What is the approach to managing a patient experiencing a seizure?

Management of Seizures in the Emergency Setting

Benzodiazepines are the first-line treatment for active seizures, followed by fosphenytoin, levetiracetam, or valproate as equally effective second-line agents for status epilepticus. 1

Initial Assessment and Management

• Ensure airway patency and maintain adequate ventilation - respiratory depression is the most important risk during seizure management 2
• Monitor vital signs and establish intravenous access 2
• Simultaneously search for and treat underlying causes of seizures, including:
  • Hypoglycemia
  • Hyponatremia
  • Hypoxia
  • Drug toxicity
  • CNS or systemic infections
  • Ischemic stroke or intracerebral hemorrhage
  • Withdrawal syndromes 1

Treatment Algorithm for Seizures

First-Line Treatment: Benzodiazepines

• Intravenous lorazepam: 4 mg given slowly (2 mg/min) for adults
  • If seizures continue after 10-15 minutes, an additional 4 mg dose may be administered 2
• Intramuscular midazolam: Effective alternative when IV access is difficult
  • Studies show IM midazolam is at least as effective as IV lorazepam for prehospital seizure cessation 3
• Buccal or sublingual midazolam/lorazepam: Alternative routes when IV access is unavailable
  • Sublingual lorazepam has shown efficacy for interrupting prolonged and repetitive seizures 4

Second-Line Treatment for Status Epilepticus

For seizures refractory to benzodiazepines, administer one of the following with similar efficacy:

• Fosphenytoin: IV administration (preferred over phenytoin due to fewer adverse effects) 1
• Levetiracetam: IV administration 1
• Valproate: IV administration up to 30 mg/kg at maximum rate of 10 mg/kg/min 1

The 2024 ACEP guidelines (Level A recommendation) state that these three agents have similar efficacy, with approximately 45-47% of patients achieving seizure cessation within 60 minutes 1

Third-Line Treatment for Refractory Status Epilepticus

For seizures continuing despite benzodiazepines and second-line agents:

• Phenobarbital: IV administration 1
• Propofol infusion: Consider for refractory cases 1
• Pentobarbital infusion: High efficacy (92%) but associated with significant hypotension (77% requiring pressors) 1
• Midazolam infusion: Continuous infusion for refractory status 1

Safety Considerations

• Monitor for respiratory depression, especially with benzodiazepines 2
• Have equipment for airway management and ventilatory support readily available 2
• Watch for hypotension, particularly with:
  • Fosphenytoin (3.2% risk of life-threatening hypotension)
  • Valproate (1.6% risk)
  • Levetiracetam (0.7% risk) 1
• Consider EEG monitoring for patients with persistent altered consciousness to rule out nonconvulsive status epilepticus 1

Special Considerations

• Time to treatment is crucial - clinical response to benzodiazepines diminishes with prolonged status epilepticus 5
• Endotracheal intubation may be required in approximately 16-26% of patients with status epilepticus 1
• The patient's home antiseizure medication does not affect the probability of stopping status epilepticus when used as a second-line agent 1
• Avoid concomitant use of CNS depressants when possible to minimize respiratory depression 2

Pitfalls to Avoid

• Delaying treatment - each minute of ongoing seizure activity increases the risk of neurological damage 6
• Underdosing benzodiazepines due to fear of respiratory depression 5
• Failing to recognize and treat nonconvulsive status epilepticus in patients with persistent altered mental status 1
• Not addressing underlying causes of seizures while treating the seizure itself 1
• Overlooking the need for maintenance antiepileptic therapy in patients susceptible to further seizure episodes 2