What is the first line of treatment for an active seizure?

First-Line Treatment for Active Seizure

The first-line treatment for an active seizure is intravenous lorazepam at a dose of 0.1 mg/kg (maximum 4 mg) administered slowly at 2 mg/minute. 1, 2, 3

Initial Management of Active Seizure

1. Immediate First Aid Measures:

   • Help the person to the ground
   • Place the person on their side in recovery position
   • Clear the area around them to prevent injury
   • Stay with the person having a seizure 4

2. When to Activate EMS:

   • First-time seizure
   • Seizures lasting >5 minutes
   • Multiple seizures without return to baseline between episodes
   • Seizures occurring in water
   • Seizures with traumatic injuries or difficulty breathing
   • Seizure in an infant <6 months of age
   • Seizure in pregnant individuals
   • If the person doesn't return to baseline within 5-10 minutes after seizure activity stops 4

3. DO NOT:

   • Restrain the person
   • Put anything in the mouth
   • Give food, liquids, or oral medicines during a seizure or when responsiveness is decreased 4

Medication Protocol for Active Seizure

First-Line Treatment:

• Lorazepam 0.1 mg/kg IV (maximum 4 mg) administered at 2 mg/minute 1, 2, 3
• If seizures continue or recur after 10-15 minutes, an additional 4 mg IV dose may be administered 2

Alternative Routes When IV Access Unavailable:

• Intramuscular midazolam (effective alternative to IV lorazepam) 1, 5
• Buccal midazolam (approved in EU) 6
• Rectal diazepam (FDA-approved for out-of-hospital treatment) 6

Second-Line Treatment (if seizures persist):

• Fosphenytoin 20 mg phenytoin equivalents/kg IV at a rate not exceeding 150 mg/minute 7
• Alternative options include:
  • Valproate 20-30 mg/kg IV (88% success rate)
  • Levetiracetam 30-50 mg/kg IV (44-73% success rate)
  • Phenobarbital 10-20 mg/kg IV (58% success rate) 1

Third-Line Treatment (for refractory status epilepticus):

• If seizures continue, initiate intravenous general anesthesia with:
  • Pentobarbital
  • Benzodiazepine drip
  • Propofol 7

Special Considerations

1. Equipment Preparation:

   • Equipment to maintain a patent airway must be immediately available prior to benzodiazepine administration 2
   • Start an IV infusion, monitor vital signs, maintain unobstructed airway, and have artificial ventilation equipment available 2

2. Monitoring:

   • Continuous cardiorespiratory monitoring
   • Frequent neurological assessments
   • EEG monitoring for patients who do not recover consciousness 1, 7

3. Potential Adverse Effects:

   • Respiratory depression (especially when combined with other sedative agents)
   • Hypotension
   • Sedation 1, 2

4. Pediatric Considerations:

   • Febrile seizures are common in children 6 months to 2 years of age
   • Antipyretics (acetaminophen, ibuprofen) are not effective for stopping or preventing febrile seizures 4

Remember that status epilepticus (seizures lasting >5 minutes or multiple seizures without return to baseline) is a medical emergency requiring aggressive treatment to prevent neuronal damage. The time to treatment is crucial, as clinical response to benzodiazepines diminishes with prolonged status epilepticus 5.