From the Guidelines
Ketamine is not the recommended initial treatment for an active seizure, and benzodiazepines should be used as the first-line agent. The initial treatment for an active seizure should focus on rapidly controlling the seizure activity to prevent further brain damage and other complications. According to the evidence from 1 and 1, benzodiazepines, such as lorazepam (Ativan) 0.1 mg/kg IV (typically 2-4 mg in adults), are the recommended first-line agents due to their rapid onset and longer duration of action. Alternatives include diazepam (Valium) 0.15-0.2 mg/kg IV (typically 5-10 mg in adults) or midazolam 10 mg intramuscular or intranasal if IV access is unavailable.
Key Considerations for Seizure Management
- Ensure the patient is positioned on their side to prevent aspiration and maintain airway patency
- Remove dangerous objects from the vicinity
- Do not restrain the patient or place anything in their mouth
- Benzodiazepines work by enhancing the effect of gamma-aminobutyric acid (GABA), the main inhibitory neurotransmitter in the brain, which helps suppress the abnormal electrical activity causing the seizure
Second-Line Agents
If seizures persist after initial benzodiazepine administration, a second dose may be given, followed by consideration of second-line agents such as:
- Fosphenytoin
- Valproate
- Levetiracetam These agents should be considered if the seizure continues beyond 5 minutes, as this would constitute status epilepticus requiring more aggressive intervention, as noted in 1.
Evidence-Based Recommendations
The Neurocritical Care Society’s Status Epilepticus Guideline Writing Committee recommended urgent control of seizures with any of the following: valproate, levetiracetam, or phenobarbital, in addition to phenytoin/fosphenytoin, as seen in 1. However, ketamine is not mentioned as a recommended initial treatment for active seizures in the provided evidence. Therefore, benzodiazepines should be used as the first-line treatment, and ketamine is not recommended as an initial treatment for active seizures.
From the FDA Drug Label
For the treatment of status epilepticus, the usual recommended dose of lorazepam injection is 4 mg given slowly (2 mg/min) for patients 18 years and older. If seizures cease, no additional lorazepam injection is required If seizures continue or recur after a 10- to 15-minute observation period, an additional 4 mg intravenous dose may be slowly administered.
The recommended initial treatment for an active seizure is lorazepam. The usual dose is 4 mg given slowly intravenously.
- Key points:
From the Research
Treatment for Active Seizure
The recommended initial treatment for an active seizure, also known as status epilepticus, typically involves the use of benzodiazepines as the first line of treatment 4, 5.
- Benzodiazepines such as lorazepam, diazepam, and midazolam are commonly used to terminate seizure activity.
- In cases where benzodiazepines are not effective, second-line agents like phenytoin, valproate, or levetiracetam may be used 4.
- For refractory status epilepticus, treatment options include midazolam infusion, thiopentone, propofol, or high-dose phenobarbitone 4.
Use of Ketamine in Status Epilepticus
Ketamine may be considered as a third-phase treatment option for nonanoxic convulsive refractory status epilepticus, although equipoise exists regarding its use compared to other treatments 6.
- Ketamine is an anesthetizing continuous IV infusion antiseizure medication that may be used in refractory cases.
- However, the evidence for its use in this context is limited, and more research is needed to determine its efficacy and safety compared to other treatment options.
Initial Treatment Recommendations
The initial treatment for an active seizure typically involves the administration of full doses of benzodiazepines, followed by a full loading dose of IV fosphenytoin, levetiracetam, valproic acid, or phenobarbital if necessary 6, 7.
- Lorazepam is as efficacious and safe as diazepam-phenytoin combination in the treatment of convulsive status epilepticus in children 7.
- The choice of initial treatment should be guided by the patient's specific needs and medical history, as well as the severity and duration of the seizure activity.