What is the appropriate triage for a patient experiencing a seizure?

From the Guidelines

Seizure triage requires immediate assessment and intervention based on seizure severity and duration, with first-line treatment for recurrent seizures being the appropriate dosing of benzodiazepines, as recommended by the most recent clinical policy approved by the ACEP board of directors in 2024 1. For active seizures, ensure patient safety by moving hazards away, placing them on their side, and never restraining them or putting anything in their mouth.

• Key considerations in seizure triage include:
  • Seizure duration: seizures lasting over 5 minutes (status epilepticus) require immediate emergency medical services
  • Seizure severity: assess for triggers like fever, infection, medication changes, or sleep deprivation
  • Patient history: consider past medical history of stroke, trauma, tumor, or other CNS disease or injury
• First-line medication for status epilepticus is intravenous lorazepam (0.1 mg/kg) or diazepam (0.15-0.2 mg/kg), followed by fosphenytoin (20 mg PE/kg) if seizures continue, as supported by the 2024 clinical policy 1.
• For prolonged seizures outside a medical setting, rectal diazepam (0.2-0.5 mg/kg) or intranasal/buccal midazolam (0.2 mg/kg) can be administered, as suggested by previous guidelines 1. After the seizure resolves, document seizure characteristics including duration, movements, consciousness level, and post-ictal state, to inform future management decisions and prevent potential neuronal damage through excitotoxicity and increased metabolic demands 1.

From the FDA Drug Label

The effectiveness of lorazepam injection in status epilepticus was established in two multi-center controlled trials in 177 patients. One study (n=58) was a double-blind active-control trial comparing lorazepam injection and diazepam Patients were randomized to receive lorazepam 2 mg IV (with an additional 2 mg IV if needed) or diazepam 5 mg IV (with an additional 5 mg IV if needed) The primary outcome measure was a comparison of the proportion of responders in each treatment group, where a responder was defined as a patient whose seizures stopped within 10 minutes after treatment and who continued seizure-free for at least an additional 30 minutes Twenty-four of the 30 (80%) patients were deemed responders to lorazepam and 16/28 (57%) patients were deemed responders to diazepam (p=0. 04).

For seizure triage, lorazepam can be considered as a treatment option.

• The effectiveness of lorazepam injection in status epilepticus has been established in clinical trials 2.
• A dose of 2 mg IV (with an additional 2 mg IV if needed) can be used for seizure triage.
• The primary outcome measure is the proportion of responders, defined as patients whose seizures stop within 10 minutes after treatment and who continue seizure-free for at least an additional 30 minutes.

From the Research

Seizure Triage

• Seizure triage involves the immediate and effective treatment of status epilepticus, a medical emergency associated with significant mortality and morbidity 3.
• Achieving seizure control within the first 1-2 hours after onset is a significant determinant of outcome, and treatment is more likely to work and be cost-effective the earlier it is given 4.
• Initial first aid measures should be accompanied by establishing intravenous access if possible and administering thiamine and glucose if required, as well as calling for help and potentially video-recording the events 4.

Treatment Options

• There is high-quality evidence supporting the use of benzodiazepines for initial treatment, with midazolam (buccal, intranasal, or intramuscular) having the most evidence where there is no intravenous access 4.
• Lorazepam or diazepam are suitable IV agents, and speed of administration and adequate initial dosing are probably more important than choice of drug 4.
• Levetiracetam and valproate are also options in established status, with the advantage of being well-tolerated as maintenance treatment and possibly having a lower risk of serious adverse events 4.
• Intravenous lorazepam is better than intravenous diazepam or intravenous phenytoin alone for cessation of seizures, and also carries a lower risk of continuation of status epilepticus requiring a different drug or general anesthesia 3.

Comparative Efficacy

• A comparison of four antiepileptic drugs in status epilepticus found that lorazepam and levetiracetam were effective in controlling seizures, while phenytoin was less effective 5.
• A systematic review and network meta-analyses found that lamotrigine, levetiracetam, and topiramate are as effective as valproate for treating generalized tonic-clonic, tonic, and clonic seizures 6.
• A prospective randomized controlled pilot study found that the efficacy of sodium valproate and levetiracetam following initial lorazepam in elderly patients with generalized convulsive status epilepticus was comparable 7.