What is the emergency medicine workup for a seizure (convulsion)?

From the Guidelines

The emergency medicine workup for a seizure should prioritize stabilizing the patient's airway, breathing, and circulation, followed by administration of benzodiazepines, and if seizures persist, consideration of second-line agents such as fosphenytoin, levetiracetam, or valproate, as recommended by the most recent guidelines 1. The workup involves a systematic approach to identify the cause and provide appropriate treatment. Begin by ensuring the patient's airway, breathing, and circulation are stable. Obtain vital signs, including blood pressure, heart rate, respiratory rate, temperature, and oxygen saturation. Laboratory tests should include a complete blood count, comprehensive metabolic panel (including glucose, sodium, calcium, and magnesium levels), toxicology screen, and antiepileptic drug levels if the patient is on medication. Some key points to consider in the workup include:

• Neuroimaging with a non-contrast CT scan of the head to rule out structural abnormalities, followed by an MRI if necessary 1.
• An electroencephalogram (EEG) may be indicated, especially for patients with altered mental status.
• For active seizures, administer benzodiazepines: lorazepam 4mg IV (or 0.1mg/kg), midazolam 10mg IM (or 0.2mg/kg), or diazepam 10mg IV (or 0.2mg/kg) 1.
• If seizures persist, consider fosphenytoin 20mg PE/kg IV, valproic acid 40mg/kg IV, or levetiracetam 60mg/kg IV (up to 4500mg), as these agents have similar efficacy 1. The workup aims to identify and treat the underlying cause, which could range from metabolic disturbances and infections to stroke, trauma, or medication effects, while preventing complications and recurrence. It is essential to note that the management of seizures can be clinically challenging, and noncompliance with antiseizure drug therapy or substance use can lower the seizure threshold 1.

From the FDA Drug Label

The treatment of status, however, requires far more than the administration of an anticonvulsant agent. It involves observation and management of all parameters critical to maintaining vital function and the capacity to provide support of those functions as required. Ventilatory support must be readily available The use of benzodiazepines, like lorazepam injection, is ordinarily only an initial step of a complex and sustained intervention which may require additional interventions (e.g., concomitant intravenous administration of phenytoin). Because status epilepticus may result from a correctable acute cause such as hypoglycemia, hyponatremia, or other metabolic or toxic derangement, such an abnormality must be immediately sought and corrected. Furthermore, patients who are susceptible to further seizure episodes should receive adequate maintenance antiepileptic therapy Any health care professional who intends to treat a patient with status epilepticus should be familiar with this package insert and the pertinent medical literature concerning current concepts for the treatment of status epilepticus.

The emergency medicine workup for a seizure should involve:

• Observation and management of vital functions
• Ventilatory support should be readily available
• Use of benzodiazepines (like lorazepam or diazepam) as an initial step
• Additional interventions (e.g. concomitant administration of other anticonvulsants like phenytoin) may be required
• Identification and correction of any underlying acute cause (e.g. hypoglycemia, hyponatremia)
• Adequate maintenance antiepileptic therapy for patients susceptible to further seizures 2
• EEG monitoring of the seizure may be helpful 3

From the Research

Emergency Medicine Workup for Seizure

• The primary goal of emergency medicine workup for seizure is to stop the seizure and prevent further brain damage 4.
• Benzodiazepines are commonly used as first-line treatment for status epilepticus due to their efficacy, tolerability, and rapid onset of action 5, 6.
• Intravenous lorazepam is often used as a first-line treatment for status epilepticus, with a success rate of 100% in some studies 7.
• Other benzodiazepines, such as diazepam, midazolam, and clonazepam, can also be used to treat seizures, with different efficacy profiles and pharmacokinetic properties 5, 6.
• Phenytoin is another antiepileptic drug that can be used to treat status epilepticus, although its efficacy compared to other medications is still being studied 8.

Treatment Options

• Intravenous administration of benzodiazepines, such as lorazepam and diazepam, is a common treatment option for status epilepticus 4, 7.
• Rectal administration of diazepam is also an option for acute home treatment of recurrent seizures 4.
• Other routes of administration, such as intranasal and intrapulmonary, are being developed and studied for the treatment of seizures 6.
• Phenytoin prodrug (ACC-9653) is an investigational new drug that has shown promise in the emergency management of seizures, with rapid onset of action and sustained efficacy 4.

Efficacy and Safety

• The efficacy and safety of benzodiazepines in the treatment of seizures have been well established, with a low risk of adverse effects 7, 5.
• Phenytoin has been shown to be less effective than other medications in stopping seizures, although its efficacy in preventing further seizures is still being studied 8.
• The choice of treatment should be based on the individual patient's needs and medical history, as well as the severity and type of seizure 5, 6.