What is the management of seizures?

Management of Seizures

Benzodiazepines are the first-line treatment for active seizures, followed by levetiracetam, fosphenytoin, or valproate as equally effective second-line options if seizures persist beyond 5 minutes. 1

Initial Management of Active Seizures

First-Line Treatment

1. Benzodiazepines are the cornerstone of initial seizure management:
   • Lorazepam: 4 mg IV slowly (2 mg/min) for adults 2
   • If seizures continue after 10-15 minutes, an additional 4 mg IV dose may be administered 2
   • Alternative benzodiazepines when IV access is unavailable:
     • Midazolam: Intramuscular or intranasal routes are effective alternatives 1, 3
     • Diazepam: Rectal administration is an option, especially in pediatric patients 4

Safety Measures During Seizure

• Protect the patient from injury
• Position patient on their side if possible
• Do not restrain the person or put anything in their mouth
• Do not give food, liquids, or oral medicines during a seizure 1
• Maintain patent airway and have equipment immediately available 2

Management of Status Epilepticus

Status epilepticus is defined as seizures lasting more than 5 minutes or multiple seizures without return to baseline 1.

Second-Line Treatment (if seizures persist after benzodiazepines)

Administer one of the following agents:

1. Fosphenytoin/Phenytoin:

   • Loading dose: 15-20 mg/kg IV at maximum rate of 50 mg/minute 5
   • Monitor ECG, blood pressure, and respiratory function during administration 5

2. Valproate:

   • 20-40 mg/kg IV (maximum rate 6 mg/kg/min)
   • Particularly effective and safe option, with less hypotension than phenytoin 6

3. Levetiracetam:

   • 30 mg/kg IV
   • Preferred in patients with hepatic dysfunction 1
   • Similar efficacy to valproate in controlling seizures 6

Third-Line Treatment (for refractory status epilepticus)

If seizures continue despite first and second-line treatments:

• Phenobarbital: IV administration
• Midazolam: Continuous infusion
• Propofol: Continuous infusion
• Pentobarbital: Continuous infusion 6

Diagnostic Workup

Essential Laboratory Tests

• Serum glucose (all patients)
• Serum sodium (all patients)
• Complete metabolic panel (if altered mental status)
• Toxicology screen (if suspected substance use)
• CBC, blood cultures (if fever present)
• Antiepileptic drug levels (for patients on seizure medications)
• CK levels (after generalized tonic-clonic seizures)
• Pregnancy test (women of childbearing age) 1

Neuroimaging

• MRI is preferred over CT for detecting brain abnormalities 1
• CT may be used in emergency settings when MRI is unavailable

Electroencephalography (EEG)

• Critical for detecting non-convulsive status epilepticus
• Should be performed within 24-48 hours of a first-time seizure
• Continuous EEG monitoring for refractory status epilepticus 1

Addressing Underlying Causes

Always search for and treat underlying causes of seizures, including:

• Hypoglycemia
• Hyponatremia
• Drug toxicity (prescribed or illicit substances)
• CNS or systemic infections
• Ischemic stroke or intracranial hemorrhage
• Withdrawal syndromes 6, 1

Common Pitfalls to Avoid

1. Delayed treatment: Seizures lasting more than 5 minutes require immediate intervention 7
2. Inadequate benzodiazepine dosing: Underdosing reduces efficacy
3. Failure to monitor respiratory status: Benzodiazepines can cause respiratory depression
4. Missing non-convulsive status epilepticus: Consider EEG for patients with prolonged altered mental status
5. Overlooking treatable causes: Always search for underlying etiology 1
6. Inappropriate use of phenytoin: Not recommended for drug-induced seizures 8

Disposition Criteria

Patients can be safely discharged if they:

• Have returned to baseline mental status
• Had a single self-limited seizure with no recurrence
• Have normal or non-acute findings on neuroimaging
• Have reliable follow-up available
• Have a responsible adult to observe them 1

Otherwise, admission is recommended, with ICU-level care for patients with refractory status epilepticus requiring continuous EEG monitoring and anesthetic agents 1.