What is the initial approach to managing a patient presenting with seizures?

Initial Management of Seizures

Benzodiazepines are the first-line treatment for active seizures, with lorazepam being the preferred option for intravenous administration due to its rapid onset of action and broad spectrum of efficacy. 1

Immediate Management of Active Seizures

1. First-line treatment:

   • Administer benzodiazepines immediately
     • IV lorazepam (preferred if IV access available)
     • Alternatives: rectal diazepam if IV access unavailable 1
   • Act quickly - efficacy decreases significantly if treatment is delayed beyond 30-60 minutes 1

2. If seizures persist after benzodiazepines:

   • Administer second-line anticonvulsants:
     • Valproate: 20-30 mg/kg IV (loading dose) - may be preferred due to fewer cardiovascular side effects 1
     • Phenytoin/fosphenytoin (requires cardiac monitoring due to hypotension risk) 1
     • Levetiracetam 1

3. For refractory status epilepticus:

   • Consider third-line agents:
     • Propofol
     • Midazolam
     • Barbiturates 1

Essential Diagnostic Evaluation

Laboratory Tests

• For all patients:

  • Serum glucose
  • Serum sodium
  • Pregnancy test (women of childbearing age) 1

• For patients with altered mental status:

  • Complete metabolic panel
  • Toxicology screen 1

• For patients with fever:

  • CBC
  • Blood cultures
  • Consider lumbar puncture 1

• Additional tests as indicated:

  • Antiepileptic drug levels (for patients on seizure medications)
  • CK levels (after generalized tonic-clonic seizure)
  • Troponin (older patients with generalized tonic-clonic seizure) 1

Imaging and Other Studies

• MRI: Preferred imaging modality 1
• CT: May be performed initially in emergency settings for:
  • Focal neurologic deficit
  • Persistent altered mental status
  • History of trauma or malignancy 1
• EEG: Recommended for first unprovoked seizure to identify epilepsy syndromes and predict recurrence risk 1

Long-Term Management Considerations

• Initiation of antiepileptic drugs:

  • Recommended for patients with two or more unprovoked seizures
  • Not recommended after a first unprovoked seizure unless specific risk factors are present:
    • History of previous brain disease/injury
    • Abnormal EEG
    • Abnormal neuroimaging
    • Focal onset of seizure 1

• For valproate therapy (if indicated):

  • Initial dose: 10-15 mg/kg/day
  • Titration: Increase by 5-10 mg/kg/week
  • Target: Optimal response typically at doses below 60 mg/kg/day
  • Therapeutic serum concentration: 50-100 μg/mL 2
  • Monitor for thrombocytopenia risk at higher concentrations (>110 μg/mL in females, >135 μg/mL in males) 2

Admission vs. Discharge Criteria

Discharge Criteria

• Return to baseline mental status
• Single self-limited seizure with no recurrence
• Normal or non-acute findings on neuroimaging
• Reliable follow-up available
• Responsible adult to observe the patient 1

Admission Criteria

• Status epilepticus or recurrent seizures
• Persistent altered mental status
• Acute symptomatic seizure
• Significant abnormality on neuroimaging requiring urgent intervention
• Inability to complete outpatient workup 1

Common Pitfalls and Caveats

1. Delayed treatment: Efficacy of benzodiazepines decreases significantly if treatment is delayed beyond 30-60 minutes of continuous seizure activity 1

2. Medication selection errors:

   • Phenytoin is ineffective for seizures secondary to alcohol withdrawal, theophylline, or isoniazid toxicity 3
   • Benzodiazepines have limitations for long-term use due to tolerance and dependence 1

3. Missed diagnosis of non-convulsive status epilepticus:

   • Consider in any patient with confusion or coma of unclear cause
   • Obtain EEG as soon as possible 3

4. Failure to identify and treat underlying causes:

   • Seizures may be provoked by organ failure, electrolyte imbalance, medications, or other medical conditions 3
   • Treatment should target the underlying cause alongside seizure control 3

5. Inadequate patient education:

   • Provide clear instructions about seizure precautions and safety measures
   • Explain driving restrictions according to local laws
   • Arrange follow-up with neurology 1