Seizures, collapse and altered consciousness

Immediate priorities

Protect the patient from injury, note the time, call for help and support airway, ventilation and circulation. Do not restrain convulsing limbs or put fingers, a bite guard or another object in the mouth. Position and suction when safe and monitor oxygenation. Check glucose promptly and treat hypoglycaemia immediately. A convulsion lasting at least five minutes, an unknown ongoing duration or recurrent seizures without recovery needs the status-epilepticus pathway; waiting thirty minutes permits preventable injury. Include any ambulance or caregiver benzodiazepine doses in the medication record.

Give a first-line benzodiazepine by the available protocol route and dose, with airway-capable monitoring. If seizures persist after appropriate initial treatment, escalate promptly to the second-line antiseizure regimen and critical-care support. Repeated uncounted sedative doses can cause respiratory failure. Refractory status may need anaesthesia, ventilation and EEG monitoring. Treat the cause concurrently: infection, trauma, electrolyte disturbance, toxic exposure, alcohol withdrawal, eclampsia and missed medicines each require more than seizure suppression alone.

History from a witness

Ask what occurred before, during and after the event. Posture, exertion, emotional triggers, prodromal sweating/nausea, palpitations, focal sensations and duration guide the differential. Describe movements, responsiveness, colour, injuries and recovery. Brief jerks can occur during syncope, and incontinence alone does not prove epilepsy. A prolonged confused recovery or lateral tongue injury supports a seizure but is interpreted with the entire account. Obtain a witness description or a consented existing video when helpful; do not demand that a bystander record an unsafe event instead of assisting.

Syncope from transient cerebral hypoperfusion often has a short duration and relatively rapid recovery. Exertional collapse, an abnormal ECG, structural cardiac disease, family history of sudden death or palpitations warrants urgent cardiac assessment. Postural symptoms, dehydration and hypotensive medicines can suggest orthostatic causes. A vasovagal pattern is reassuring only after concerning alternatives are assessed. Persistent altered consciousness needs an ABC assessment and consideration of hypoxia, sepsis, poisoning, stroke and metabolic illness, not an automatic “postictal” label.

First seizure versus epilepsy

Distinguish a provoked acute symptomatic seizure from an unprovoked seizure. Electrolyte/glucose testing, ECG, pregnancy assessment when relevant and directed toxicology help identify triggers. Neuroimaging urgency depends on focal signs, persistent confusion, injury, immunosuppression and other red flags. MRI and EEG can contribute to specialist evaluation of an unprovoked seizure; a normal EEG does not exclude epilepsy and an incidental abnormality does not replace the clinical diagnosis. Lumbar puncture is selected for infection or inflammatory concerns after assessing safety.

A single event does not automatically justify lifelong medication. Recurrence risk, investigations, occupation, driving, pregnancy potential and preferences inform specialist treatment. If established epilepsy worsens, ask about adherence, sleep deprivation, illness, interactions and substance exposure before simply increasing doses. Some antiseizure drugs worsen particular seizure types. Valproate has substantial reproductive risks and requires careful Australian product-information and specialist assessment. Provide a written rescue plan where appropriate, including the threshold for calling an ambulance and a limit on rescue doses.

Childhood events

A simple febrile seizure is generally a brief, generalised event in a child in the typical age range, with no recurrence during the same illness and full recovery. Focal, prolonged or recurrent events, unusual age, persistent altered state or meningism require broader assessment. Investigate the fever source; do not assume fever proves a benign seizure. Antipyretics improve comfort but do not reliably prevent future febrile seizures. Avoid routine long-term antiseizure therapy or CT for every otherwise typical simple event; follow the age-specific local pathway.

For an infant with episodes of flexion clusters, regression or unusual movements, consider epileptic spasms and arrange urgent paediatric/neurological evaluation. Not all jerking is epilepsy: sleep myoclonus, tics and movement disorders have different patterns. Functional seizures are real symptoms requiring respectful assessment, often specialist confirmation and psychological treatment; they must not be inferred simply because initial tests are normal. Comorbid epilepsy is possible. Avoid accusatory language that can damage future care.

Safety and applied reasoning

After recovery, discuss bathing, swimming, heights, machinery and supervision without imposing unnecessary restrictions on all activities. Assess driving under current Austroads and licensing rules, distinguishing private and commercial standards. Explain the reason for medication adherence and how to seek advice about side effects rather than stopping abruptly. For example, someone who briefly collapses while sprinting and rapidly recovers needs an ECG and cardiac-risk assessment even if two limb jerks were seen. A patient convulsing for six minutes needs immediate status treatment before a detailed outpatient epilepsy history.

RCH acute seizure guidance and Austroads seizures and epilepsy.

Review checkpoints

• A convulsive seizure lasting at least five minutes needs urgent status-epilepticus treatment.
• Count prehospital benzodiazepine doses before giving further treatment.
• An ECG is important when assessing unexplained collapse.