What is the recommended treatment for acute convulsions?

Treatment of Acute Convulsions

For acute convulsions, administer a benzodiazepine immediately, with IV lorazepam or diazepam preferred when IV access is available, or rectal diazepam when IV access is unavailable. 1

Initial Management

• Establish airway, breathing, and circulation while providing high-flow oxygen and appropriate airway management 2
• Place patient in recovery position to prevent aspiration 2
• Check blood glucose immediately to rule out hypoglycemia as a cause of seizures 2
• Establish vascular access (IV or intraosseous) for medication administration 2

First-Line Treatment

When IV Access is NOT Available:

• Administer rectal diazepam (intramuscular diazepam is not recommended due to erratic absorption) 1
• Intramuscular phenobarbital may be considered when rectal diazepam is not possible due to medical or social reasons 1
• Alternative routes include buccal or intranasal midazolam, which have shown similar efficacy to IV administration 3

When IV Access IS Available:

• Administer IV benzodiazepine (lorazepam or diazepam) - lorazepam is preferred over diazepam when available 1
• Lorazepam dose: 4 mg given slowly (2 mg/min) for adults; may repeat once after 10-15 minutes if seizures continue 4
• Lorazepam has a longer duration of action (up to 72 hours) compared to diazepam (<2 hours) 5

Second-Line Treatment (for Persistent Seizures)

• For sustained control or if seizures continue after benzodiazepines, administer one of the following second-line agents 1:

  • Fosphenytoin: 18-20 mg/kg IV over 20 minutes 1
  • Valproate: 20-30 mg/kg IV at rate of 40 mg/min 1
  • Levetiracetam: 30-50 mg/kg IV at 100 mg/min 1, 2

• All three agents (fosphenytoin, valproate, and levetiracetam) have similar efficacy (45-47% seizure cessation at 60 minutes) 1, 2

Considerations for Second-Line Agent Selection

• Valproate may be preferred for patients with cardiac issues due to lower risk of hypotension (1.6%) compared to fosphenytoin (3.2%) 1, 2
• Valproate has been shown to be as effective as phenytoin with potentially fewer adverse effects 1
• Levetiracetam has fewer drug interactions and contraindications, making it suitable for many patients 1, 6

Management of Refractory Status Epilepticus

• For seizures continuing despite first and second-line treatments, consider 1:
  • Phenobarbital IV (10-20 mg/kg; may repeat 5-10 mg/kg at 10 min) 1
  • Propofol (2 mg/kg bolus, followed by 5 mg/kg/hr infusion) 1
  • Consider endotracheal intubation for respiratory support in refractory cases 2

Important Caveats and Pitfalls

• Respiratory depression is the most common serious adverse effect of benzodiazepines - equipment to maintain patent airway should be immediately available 4, 3
• Do not physically restrain the patient during a convulsion 2
• Do not place anything in the patient's mouth during a convulsion 2
• Delayed treatment of status epilepticus increases mortality - treat promptly 2
• Non-convulsive status epilepticus may occur after apparent seizure control - consider EEG monitoring in patients with persistent altered mental status 7
• Simultaneously search for and treat underlying causes (infection, metabolic abnormalities, trauma, stroke, toxins) 1, 6

Long-Term Management Considerations

• Antiepileptic drugs should not be routinely prescribed after a first unprovoked seizure 1
• Consider discontinuation of antiepileptic treatment after 2 seizure-free years 1
• For long-term management, monotherapy with standard antiepileptic drugs (carbamazepine, phenobarbital, phenytoin, valproic acid) is preferred 1, 8