What is the appropriate treatment for a patient experiencing seizures?

Management of Seizures in Adults

For patients experiencing active seizures, immediate first aid should include helping the person to the ground, placing them on their side in the recovery position, clearing the area around them, and activating EMS for seizures lasting >5 minutes, multiple seizures without return to baseline, or other concerning features. 1

Initial Assessment and Management

Active Seizure Management

1. First Aid Measures:

   • Help person to ground in recovery position
   • Clear area of dangerous objects
   • Do NOT restrain the person 1
   • Do NOT put anything in the mouth 1
   • Stay with the person throughout the seizure 1

2. When to Activate EMS 1:

   • First-time seizure
   • Seizure lasting >5 minutes
   • Multiple seizures without return to baseline
   • Seizures with traumatic injuries
   • Difficulty breathing or choking
   • Seizure in water
   • Seizure in pregnant individuals
   • Seizure in infant <6 months
   • Person does not return to baseline within 5-10 minutes after seizure stops

3. Immediate Medical Treatment for active seizures:

   • Administer benzodiazepines if seizures are not self-limiting 1, 2
   • Lorazepam IV is first-line with approximately 65% success rate 2
   • If IV access unavailable, consider:
     • Midazolam IM (0.2 mg/kg, max 6 mg) 2
     • Rectal diazepam (0.5 mg/kg, up to 20 mg) 2

Post-Seizure Evaluation

1. Identify and treat underlying causes:

   • Hypoglycemia
   • Electrolyte abnormalities
   • Infections
   • Toxic ingestions
   • Stroke or other neurological conditions

2. Essential Diagnostic Testing:

   • Noncontrast brain CT for suspected acute stroke 1
   • ECG to assess cardiac rhythm 1
   • EEG for patients with first-time unprovoked seizure 2, 3
   • MRI with epilepsy protocol for unprovoked seizures 2, 3

Treatment Approach Based on Seizure Type

1. Provoked Seizures

• Do not initiate antiepileptic medication in the ED for patients with provoked seizures 1, 2
• Focus on identifying and treating the precipitating medical condition 1
• Common causes: metabolic disorders, acute febrile illnesses, toxic ingestion 4, 5

2. First Unprovoked Seizure

• Do not initiate antiepileptic medication in the ED for patients with a first unprovoked seizure without evidence of brain disease or injury 1, 2
• Risk of recurrence within 5 years is approximately 33-50% 1
• Consider outpatient follow-up within 1-2 weeks 2

3. First Unprovoked Seizure with Brain Disease/Injury History

• May initiate antiepileptic medication in the ED or defer in coordination with other providers 1, 2
• Higher risk of recurrence warrants consideration of treatment 1

4. Established Epilepsy with Breakthrough Seizure

• Evaluate medication compliance (58.5% of patients with known seizure disorder are immediately noncompliant) 5
• Consider medication adjustments or addition of second-line agents
• Schedule follow-up within 1-2 weeks 2

Status Epilepticus Management

Status epilepticus (seizures lasting >5 minutes or multiple seizures without return to baseline) requires immediate intervention:

1. First-line: Benzodiazepines (lorazepam IV preferred) 2

2. Second-line (if seizures continue after benzodiazepines):

   • Fosphenytoin: 15-20 mg PE/kg IV 2
   • Valproate: 20-30 mg/kg IV (88% success rate) 2
   • Levetiracetam: 30-50 mg/kg IV (44-73% success rate) 2
   • Phenobarbital: 10-20 mg/kg IV (58% success rate) 2

3. Refractory Status:

   • Consider propofol (2 mg/kg bolus, 5 mg/kg/h infusion) 2
   • Transfer to ICU for continuous EEG monitoring

Medication Selection for Chronic Management

When long-term treatment is indicated:

1. Partial Seizures:

   • Most antiepileptic drugs are effective 6
   • Common options: levetiracetam 7, topiramate 8, carbamazepine

2. Generalized Seizures:

   • Preferred options: valproate, lamotrigine, topiramate 6
   • Levetiracetam also effective for myoclonic and primary generalized tonic-clonic seizures 7

3. Considerations for Selection:

   • Seizure type and epilepsy syndrome
   • Comorbidities
   • Side effect profile
   • Dosing interval
   • Cost
   • Contraindications (e.g., valproic acid contraindicated in females who may become pregnant) 2

Common Pitfalls to Avoid

1. Failing to recognize status epilepticus - Seizures lasting >5 minutes require immediate intervention 1

2. Restraining the person during a seizure - This can cause injury 1

3. Putting objects in the mouth - This is dangerous and unnecessary 1

4. Administering antipyretics for febrile seizures - Not effective for stopping seizures or preventing recurrence 1

5. Prophylactic use of anticonvulsants - Not recommended in acute stroke patients 1

6. Overlooking medication noncompliance - A major cause of breakthrough seizures 5

7. Treating all seizure-like events as epileptic - Many conditions mimic seizures (pseudoseizures, syncope, migraine) 6

8. Continuing ineffective treatments - If trials of more than two antiepileptic drugs fail, refer to an epilepsy center 6