What is the management and treatment for a patient experiencing convulsions?

Management of Convulsions

The management of convulsions requires immediate administration of benzodiazepines as first-line treatment, followed by second-line agents such as levetiracetam, fosphenytoin, or valproate if seizures persist despite optimal benzodiazepine dosing. 1

Initial Assessment and Stabilization

• Ensure patent airway, breathing, and circulation
• Position patient on their side to prevent aspiration
• Protect from injury by removing nearby objects
• Do not restrain the patient or place objects in their mouth
• Monitor vital signs continuously
• Establish IV access if possible

First-Line Treatment: Benzodiazepines

For active convulsions:

• Lorazepam 4 mg IV given slowly (2 mg/min) is the preferred first-line agent 2

  • If seizures continue after 10-15 minutes, an additional 4 mg dose may be administered
  • Success rate of approximately 65% in controlling seizures within 20 minutes 3

• Alternative options if IV access is unavailable:

  • Midazolam 0.2 mg/kg IM (maximum 6 mg per dose) 3
  • Diazepam 5-10 mg IM (less preferred due to slower absorption) 4

Second-Line Treatment (for Refractory Seizures)

If seizures continue despite benzodiazepine administration, administer one of the following:

• Valproate IV: 20-30 mg/kg at 40 mg/min (88% success rate) 3

  • Preferred in hemodynamically unstable patients

• Levetiracetam IV: 30-50 mg/kg at 100 mg/min (44-73% success rate) 3

  • Favorable safety profile with minimal adverse effects

• Fosphenytoin IV: 18-20 mg/kg at 50 mg/min (56% success rate) 3

  • Requires ECG and blood pressure monitoring due to risk of hypotension and cardiac dysrhythmias

Third-Line Treatment (for Highly Refractory Status Epilepticus)

If seizures persist after second-line therapy:

• Propofol: 2 mg/kg bolus, followed by 5 mg/kg/h infusion 3

  • Requires intubation and mechanical ventilation
  • Risk of hypotension (42%) requiring vasopressors

• Pentobarbital: Higher success rate than propofol (92% vs 73%) but higher risk of hypotension (77%) 3

• Midazolam infusion: 8-20 mg bolus, followed by 4-30 mg/h infusion 3

Concurrent Management

• Search for and treat underlying causes:

  • Check blood glucose (hypoglycemia)
  • Assess electrolytes (hyponatremia)
  • Evaluate for hypoxia
  • Screen for drug toxicity
  • Consider CNS or systemic infection
  • Rule out stroke, intracranial hemorrhage, or withdrawal syndromes 1, 3

• Consider EEG monitoring, especially if:

  • Patient received paralytic agents
  • Patient does not regain consciousness after apparent cessation of seizures
  • Nonconvulsive status epilepticus is suspected 1, 3

Special Considerations

• Intubation: May be necessary in 17-26% of cases depending on medication used 3
• Adherence to treatment protocols is associated with better outcomes and shorter hospital stays 5
• Timing is critical: Achieving seizure control within 1-2 hours after onset significantly improves outcomes 6

Common Pitfalls to Avoid

1. Delaying treatment: Immediate intervention is crucial for better outcomes
2. Inadequate dosing: Underdosing benzodiazepines reduces efficacy
3. Improper positioning: Position patient on side only after convulsions cease to prevent shoulder dislocation 7
4. Neglecting to search for underlying causes: Always investigate and treat the underlying etiology
5. Failure to escalate therapy: If first-line treatment fails, promptly initiate second-line agents

By following this structured approach to managing convulsions, you can optimize patient outcomes and reduce the risk of complications associated with prolonged seizure activity.