What is the step-by-step management of a 45-year-old patient having a seizure, including medications and doses?

Management of Active Seizures in a 45-Year-Old Adult

For a 45-year-old patient actively having seizures, immediate administration of intravenous benzodiazepines is the first-line treatment, followed by second-line antiepileptic drugs if seizures persist. 1

Step 1: Initial Assessment and Stabilization (0-5 minutes)

• Ensure patient safety by positioning them on their side to prevent aspiration 2
• Establish and maintain airway, breathing, and circulation 2
• Administer supplemental oxygen if needed 2
• Obtain IV access immediately 2
• Monitor vital signs including oxygen saturation 2

Step 2: First-Line Treatment (5-10 minutes)

• Administer IV lorazepam 0.1 mg/kg (typically 4-8 mg) over 2 minutes 1, 3
• If IV access is not immediately available, consider:
  • IM midazolam 0.2 mg/kg (maximum 10 mg per dose) 1, 4
  • Rectal diazepam 0.5 mg/kg up to 20 mg 1

Lorazepam is preferred over diazepam due to its longer duration of action and lower risk of seizure recurrence (RR 0.64,95% CI 0.45 to 0.90) 3

Step 3: Second-Line Treatment (if seizures continue after 10-20 minutes)

• Administer one of the following IV medications:
  • Fosphenytoin 20 mg PE/kg at 150 mg PE/min (preferred over phenytoin due to fewer adverse effects) 5, 2
  • Valproate sodium 30 mg/kg over 10 minutes (not exceeding 20 mg/min) 1, 6
  • Levetiracetam 30 mg/kg IV over 15 minutes 1

Valproate has shown similar efficacy to phenytoin (88% seizure control in both groups) with fewer cardiovascular side effects 1

Step 4: Third-Line Treatment (if seizures continue after 30-40 minutes)

• Consider one of the following options for refractory status epilepticus:
  • IV midazolam loading dose 0.15-0.2 mg/kg, followed by continuous infusion starting at 1 mg/kg/min, increasing by 1 mg/kg/min every 15 minutes (maximum 5 mg/kg/min) until seizures stop 1
  • IV propofol 2 mg/kg loading dose, followed by continuous infusion 1
  • IV phenobarbital 20 mg/kg at 50-75 mg/min 1

Concurrent Management

• Obtain blood samples for:
  • Complete blood count, electrolytes, glucose, calcium, magnesium 7
  • Anticonvulsant levels (if patient is on chronic therapy) 8
  • Toxicology screen if indicated 7
• Treat any identified precipitating factors:
  • Administer 50 ml of 50% dextrose IV if hypoglycemic 1
  • Correct electrolyte abnormalities (especially sodium, calcium, magnesium) 7
  • Administer thiamine 100 mg IV if alcohol withdrawal is suspected 7

Monitoring and Follow-up

• Continuous cardiac monitoring and pulse oximetry throughout treatment 1
• Be prepared to provide respiratory support, as benzodiazepines may cause respiratory depression 1
• Monitor for hypotension, especially with rapid infusion of antiepileptic drugs 6
• Consider EEG monitoring if seizures persist despite treatment 1

Common Pitfalls and Caveats

• Do not delay treatment while waiting for laboratory results in an actively seizing patient 1
• Avoid intramuscular phenytoin due to erratic absorption and local tissue injury 5
• Be aware that rapid infusion of valproate may cause hypotension 6
• Benzodiazepines may cause respiratory depression, especially when combined with other sedative agents 1
• If using propofol, monitor for propofol infusion syndrome (metabolic acidosis, rhabdomyolysis, cardiac dysfunction) 1
• For patients with refractory status epilepticus not responding to the above measures, consider transfer to ICU for general anesthesia 1