What is the initial treatment for inpatient seizures?

Initial Treatment for Inpatient Seizures

New-onset seizures in admitted patients with acute stroke should be treated using appropriate short-acting medications such as lorazepam IV if they are not self-limiting. 1

First-Line Treatment

Lorazepam is the recommended first-line treatment for inpatient seizures that are not self-limiting. The FDA-approved dosing is:

• Adults: 4 mg IV given slowly (2 mg/min)
• If seizures continue after 10-15 minutes, an additional 4 mg IV dose may be administered 2

Important considerations when administering lorazepam:

• Equipment to maintain a patent airway must be immediately available
• Continuous monitoring of vital signs is essential
• An intravenous infusion should be started
• An unobstructed airway should be maintained
• Artificial ventilation equipment should be available 2

Second-Line Treatment (If Seizures Continue)

If seizures continue despite optimal dosing of benzodiazepines, a second-line agent should be administered. According to the most recent guidelines, any of the following agents can be used with similar efficacy 1:

• Fosphenytoin: 15-20 mg/kg IV at a rate not exceeding 50 mg per minute
• Levetiracetam: 30-50 mg/kg IV
• Valproate: 20-30 mg/kg IV at a maximum rate of 10 mg/kg/min 1, 3

The ESETT trial showed that these three medications have similar efficacy rates for terminating status epilepticus (45-47%) when used as second-line agents 1.

Monitoring During Treatment

• Continuous cardiac monitoring during and after treatment
• Frequent blood pressure checks
• Continuous pulse oximetry
• Monitor for respiratory depression, which is more common with benzodiazepines 3

Special Considerations

For Stroke Patients

• A single, self-limiting seizure occurring at the onset or within 24 hours after an ischemic stroke should not be treated with long-term anticonvulsant medications
• Patients with immediate post-stroke seizures should be monitored for recurrent seizure activity during routine monitoring of vital signs and neurological status
• Prophylactic use of anticonvulsants in stroke patients is not recommended and may have negative effects on neurological recovery 1

Medication-Specific Considerations

• Phenytoin/Fosphenytoin: Higher risk of hypotension, cardiac dysrhythmias, and purple glove syndrome
• Valproate: Contraindicated in females who may become pregnant and patients with liver disease
• Lorazepam: Higher risk of respiratory depression and need for mechanical ventilation 3, 4

Common Pitfalls to Avoid

1. Underdosing lorazepam: A study showed that patients who received less than the recommended 4 mg dose had significantly higher rates of progression to refractory status epilepticus (87% vs. 62%, p=0.03) 4

2. Delayed treatment: Rapid treatment is essential as prolonged seizures become increasingly resistant to medications

3. Inadequate monitoring: Failure to monitor vital signs and respiratory status can lead to preventable complications

4. Using intramuscular phenytoin or valproate: These should not be given intramuscularly due to poor absorption and risk of tissue damage 5

5. Failure to investigate underlying causes: Seizures may be symptoms of other acute conditions that require specific treatment

By following this evidence-based approach to inpatient seizure management, clinicians can optimize outcomes while minimizing complications from both seizures and their treatment.