What is the initial treatment for inpatient seizures?

Initial Treatment for Inpatient Seizures

The initial treatment for inpatient seizures is intravenous lorazepam at a dose of 4 mg given slowly (2 mg/min) for adult patients. 1

First-Line Treatment Algorithm

1. Immediate intervention with benzodiazepines:

   • Administer lorazepam 4 mg IV slowly over 2 minutes 1
   • Ensure equipment to maintain a patent airway is immediately available 1
   • Monitor vital signs, including continuous cardiac monitoring and pulse oximetry

2. If seizures persist after 10-15 minutes:

   • Administer a second dose of lorazepam 4 mg IV 1
   • Prepare for second-line therapy if seizures continue

Second-Line Treatment (for seizures refractory to benzodiazepines)

If seizures continue despite optimal dosing of benzodiazepines, proceed with one of the following second-line agents (all have similar efficacy) 2:

• Fosphenytoin: 15-20 mg/kg IV at a rate not exceeding 50 mg per minute 3
• Levetiracetam: 30-50 mg/kg IV 4
• Valproate: 20-30 mg/kg IV at a maximum rate of 10 mg/kg/min 4

The 2024 ACEP Clinical Policy (Level A recommendation) confirms that fosphenytoin, levetiracetam, or valproate may be used with similar efficacy for seizures refractory to benzodiazepines 2.

Important Considerations

Monitoring

• Continuous cardiac monitoring during and after treatment
• Frequent blood pressure checks
• Continuous pulse oximetry
• Monitor for respiratory depression

Medication-Specific Considerations

1. Lorazepam:

   • Success rate of approximately 65% 4
   • Primary concern: respiratory depression 1
   • Underdosing (less than 4 mg) is associated with progression to refractory status epilepticus 5

2. Fosphenytoin:

   • Administer at a rate not exceeding 50 mg per minute 3
   • Monitor for hypotension and cardiac arrhythmias 4

3. Valproate:

   • Success rate of approximately 88% 4
   • Fewer cardiovascular side effects than phenytoin 4
   • Contraindicated in females who may become pregnant 4

4. Levetiracetam:

   • Success rate of 44-73% 4
   • Minimal adverse effects 4
   • May be preferred in patients with respiratory compromise or hypotension 6

Common Pitfalls to Avoid

1. Underdosing lorazepam: Using less than the recommended 4 mg dose significantly increases the risk of progression to refractory status epilepticus 5

2. Delayed administration of second-line agents: If seizures continue after appropriate benzodiazepine dosing, promptly administer a second-line agent 2

3. Intramuscular administration of phenytoin or valproate: These medications should not be given intramuscularly due to poor absorption and risk of tissue necrosis 3, 7

4. Prophylactic use of anticonvulsants: This is not recommended in patients with ischemic stroke and may have negative effects on neurological recovery 2

5. Failure to investigate underlying causes: Always investigate possible triggers such as infection, metabolic abnormalities, or medication effects 1

The evidence strongly supports using lorazepam as the first-line treatment for inpatient seizures, with fosphenytoin, levetiracetam, or valproate as equally effective second-line options if seizures persist despite benzodiazepine administration.