What is the approach to a patient with a seizure?

Approach to a Patient with Seizure

The management of a patient with seizure requires immediate stabilization, identification of underlying causes, and appropriate treatment based on seizure type and duration, with benzodiazepines as first-line therapy for ongoing seizures and consideration of second-line agents for status epilepticus. 1

Initial Management and Stabilization

• Ensure patent airway, adequate breathing, and circulation (ABC) before any medication administration 2
• Position the patient on their side to prevent aspiration if unconscious 3
• Do not place objects in the patient's mouth during a seizure 3
• Loosen tight clothing around the neck 3
• Time the seizure duration - status epilepticus is defined as seizure lasting >5 minutes or multiple seizures without return to baseline 1
• Maintain NPO status until swallowing ability is assessed to prevent aspiration 4
• Establish intravenous access for medication administration if seizures are ongoing 2

Immediate Pharmacological Management

• For ongoing seizures or status epilepticus, administer benzodiazepines as first-line therapy 5, 2
• Lorazepam 4 mg IV slowly (2 mg/min) is recommended for adults with status epilepticus 2
• If seizures continue after 10-15 minutes, an additional 4 mg IV dose may be administered 2
• For second-line treatment in persistent status epilepticus, administer one of the following (Level B recommendation) 5:
  • Phenytoin 18-20 mg/kg IV at 50 mg/min 5
  • Fosphenytoin 18-20 mg/kg PE IV at 150 mg/min 5
  • Valproate 30 mg/kg IV at 6 mg/kg/hour 5
• For refractory status epilepticus, consider levetiracetam, propofol, or barbiturates (Level C recommendation) 5

Diagnostic Evaluation

• Obtain fingerstick glucose immediately to identify and treat hypoglycemia 2, 6
• Laboratory tests based on clinical presentation 1:
  • Basic metabolic panel to assess for electrolyte abnormalities, particularly sodium and glucose 1
  • Consider calcium, magnesium levels in patients with risk factors 1
  • Pregnancy test for women of childbearing age 1
• Consider neuroimaging (CT or MRI) for patients with 1:
  • First unprovoked seizure
  • Focal neurological deficits
  • Persistent altered mental status
  • Trauma
  • Fever or signs of infection
• Consider electroencephalography (EEG) for patients with 1:
  • Unexplained altered mental status
  • Suspected non-convulsive status epilepticus
  • Fluctuating level of consciousness

Management Based on Seizure Type

First Unprovoked Seizure

• Emergency physicians need not initiate antiepileptic medication in the ED for patients with a first unprovoked seizure without evidence of brain disease or injury (Level C recommendation) 1
• May initiate antiepileptic medication for patients with first unprovoked seizure with remote history of brain disease or injury (Level C recommendation) 1

Provoked Seizure

• Identify and treat the underlying cause (hypoglycemia, hyponatremia, drug toxicity, alcohol withdrawal) 1, 6
• Emergency physicians need not initiate antiepileptic medication in the ED for patients with provoked seizures (Level C recommendation) 1

Status Epilepticus

• Status epilepticus requires immediate treatment following the protocol outlined above 1, 5
• Ventilatory support must be readily available 2
• Monitor vital signs continuously 2
• Consider consultation with a neurologist if patient fails to respond to initial treatment 2

Seizures in Intracerebral Hemorrhage

• Administer antiseizure drugs to patients with ICH, impaired consciousness, and confirmed electrographic seizures (Class 1, Level C-LD) 1
• Consider continuous EEG monitoring (≥24 hours) for patients with ICH and unexplained abnormal or fluctuating mental status (Class 2a, Level C-LD) 1
• Prophylactic antiseizure medication is not beneficial in patients with ICH without evidence of seizures (Class 3: No Benefit, Level B-NR) 1

Post-Seizure Management

• Maintain NPO status until swallowing assessment confirms safe oral intake 4
• Continue monitoring for changes in swallowing ability as clinical status can change in the first hours following seizures 4
• Consider alternative routes for medication administration while patient is NPO 4
• Observe for early seizure recurrence, which commonly occurs within 6 hours (mean time to recurrence: 121 minutes) 4

Disposition

• Patients with first-time seizure generally require admission for observation and further evaluation 7
• Patients with known epilepsy who have had a single typical seizure and have returned to baseline may not require transport to the hospital 8
• Patients with status epilepticus, abnormal neurological examination, or underlying medical conditions require admission 7

Common Pitfalls to Avoid

• Failing to recognize status epilepticus and delaying appropriate treatment 1
• Allowing oral intake too early before proper swallowing assessment 4
• Not identifying and treating underlying causes of provoked seizures 6
• Inadequate airway management during seizure episodes 2
• Inappropriate use of phenytoin in alcohol withdrawal seizures 6