How to manage and control seizures?

Emergency Seizure Management: Breaking Seizures Effectively

Benzodiazepines are the first-line treatment for actively seizing patients, followed by fosphenytoin, levetiracetam, or valproate as equally effective second-line agents if seizures continue. 1

Initial Management of Active Seizures

• Ensure airway patency, monitor vital signs, and have artificial ventilation equipment available during seizure management 1
• Administer benzodiazepines as first-line treatment (Level A recommendation) to rapidly terminate seizure activity and prevent progression to status epilepticus 1
• For patients who continue to seize after receiving benzodiazepines, administer one of the following second-line agents (Level C recommendation): high-dose phenytoin/fosphenytoin, phenobarbital, valproic acid, midazolam infusion, pentobarbital infusion, or propofol infusion 2

Second-Line Treatment Options

• Phenytoin/Fosphenytoin: Administer 20 mg/kg IV at maximum rate of 50 mg/min; requires ECG and blood pressure monitoring due to cardiovascular risks 3
• Valproic acid: Administer 20-30 mg/kg IV over 5-20 minutes; shows 88% efficacy with minimal risk of hypotension (0% vs 12% with phenytoin) 3
• Levetiracetam: Administer 30 mg/kg IV over 5 minutes; reported success rates of 68-73% 3
• Phenobarbital: Administer 20 mg/kg IV over 10 minutes; reported success rate of 58.2% as an initial agent 3

Management of Refractory Status Epilepticus

• For seizures continuing despite optimal dosing of first and second-line agents, consider one of the following options:
  • Midazolam: IV loading dose of 0.15-0.20 mg/kg, followed by continuous infusion of 1 mg/kg per minute 3
  • Propofol: 2 mg/kg bolus, followed by 3-7 mg/kg/hour infusion (requires respiratory support) 3
  • Pentobarbital: Bolus of 13 mg/kg and infusion of 2-3 mg/kg per hour (higher success rate than propofol but causes more hypotension) 3

Medication Efficacy Comparisons

• All three common second-line agents (fosphenytoin, levetiracetam, valproate) have similar efficacy, with cessation of status epilepticus in approximately 45-47% of patients 1
• Pentobarbital has a treatment success rate of 92% compared to 80% for midazolam and 73% for propofol in refractory status epilepticus, but is associated with higher rates of hypotension requiring pressors (77% vs 42% and 30%, respectively) 2
• Valproate appears to cause less hypotension than phenytoin while maintaining similar efficacy 3

Addressing Underlying Causes

• Simultaneously search for and treat underlying causes of seizures, including hypoglycemia, hyponatremia, hypoxia, drug toxicity, CNS infection, ischemic stroke, intracerebral hemorrhage, and withdrawal syndromes 3
• Acute symptomatic seizures require treatment of the underlying cause rather than long-term antiseizure medication 4

Special Considerations

• Consider non-convulsive status epilepticus in any patient with altered mental status after a motor seizure; EEG is the definitive test 2
• Status epilepticus is operationally defined as seizure activity lasting 5 minutes or more for treatment purposes (traditional definition was 20+ minutes) 3
• Levetiracetam is currently the most commonly prescribed antiseizure medication in nursing homes, followed by lamotrigine, valproic acid, and phenytoin 5

Common Pitfalls to Avoid

• Inadequate benzodiazepine dosing before moving to second-line agents; ensure optimal dosing of first-line therapy 1
• Failure to identify and treat underlying causes of seizures 1
• Insufficient monitoring after apparent seizure cessation; patients require continued observation for recurrence 1
• Phenytoin is ineffective for seizures secondary to alcohol withdrawal, theophylline toxicity, or isoniazid toxicity 4

By following this evidence-based approach to seizure management, healthcare providers can effectively break seizures while minimizing complications and improving patient outcomes.