CCFP priority topic 86 of 105
Seizures on the CCFP exam
6 key features, the mistakes that cost marks, and a practice question.
Checked by a Canadian family physician, MD, CCFP. Updated October 20, 2026.
What the exam tests
Key features
The CFPC’s 6 key features for Seizures. Each one below has how the exam asks it, the common mistakes and the approach.
Practice question
Try one before you read
A real case from the bank, in the new short-menu format. Answer it first. Then read the key features.
Key feature 1 of 6
Stopping a seizure
Protect the airway, end the seizure with drugs early, and look for fixable causes.
CFPC skill Clinical reasoning, selectivityPhase Treatment, diagnosis, hypothesis generationSources Health Canada
On the exam
A child with gastroenteritis, on intravenous (IV) fluids, has a seizure on the ward. Expect one best answer for the first drug.
Pick the first drug and dose.
Common mistakes
Waiting for the sodium result, or giving hypertonic saline first. A second-line drug before a benzodiazepine is wrong too, and so is a decimal slip in the dose.
Approach
- Turn the patient on their side to keep the airway clear. Have suction, oxygen and airway equipment at the bedside before any IV benzodiazepine.
- Give a benzodiazepine first, before you know the cause. IV lorazepam is a first drug for status epilepticus, a seizure that will not stop. It is not for long-term control.
- Adult IV lorazepam: 0.05 mg/kg by slow injection, up to 4 mg. Still seizing after 10 to 15 minutes? Give one more dose. No more than 8 mg in 12 hours.
- If the second dose fails after another 10 to 15 minutes, move on to other measures. Do not wait for test results.
- In a child, dose by weight. Say the number aloud and check it twice to catch a decimal slip.
- Check glucose at the bedside now. Send sodium and calcium. Correct low sugar, calcium or sodium as soon as you find it.
- Older or frail patients: start at about half the dose. Watch breathing closely, as it can slow or stop.
Key feature 2 of 6
Faint or fit?
Use the story of an unclear spell to tell a seizure from a faint.
CFPC skill Clinical reasoningPhase HistorySources Choosing Wisely Canada
On the exam
A teenager "went stiff and shook" and was found by a parent. Expect a short menu (pick several from a list) of questions to ask.
Pick the questions that sort it out.
Common mistakes
Calling any jerking a seizure: a faint can cause a few jerks. Ordering a brain scan or brain-wave test before you have the story is wrong too.
Approach
- Get the story from someone who saw it. Ask the patient what came just before and just after.
- Before: standing up, pain, heat or a long stand, with sweating, nausea or fading vision, point to a faint (syncope).
- During: stiffening first, then rhythmic jerking, with no response, points to a seizure. A few brief jerks after a fall fit a faint.
- After: quick, clear waking fits a faint. Confusion, deep drowsiness, sore muscles or a bitten side of the tongue point to a seizure.
- A faint during exercise or with a racing heart points to the heart, not the brain.
- A typical faint with a normal exam needs no brain scan and no electroencephalogram (EEG), a brain-wave test.
Key feature 3 of 6
How much to test
Let the history decide how far to investigate a seizure, and avoid needless tests.
CFPC skill Clinical reasoningPhase HistorySources Choosing Wisely Canada, Health Canada
On the exam
A previously well child has one seizure, has no fever and is waking up. Expect a short menu (pick several from a list) of tests tonight.
Pick the tests that change tonight's care.
Common mistakes
A brain scan, EEG, lumbar puncture or stool culture tonight. None of them finds a fixable cause in a child with no fever who is waking normally.
Approach
- Known epilepsy, the usual seizure, back to normal: ask about missed doses and check a drug level. Little else is needed.
- Do not routinely scan the brain after a seizure in known epilepsy. Most patients had imaging when it was diagnosed.
- Scan if the patient was never imaged, or if the exam now shows new focal signs.
- A first seizure: check glucose, sodium and calcium first. These find the causes you can fix tonight.
- An EEG helps later to classify an unprovoked seizure. It cannot find a fixable cause tonight.
- A new seizure type in a known patient needs a fresh look, not just a level.
| Story | Test now | Hold off on |
|---|---|---|
| Known epilepsy, usual seizure, back to normal | Drug level; ask about missed doses | Routine brain scan |
| First seizure, no fever, waking, normal exam | Glucose, sodium, calcium | Brain scan, lumbar puncture, cultures |
| Any seizure with new focal signs | Brain imaging | Sending the patient home first |
Key feature 4 of 6
The focal exam
Examine every patient after a seizure for signs that point to one part of the brain.
CFPC skill Clinical reasoningPhase PhysicalSources Choosing Wisely Canada
On the exam
A drowsy child, an hour after a first seizure. Expect a short menu (pick several from a list) of exam steps.
Pick the exam steps that count now.
Common mistakes
Testing gait, finger-to-nose or eyesight in a drowsy child: none can be done or read yet. Tapping the face for low calcium instead of sending a blood test.
Approach
- Look for focal signs: signs that point to one part of the brain, such as weakness on one side.
- Check what a drowsy patient can show: how alert, pupils, eye movements, face, and whether all four limbs move the same.
- Compare reflexes and the big-toe response on each side.
- Look for a head injury and a stiff neck. In an infant, feel for a bulging soft spot.
- Leave gait, coordination and eyesight until the patient is awake and can cooperate.
- Skin marks linked to brain conditions belong to the later work-up of unprovoked or repeated seizures.
- Focal signs change the plan. They are a reason to image the brain.
Key feature 5 of 6
Known epilepsy, worse now
When seizures return or change in known epilepsy, look for the trigger and other causes.
CFPC skill Clinical reasoningPhase History, hypothesis generationSources Health Canada
On the exam
A 16-year-old girl, controlled on lamotrigine for 18 months, has had morning jerks for 3 weeks. Expect a short menu (pick several from a list), then one best answer.
Pick what to ask, then the best change.
Common mistakes
Re-taking her first-diagnosis history, or blaming a cold that began after the jerks. Then adding a second drug, or switching to carbamazepine, when her new pill is the cause.
Approach
- Ask about missed doses first. Then ask about sleep, alcohol, other drugs and recent illness. Match each to when the change began.
- Ask about every new drug, not only seizure drugs. A combined pill (with estrogen) lowers lamotrigine levels. Other estrogen products, such as the patch, may do the same.
- On a combined pill, lamotrigine levels rise in the pill-free week. Breakthrough seizures have been reported, and most women need a dose change.
- Carbamazepine is a poor switch. It makes hormonal contraception less reliable and can make some seizure types worse.
- Check a drug level when doses may have been missed.
- Think beyond epilepsy: low sugar, low sodium, alcohol withdrawal or a new brain lesion. Carbamazepine itself can lower sodium.
| Drug | Effect on lamotrigine | What to do |
|---|---|---|
| Combined pill (ethinyl estradiol) | Clearance about doubles. Level falls, then rises in the pill-free week. | Adjust the dose in most women |
| Carbamazepine, phenytoin, phenobarbital, primidone | Level falls by about 40% | Review the dose when one starts or stops |
| Valproate | Level rises | Review the dose when it starts or stops |
Key feature 6 of 6
Long-term care
At each visit for controlled epilepsy, check adherence, side effects, daily life and drug harms.
CFPC skill Clinical reasoning, patient-centred approachPhase Treatment, history, hypothesis generationSources Health Canada, Choosing Wisely Canada
On the exam
A teen, seizure-free for a few weeks since a missed-dose problem was fixed, asks about a learner's licence. Expect one best answer.
Pick the right advice on driving.
Common mistakes
Saying a learner's licence, daytime-only driving or a normal EEG makes it safe. A drug level back in range does not prove control: seizure-free time does.
Approach
- Each visit, ask about missed doses, sleep, alcohol, side effects and mood. Antiseizure drugs carry a small risk of suicidal thoughts.
- Ask about driving, work, sport and seizures in front of friends. After a seizure, driving waits until the provincial licensing rules allow it.
- Carbamazepine: check a blood count and liver tests before starting and from time to time. Tell the patient to report fever, sore throat, mouth sores or easy bruising.
- Carbamazepine lowers sodium in 10 to 15% of patients. If at risk, check sodium before starting, after about 2 weeks, then monthly for 3 months.
- Before an antibiotic: macrolides such as clarithromycin, and ciprofloxacin, raise carbamazepine levels. Watch for dizziness, drowsiness, unsteadiness and double vision.
- Carbamazepine makes hormonal contraception unreliable. Advise another method during treatment and for 2 weeks after.
- Avoid valproate in anyone who could become pregnant if another drug works. If it is needed: contraception, counselling and the lowest dose that works.
| Drug | Watch for | What to do |
|---|---|---|
| Carbamazepine | Low white cells or platelets, low sodium, liver injury, serious rash | Blood count and liver tests at baseline and then periodically; sodium if at risk |
| Valproate | Birth defects and lower IQ after exposure in pregnancy | Avoid in anyone who could become pregnant if another drug works |
| Long-term antiseizure drugs, such as carbamazepine, phenytoin, lamotrigine, valproate | Thinner, weaker bones | Think of bone health on long-term treatment |
Flashcards
Answer it first, then check.
KF 1An adult is still seizing 15 minutes after IV lorazepam. What next?
A second dose of 0.05 mg/kg. If that fails after another 10 to 15 minutes, move to other measures. Source: Health Canada
KF 1Name three blood problems to fix fast in a seizing patient.
Low glucose, low calcium and low sodium. Correct each one as soon as you find it. Source: Health Canada
KF 2He felt hot and sweaty, went pale, fell and jerked twice. Seizure or faint?
Most likely a faint. Warning signs of heat and sweating, then a few jerks after the fall, fit syncope.
KF 3Known epilepsy, her usual seizure, back to normal. Does she need a brain scan?
Not routinely. Ask about missed doses and check a level. Scan for new focal signs or if never imaged. Source: Choosing Wisely Canada
KF 4A drowsy child after a first seizure. Which exam steps can wait?
Gait, coordination and eyesight. They need an alert child who can cooperate.
KF 5Lamotrigine-controlled seizures break through after she starts a combined pill. Why?
The estrogen pill about doubles lamotrigine clearance, so the level falls. Most women need a dose change. Source: Health Canada
KF 6She takes carbamazepine and needs an antibiotic. Which ones raise its level?
Macrolides such as clarithromycin or erythromycin, and ciprofloxacin. Watch for dizziness, unsteadiness and double vision. Source: Health Canada
FAQ
Which Canadian guideline covers seizures?
No single Canadian guideline covers this whole topic. This page draws on Health Canada drug monographs and the Canadian neurology Choosing Wisely list. The exam tests your reasoning, step by step.
Do I need exact doses?
Know the first steps cold: airway, a benzodiazepine, then glucose. Adult IV lorazepam is 0.05 mg/kg, up to 4 mg. In a child, check every weight-based dose twice.
Do I need the driving rules by the month?
Know the principle. After a seizure, driving stops until the licensing rules allow it. The wait depends on the seizure type and the province, so look it up for each case.
Is a seizure in known epilepsy always the epilepsy?
No. Look for low sugar or sodium, alcohol, new drugs and illness too. Carbamazepine itself can lower sodium, and a new pill can lower a lamotrigine level.
Sources
Written from the CFPC Assessment Objectives and Canadian guidelines first. Checked by a Canadian family physician, MD, CCFP.
Last reviewed October 20, 2026For exam study. Not advice for a patient in front of you.
- Assessment Objectives for Certification in Family Medicine, 2nd editionCollege of Family Physicians of Canada · 2020
- Drug Product DatabaseHealth Canada
- Choosing Wisely recommendationsChoosing Wisely Canada