What are the steps in managing seizures?

Management of Seizures: Stepwise Approach

Initial Stabilization and Assessment

Immediately establish airway, breathing, and circulation while providing high-flow oxygen and appropriate airway management for seizing patients. 1, 2

• Check blood glucose immediately to rule out hypoglycemia as the cause of seizures 1, 2
• Position the patient on their side in recovery position to prevent aspiration 3
• Establish intravenous or intraosseous access for medication administration 3
• Do not restrain the patient or place anything in their mouth during active seizure 3

First-Line Treatment: Benzodiazepines

Administer intravenous benzodiazepines as first-line treatment for active seizures, with lorazepam preferred over diazepam. [1,2, @37@]

• If IV access is unavailable, administer rectal diazepam or consider intramuscular phenobarbital 3
• Status epilepticus is defined as seizure lasting longer than 5 minutes or multiple seizures without return to neurologic baseline 4
• The landmark Treiman trial demonstrated lorazepam achieved 65% seizure cessation compared to 44% for phenytoin alone [@37@]

Second-Line Treatment: After Benzodiazepine Failure

If seizures persist 5-30 minutes after adequate benzodiazepine dosing, immediately administer one of three equally effective second-line agents: fosphenytoin, levetiracetam, or valproate (Level A recommendation). 4, 1, 2

The ESETT Trial Evidence (Class I, 2019)

The highest quality evidence shows no significant difference in efficacy between the three second-line agents, with seizure cessation at 60 minutes of:

• Levetiracetam: 47% (95% CrI 39-55) 4
• Fosphenytoin: 45% (95% CrI 36-54) 4
• Valproate: 46% (95% CrI 38-55) 4

Specific Dosing and Selection Criteria

Fosphenytoin: 18-20 PE/kg IV at maximum rate of 150 PE/min 1, 3

• Advantages: Can be given IM if needed 1
• Avoid in patients with cardiac disease due to 3.2% risk of life-threatening hypotension and cardiac dysrhythmias 4, 1, 2
• Causes hypotension in 12% of patients [@39@]

Levetiracetam: 30-60 mg/kg IV (typically 1,000-3,000 mg in adults) at 100 mg/min 1, 3

• Preferred for patients with cardiac disease due to lowest hypotension risk (0.7%) 4, 1, 2
• Favorable side effect profile with fewer drug interactions 1
• Disadvantages: May cause nausea and rash 1

Valproate: 20-40 mg/kg IV (typically 30 mg/kg) at maximum rate of 10 mg/kg/min 1, 3

• Advantages: Rapid administration with minimal cardiorespiratory effects (1.6% hypotension risk) 4, 1, 2
• Absolutely contraindicated in liver disease 1
• Risk of thrombocytopenia 1
• Avoid in women of childbearing age due to teratogenicity 5

Intubation Considerations

Approximately 16-26% of patients with status epilepticus require endotracheal intubation, with rates varying by agent: levetiracetam 20%, fosphenytoin 26.4%, valproate 16.8% 4, 2

Third-Line Treatment: Refractory Status Epilepticus

For seizures continuing after benzodiazepines and second-line agents, administer phenobarbital IV or consider continuous infusions of propofol, pentobarbital, or midazolam. 2

• Pentobarbital infusion has 92% efficacy but 77% require vasopressors for hypotension 2
• Consider intubation with rapid sequence induction for refractory status epilepticus 3

Simultaneous Evaluation for Underlying Causes

While administering antiseizure medications, immediately search for and treat reversible causes:

• Hypoglycemia (treat if present) 1, 2
• Hyponatremia 1, 2
• Hypoxia (ensure adequate oxygenation) 1, 2
• Ischemic stroke or intracerebral hemorrhage 2
• CNS or systemic infection 1
• Drug toxicity (obtain toxicology screen) 1
• Withdrawal syndromes 2
• Mass lesion (consider neuroimaging if concern exists) 1

Critical Pitfalls to Avoid

Do not miss nonconvulsive status epilepticus in patients with persistent altered consciousness after apparent seizure cessation. 1, 2

• EEG monitoring should be considered for patients with persistent altered mental status 2
• Clinical criteria alone cannot distinguish postictal state from ongoing nonconvulsive seizures 4

Do not delay second-line treatment—increased time to treatment increases mortality. 3

The patient's home antiseizure medication does not affect the probability of stopping status epilepticus when used as second-line agent, so do not avoid using their home medication 2