What is the immediate treatment for a patient experiencing active convulsions?

Immediate Treatment for Active Convulsions

The immediate treatment for a patient experiencing active convulsions is intravenous benzodiazepines, with lorazepam 0.1 mg/kg IV (maximum 4 mg) administered slowly at 2 mg/min being the preferred first-line agent. 1, 2

First-Line Treatment: Benzodiazepines

• Intravenous lorazepam (0.1 mg/kg, maximum 4 mg) is the preferred first-line agent due to its longer duration of action compared to other benzodiazepines 3
• If IV access is not immediately available, alternative routes include:
  • Intramuscular midazolam (which shows similar efficacy to IV diazepam) 4
  • Buccal midazolam 4
  • Rectal diazepam (0.2-0.5 mg/kg) if other routes are not accessible 5, 4
• For IV diazepam, the recommended dose is 5-10 mg administered slowly (no faster than 5 mg/minute) 5
• Respiratory support equipment should be immediately available when administering benzodiazepines due to risk of respiratory depression 5, 2

Second-Line Treatment (If Seizures Continue After 5-10 Minutes)

• If convulsions persist for more than 10 minutes after benzodiazepine administration, administer an additional antiepileptic medication (Level A recommendation) 6
• Recommended second-line agents include:
  • Intravenous valproate (30 mg/kg IV at 6 mg/kg/min) - shown to be effective in 88% of cases with fewer adverse effects like hypotension compared to phenytoin 6, 1
  • Intravenous phenytoin or fosphenytoin (20 mg/kg at maximum rate of 50 mg/min) 6, 7
  • Intravenous levetiracetam (30 mg/kg) - particularly useful in patients with liver disease or drug interactions 1, 6

Treatment Algorithm for Active Convulsions

1. Immediate stabilization (0-5 minutes):

   • Ensure airway, breathing, and circulation 1
   • Position patient on side to prevent aspiration 1
   • Administer oxygen if available 6

2. First-line treatment (0-5 minutes):

   • Administer IV lorazepam 0.1 mg/kg (max 4 mg) at 2 mg/min 2, 3
   • If IV access is unavailable, use alternative routes (IM, buccal, or rectal) 4

3. Second-line treatment (if seizures persist after 5-10 minutes):

   • Administer IV valproate (30 mg/kg) or IV levetiracetam (30 mg/kg) or IV phenytoin/fosphenytoin (20 mg/kg) 6, 1
   • Choice between these agents depends on patient comorbidities and potential drug interactions 1

4. Refractory status treatment (if seizures persist after second-line therapy):

   • Consider IV propofol, barbiturates, or high-dose benzodiazepine infusion 6, 8
   • Intubation and ventilatory support may be necessary at this stage 8

Simultaneous Evaluation for Underlying Causes

• While treating the seizure, search for and address treatable causes including 6:
  • Hypoglycemia (check blood glucose immediately) 6
  • Electrolyte abnormalities (particularly hyponatremia) 6
  • Hypoxia 6
  • Drug toxicity or withdrawal 6
  • Systemic or CNS infection 6
  • Stroke or intracranial hemorrhage 6

Important Considerations and Pitfalls

• Respiratory depression is the most common serious adverse effect of benzodiazepines, occurring in up to 18% of cases - always have ventilatory support available 4
• Lorazepam is associated with lower rates of respiratory depression compared to diazepam (RR 0.72,95% CI 0.55 to 0.93) 4
• IV phenytoin can cause cardiac arrhythmias, hypotension, and tissue injury at injection sites - administer slowly and monitor cardiac status 9
• Valproate has been shown to have fewer adverse effects than phenytoin, particularly regarding hypotension (0% vs 12%) 6
• Delays in treatment increase the risk of neurological damage - treatment should be initiated promptly for any convulsion lasting ≥5 minutes 7, 8