What is the management approach for a patient experiencing a seizure with intact mental status?

From the Guidelines

The management of a patient experiencing a seizure with intact mental status should prioritize benzodiazepines as the first-line treatment, with lorazepam or diazepam being preferred options, as per the latest clinical policy approved by the ACEP board of directors in 2024 1. When managing a patient with a seizure and intact mental status, it is crucial to focus on safety, observation, and appropriate medical intervention. The key steps include:

• Ensuring the patient is in a safe environment by removing dangerous objects and helping them to a seated or lying position if possible
• Not restraining the patient or placing anything in their mouth
• Timing the seizure duration and observing for progression to impaired consciousness or generalized seizure activity
• Administering benzodiazepines, such as lorazepam 2-4 mg IV/IM or diazepam 5-10 mg IV, as the first-line treatment for acute management
• Considering the use of prescribed rescue medications, like rectal diazepam or buccal/intranasal midazolam, as directed After the seizure resolves, a thorough neurological assessment should be performed to determine the underlying cause and guide long-term management. According to the latest clinical policy 1, the management of seizures can be clinically challenging, and noncompliance with antiseizure drug therapy or substance use can lower the seizure threshold, making it essential to consider these factors in the patient's treatment plan. The use of antiepileptic drugs, such as levetiracetam, lamotrigine, or carbamazepine, may be prescribed based on seizure type and patient factors, as part of the long-term management strategy 1.

From the FDA Drug Label

Primary Generalized Tonic-Clonic Seizures During clinical development, the number of patients with primary generalized tonic-clonic epilepsy exposed to levetiracetam was considerably smaller than the number with partial epilepsy, described above. In patients 6 years of age and older experiencing primary generalized tonic-clonic seizures, levetiracetam is associated with behavioral abnormalities

The management approach for a patient experiencing a seizure with intact mental status is not directly addressed in the provided drug label. However, it mentions that levetiracetam is associated with behavioral abnormalities in patients with primary generalized tonic-clonic seizures.

• Key points to consider in management:
  • Gradual withdrawal of antiepileptic drugs, including levetiracetam, to minimize the potential of increased seizure frequency 2.
  • Monitoring for behavioral abnormalities, such as irritability and non-psychotic behavioral disorders, which are commonly reported in levetiracetam-treated patients 2. The FDA label does not provide specific guidance on managing seizures with intact mental status.

From the Research

Management Approach for Seizure with Intact Mental Status

The management of a patient who has had a seizure with intact mental status is driven by the history and physical examination 3.

• Diagnostic Evaluation: Patients with comorbidities, a focal neurologic examination, or who have not returned to a normal baseline mental status require an extensive diagnostic evaluation including a noncontrast head computed tomography (CT) scan in the emergency department (ED) 3.
• Laboratory Tests: Adults with a first-time seizure, with no comorbidities, and who have returned to a normal baseline require only serum glucose and electrolyte determination 3.
• Pregnancy Test: Women of reproductive age also require a pregnancy test 3.
• Hospitalization and Antiepileptic Medications: Patients with a normal neurologic examination, normal laboratory results, and no signs of structural brain disease do not require hospitalization or antiepileptic medications 3.
• Antiepileptic Therapy: Initiation of antiepileptic therapy depends on the assessed risk for recurrence, in conjunction with a neurologist consultation 3.

Antiepileptic Drug Monotherapy

For patients with epilepsy, antiepileptic drug monotherapy is commonly used, and current guidelines recommend carbamazepine or lamotrigine as first-line treatment for partial onset seizures and sodium valproate for generalized onset seizures 4.

• Treatment Options: Levetiracetam may be a suitable alternative to carbamazepine and lamotrigine for individuals with partial onset seizures 4.
• Adverse Events: The most commonly reported adverse events across all drugs were drowsiness/fatigue, headache or migraine, gastrointestinal disturbances, dizziness/faintness, and rash or skin disorders 4.

Pharmacotherapy of Myoclonic Seizures

Valproate is commonly the first choice for the treatment of myoclonic seizures, alone or in combination with some benzodiazepines or levetiracetam 5.

• Treatment Options: There is emerging evidence to support the efficacy of some newer antiepileptic drugs, and avoidance of medications that may aggravate myoclonic seizures is crucial 5.
• Clinical Experience: Pharmacological treatment of myoclonic seizures is based on clinical experience with little evidence from randomized clinical trials 5.