From the Research
The NSW Clinical Practice Guidelines (CPG) for seizure management prioritize a stepwise approach to treating seizures, with first-line treatment being midazolam, administered at 5mg IV/IO for adults or 0.15mg/kg IV/IO for children (maximum 5mg), which can be repeated once after 5 minutes if seizures continue, as supported by recent studies 1.
Seizure Management Approach
The approach to seizure management involves a stepwise treatment plan, with the primary goal of terminating seizure activity quickly to prevent neuronal damage from prolonged seizures. This is crucial, as continuous seizure activity increases the risk of status epilepticus, which carries significant morbidity and mortality.
First-Line Treatment
The first-line treatment for ongoing seizures is midazolam, which works by enhancing GABA inhibitory effects in the brain. The recommended dose is 5mg IV/IO for adults or 0.15mg/kg IV/IO for children (maximum 5mg), which can be repeated once after 5 minutes if seizures continue. If IV/IO access is unavailable, midazolam can be given intramuscularly at 10mg for adults or 0.15mg/kg for children.
Second-Line Treatment
For prolonged seizures not responding to midazolam, levetiracetam is recommended at 30mg/kg IV/IO (maximum 3000mg) administered over 15 minutes. Levetiracetam helps stabilize neuronal membranes through SV2A protein modulation, as studied in 2.
Airway Management and Additional Interventions
Airway management is crucial during seizures, with positioning in the recovery position, supplemental oxygen if SpO2 is below 94%, and suction as needed. Blood glucose should be checked promptly, with dextrose 10% (25g) IV/IO administered if hypoglycemia is detected.
Antiepileptic Drug Efficacy
Recent studies, such as 1, have compared the efficacy of antiepileptic drugs for patients with generalized epileptic seizures. The results suggest that lamotrigine, levetiracetam, and topiramate are as effective as valproate for treating generalized tonic-clonic, tonic, and clonic seizures. Meanwhile, valproate and ethosuximide are the best options for the treatment of absence seizures, promoting better control of seizures.
Key Considerations
When selecting an antiepileptic drug, it is essential to consider comorbid conditions, including depression, migraine, chronic pain, obesity, and nephrolithiasis, or patient characteristics, especially for women of childbearing potential and older adults, as discussed in 3.