What are the guidelines for managing seizures?

Guidelines for Managing Seizures

For seizure management, first-line treatment for status epilepticus is intravenous benzodiazepines (preferably lorazepam if available), followed by phenytoin/fosphenytoin, valproate, or levetiracetam as second-line agents. 1

Initial Seizure Management

First Aid for Seizures

• When to activate EMS: 1

  • First-time seizure
  • Seizures lasting >5 minutes
  • Multiple seizures without return to baseline
  • Seizures occurring in water
  • Seizures with traumatic injuries, breathing difficulties, or choking
  • Seizures in infants <6 months
  • Seizures in pregnant individuals
  • Failure to return to baseline within 5-10 minutes after seizure stops

• Immediate actions: 1

  • Help person to the ground
  • Place in recovery position (on their side)
  • Clear area of dangerous objects
  • Stay with the person
  • Do NOT restrain the person
  • Do NOT put anything in the mouth
  • Do NOT give food, liquids, or oral medicines during seizure or decreased responsiveness

Acute Management of Status Epilepticus

Status Epilepticus Treatment Algorithm: 1, 2

1. First-line (IV access available):

   • IV benzodiazepine (lorazepam preferred over diazepam)
   • Lorazepam dosing: 4 mg IV given slowly (2 mg/min) for adults
   • If seizures continue after 10-15 minutes, additional 4 mg IV dose may be administered

2. First-line (IV access not available):

   • Rectal diazepam (IM diazepam not recommended due to erratic absorption)
   • IM phenobarbital may be considered when rectal diazepam is not possible

3. Second-line (if seizures persist after benzodiazepines):

   • IV phenytoin/fosphenytoin (loading dose: 15-20 mg/kg at rate not exceeding 50 mg/min) 3
   • IV valproate (30 mg/kg)
   • IV levetiracetam (60 mg/kg, up to 4500 mg)
   • IV phenobarbital

Long-term Seizure Management

Selection of Antiseizure Medications (ASMs)

For Focal (Partial) Seizures: 1, 4, 5, 6

• First-line options:
  • Carbamazepine
  • Lamotrigine
  • Oxcarbazepine
  • Levetiracetam (avoid if psychiatric history)

For Generalized Seizures: 1, 7, 4, 5

• First-line options:
  • Valproic acid (avoid in women of childbearing potential)
  • Lamotrigine
  • Levetiracetam

Dosing Considerations

• Monotherapy is preferred over polytherapy to minimize side effects 1
• Start with low doses and titrate gradually to minimize adverse effects 8
• For carbamazepine: 8
  • Adults: Initial 200 mg twice daily, increase weekly by up to 200 mg/day
  • Children 6-12 years: Initial 100 mg twice daily, increase weekly by up to 100 mg/day
  • Children <6 years: 10-20 mg/kg/day divided twice or three times daily

Special Populations

Women of Childbearing Potential: 1

• Avoid valproic acid if possible
• Use monotherapy at minimum effective dose
• Take folic acid routinely
• Standard breastfeeding recommendations remain appropriate

Patients with Intellectual Disability: 1

• Same range of investigations and treatments as general population
• Consider valproic acid or carbamazepine instead of phenytoin or phenobarbital due to lower risk of behavioral adverse effects

Treatment Duration and Discontinuation

• Discontinuation should be considered after 2 seizure-free years 1
• Decision to withdraw should consider clinical, social, and personal factors
• Involve patient and family in decision-making

Monitoring and Follow-up

• Monitor serum drug levels to ensure therapeutic range and avoid toxicity 3, 8
• Therapeutic range for phenytoin: 10-20 mcg/mL total concentration 3
• Regular follow-up to assess efficacy and adverse effects

Common Pitfalls to Avoid

1. Failure to recognize status epilepticus - Remember that seizures lasting >5 minutes or multiple seizures without return to baseline constitute a medical emergency

2. Inappropriate first aid - Never restrain the person or put anything in their mouth during a seizure

3. Inadequate loading doses - Underdosing antiseizure medications can lead to treatment failure

4. Not considering drug interactions - Many antiseizure medications interact with other drugs through hepatic enzyme induction

5. Using valproate in women of childbearing potential without discussing risks - Valproate has significant teratogenic potential

6. Prophylactic antiseizure medications - Should not be routinely prescribed after a first unprovoked seizure 1

7. Antipyretics for febrile seizures - Not effective for stopping seizures or preventing subsequent febrile seizures 1

By following these guidelines and considering individual patient factors, seizures can be effectively managed in most patients, with approximately 60-70% achieving seizure freedom with appropriate treatment 5.