical care.
Throughout: airway, oxygen, blood glucose (treat hypoglycaemia), monitoring of breathing and SpOâ‚‚, and looking for causes such as infection, head injury, eclampsia (give magnesium sulfate in pregnancy), or missed medicines. Benzodiazepines can depress breathing, so monitor closely.
Febrile seizures in children
Seizures with fever are common in children aged about 6 months to 5 years and usually harmless. But always look for the cause of fever: in endemic areas, test for malaria; consider meningitis, especially in a child who is very unwell or under 1 year. Seek medical review for any first seizure.
After the seizure (post-ictal care)
- Recovery position; check airway and breathing.
- Observations including GCS and glucose.
- Check for injuries, including to the tongue and head.
- Let the person rest; speak calmly; they may be confused and tired.
- Maintain dignity: cover the person; help with clean clothes if incontinent.
Supporting people with epilepsy
- Explain the importance of taking antiseizure medicines every day; most people can become seizure-free with treatment. Affordable medicines like phenobarbital and carbamazepine are on the WHO essential medicines list.
- Counsel women of childbearing age: some medicines (especially sodium valproate) carry serious risks in pregnancy; they need specialist advice and folic acid.
- Safety advice: avoid swimming alone, cooking over open fires, and working at heights until seizures are controlled; follow national driving rules.
- Challenge stigma. In many communities, epilepsy is wrongly believed to be contagious or caused by spirits. People with epilepsy face exclusion from school, work and marriage. Epilepsy is a brain condition, it is not contagious, and it is treatable.
Related: Hypoglycaemia · Eclampsia · Meningitis
Based on WHO epilepsy fact sheets and mhGAP guidance, NICE NG217 (Epilepsies) and Resuscitation Council UK guidance on status epilepticus. Educational content: follow your local protocol.