Management of Active Seizures in a 28-Year-Old Man
Active seizures in adults should be treated immediately with intravenous lorazepam 0.1 mg/kg (maximum 4 mg) as first-line therapy, which can be repeated once after 5 minutes if seizures persist, followed by levetiracetam 40 mg/kg IV (maximum 2500 mg) as the preferred second-line agent. 1
Step 1: Initial Assessment and Stabilization (0-5 minutes)
- Ensure airway, breathing, and circulation
- Position patient on their side (recovery position) to prevent aspiration
- Clear area of hazardous objects
- Administer oxygen if available
- Establish IV access
- Check vital signs (heart rate, blood pressure, temperature, oxygen saturation)
- Assess for signs of trauma or injury
Step 2: First-Line Medication (5-10 minutes)
- Lorazepam 0.1 mg/kg IV (maximum 4 mg) 1
- Can be repeated once after 5 minutes if seizures continue
- Monitor for respiratory depression
- If IV access is not available, consider midazolam 10 mg intramuscular or intranasal as an alternative
Step 3: Second-Line Medication (10-20 minutes)
If seizures persist after benzodiazepine administration:
- Levetiracetam 40 mg/kg IV (maximum 2500 mg) 1
- Preferred due to minimal adverse effects and drug interactions
- Efficacy rate of 44-73% in status epilepticus
Step 4: Alternative Second-Line Options (if levetiracetam unavailable or contraindicated)
Valproate 20-30 mg/kg IV (efficacy rate 88%) 1
- Monitor for gastrointestinal disturbances, somnolence, tremor
- Avoid in patients with liver disease
Phenytoin/Fosphenytoin 18-20 mg/kg IV (efficacy rate 56%) 1, 2
- Administer at rate not exceeding 50 mg/minute
- Monitor ECG and blood pressure during infusion
- Watch for hypotension, cardiac dysrhythmias, purple glove syndrome
Step 5: Third-Line Medication (20-40 minutes)
If seizures continue despite second-line therapy:
- Phenobarbital 10-20 mg/kg IV (efficacy rate 58%) 1
- Monitor for respiratory depression and hypotension
- Consider intubation for airway protection
Step 6: Anesthetic Agents (40-60 minutes)
For refractory status epilepticus:
Propofol 2 mg/kg bolus followed by 5 mg/kg/hour infusion 1
- Monitor for hypotension (occurs in 42% of cases)
- Requires ICU admission and mechanical ventilation
Midazolam 0.2 mg/kg bolus followed by 0.1-0.4 mg/kg/hour infusion 1
- Alternative to propofol
- May require dose escalation due to tachyphylaxis
Step 7: Additional Considerations and Monitoring
Obtain urgent laboratory studies:
- Electrolytes, glucose, complete blood count, renal and liver function
- Toxicology screen if substance use is suspected
- Consider anti-epileptic drug levels if patient is on therapy
Neuroimaging (CT or MRI) once seizures are controlled
EEG monitoring, especially if patient requires neuromuscular blockade
Investigate and treat underlying causes (infection, trauma, metabolic disturbances)
Maintenance Therapy After Seizure Control
- For first unprovoked seizure: Consider starting maintenance therapy if high risk for recurrence
- For established epilepsy or recurrent seizures:
- Levetiracetam 500-1000 mg twice daily (preferred for young adults) 1
- Carbamazepine 200 mg twice daily initially, increasing by 200 mg/day weekly to 800-1200 mg/day in divided doses 3
- Valproate 10-15 mg/kg/day in divided doses, increasing by 5-10 mg/kg/week to optimal response (usually 1000-2000 mg/day) 4
Important Considerations
- Do not use prophylactic anticonvulsants in patients without seizure history 5
- A single, self-limiting seizure occurring at onset or within 24 hours of stroke should not be treated with long-term anticonvulsants 5
- Monitor for drug-specific adverse effects and drug interactions
- Avoid valproate in young women due to teratogenicity risk 1
- Levetiracetam is preferred in patients with renal impairment and liver disease 1
By following this step-by-step approach, you can effectively manage active seizures while minimizing morbidity and mortality risks and preserving quality of life for the patient.