What is the initial treatment for patients experiencing seizures?

Initial Treatment for Seizures

The initial treatment for patients experiencing seizures should be intravenous benzodiazepines as the first-line therapy, followed by a second-line agent such as fosphenytoin, levetiracetam, or valproate if seizures persist. 1

Initial Assessment and Stabilization

• Rapid initial evaluation of airway, breathing, and circulation should be performed for all patients with suspected acute seizures 2
• Assess neurological status using a standardized stroke scale such as the National Institutes of Health Stroke Scale (NIHSS) to determine focal deficits and seizure severity 2
• Monitor vital signs including heart rate, rhythm, blood pressure, temperature, oxygen saturation, and hydration status 2
• Obtain acute blood work including electrolytes, random glucose, complete blood count, coagulation status (INR, aPTT), and creatinine 2

First-Line Treatment

• Administer intravenous benzodiazepines as the first-line treatment for active seizures 1
• For self-limiting seizures that have stopped by the time of medical evaluation, immediate anticonvulsant therapy may not be necessary 2
• New-onset seizures occurring within 24 hours of stroke onset should be treated with appropriate short-acting medications (e.g., lorazepam IV) if they are not self-limiting 2

Second-Line Treatment Options

If seizures persist despite benzodiazepine administration, proceed with one of these second-line agents:

1. Valproate:

   • Dosage: 20-30 mg/kg IV at a maximum rate of 10 mg/kg/min 1
   • Advantages: Rapid administration, minimal cardiorespiratory side effects 1
   • Disadvantages: Contraindicated in liver disease, risk of thrombocytopenia 1
   • Efficacy: 46% seizure cessation rate at 60 minutes 1

2. Levetiracetam:

   • Dosage: 30-50 mg/kg IV at 100 mg/min 1
   • Advantages: Favorable side effect profile, fewer drug interactions 1
   • Disadvantages: Potential to cause nausea and rash 1
   • Efficacy: 47% seizure cessation rate at 60 minutes 1

3. Fosphenytoin:

   • Dosage: 18-20 PE/kg IV at a maximum rate of 150 PE/min 1
   • Advantages: Can be administered IM if needed 1
   • Disadvantages: Risk of hypotension (3.2%) and cardiac dysrhythmias 1
   • Efficacy: 45% seizure cessation rate at 60 minutes 1

Simultaneous Management of Underlying Causes

While administering antiseizure medications, simultaneously investigate and treat potential causes:

• Check blood glucose and treat hypoglycemia 1
• Evaluate for hyponatremia and other electrolyte abnormalities 1
• Assess for hypoxia and ensure adequate oxygenation 1
• Consider toxicology screen for drug toxicity 1
• Evaluate for CNS infection or systemic infection 1
• Consider neuroimaging if there's concern for stroke, hemorrhage, or mass lesion 1

Special Considerations

Seizures Associated with Stroke

• Single, self-limiting seizures occurring at the onset or within 24 hours after ischemic stroke should not be treated with long-term anticonvulsant medications 2
• Prophylactic use of anticonvulsant medications in patients with ischemic stroke is not recommended and may have negative effects on neurological recovery 2
• Monitor patients with immediate post-stroke seizures for recurrent seizure activity during routine monitoring of vital signs and neurological status 2

Seizures Associated with Brain Tumors

• For patients with brain metastases presenting with seizures, anticonvulsant medication should be administered 2
• The American Academy of Neurology recommends that anticonvulsants be administered only to patients at risk for seizure, and use should be minimized to single therapy at the lowest effective dose 2

Long-Term Management Considerations

• For patients with epilepsy, antiepileptic drugs (AEDs) are the standard treatment 3
• Selection of the appropriate AED depends on type of seizure and epilepsy present, along with individual drug characteristics including pharmacokinetics, side effects, dosing interval, and cost 3
• Generalized seizures preferentially respond to valproate, lamotrigine, and topiramate 3

Common Pitfalls to Avoid

• Not recognizing non-convulsive status epilepticus, which may require EEG monitoring 1
• Overlooking the underlying cause of the seizure and failing to address it 1
• Administering prophylactic anticonvulsants to patients without a history of seizures 2
• Using phenytoin for seizures secondary to alcohol withdrawal, theophylline, or isoniazid toxicity, where it may be ineffective 4

Follow-up Recommendations

• For patients with few seizures prior to antiparasitic therapy, resolution of cystic lesions on imaging, and no seizures for 24 consecutive months, consider tapering off and stopping antiepileptic drugs 2
• In patients with single enhancing lesions who have been seizure-free for 6 months, consider tapering off and stopping antiepileptic drugs after resolution of the lesion if there are no risk factors for recurrent seizures 2