What is the initial treatment for a patient presenting to the Emergency Department (ED) with convulsions?

Emergency Department Treatment Protocol for Convulsions

Administer intravenous lorazepam 4 mg (0.1 mg/kg) at 2 mg/min immediately as first-line treatment for any patient with active seizure activity lasting >5 minutes. 1, 2, 3

First-Line Treatment: Benzodiazepines

• Lorazepam 4 mg IV push over 2 minutes is the preferred benzodiazepine, demonstrating 65% efficacy in terminating overt generalized convulsive status epilepticus and superior performance compared to phenytoin (44% efficacy) in the landmark Veterans Affairs cooperative trial. 1, 4

• If seizures cease after the initial 4 mg dose, no additional lorazepam is required. 3

• If seizures continue or recur after 10-15 minutes of observation, administer a second 4 mg IV dose of lorazepam slowly. 3

• Intramuscular midazolam is a non-inferior alternative to IV lorazepam when IV access is delayed or unavailable. 5, 6

• Critical pitfall: Underdosing lorazepam (using <4 mg in adults >40 kg) significantly increases progression to refractory status epilepticus (87% vs 62%, p=0.03), so always use the full 4 mg dose. 7

Concurrent Immediate Actions

• Establish IV access, monitor vital signs continuously, ensure airway patency, and have ventilatory support equipment immediately available at bedside. 3, 8

• Check fingerstick glucose, basic metabolic panel, and toxicology screen while administering benzodiazepines to identify treatable causes (hypoglycemia, hyponatremia, drug toxicity). 2

• Airway management warning: Respiratory depression is the most important risk with lorazepam; be prepared for immediate intubation, particularly in patients receiving multiple doses or those over age 50. 3

Second-Line Treatment (If Seizures Persist After Benzodiazepines)

Administer valproate 30 mg/kg IV (infused at 6 mg/kg/hour) as the preferred second-line agent immediately if seizures continue despite adequate benzodiazepine dosing. 1, 2

Valproate (Preferred Second-Line)

• Dose: 30 mg/kg IV at 6 mg/kg/hour infusion rate, followed by maintenance infusion of 1-2 mg/kg/hour 1, 2
• Achieves seizure cessation in 88% of patients within 20 minutes in refractory status epilepticus 1, 2
• Superior safety profile with 0% incidence of hypotension compared to phenytoin's 12% rate 1, 9
• Contraindication: Avoid in women of childbearing potential (teratogenic risk) and young children (hepatotoxicity risk) 2

Levetiracetam (Alternative Second-Line)

• Dose: 30 mg/kg IV at 5 mg/kg/minute (or up to 50 mg/kg at 100 mg/min) 1, 9
• Demonstrates 73% efficacy in refractory status epilepticus, comparable to valproate (68%) 1
• Lowest rate of life-threatening hypotension (0.7%) among second-line agents 9
• Minimal adverse effects (occasional nausea, transient transaminitis) 1

Fosphenytoin/Phenytoin (Traditional Second-Line)

• Dose: 20 mg/kg IV (phenytoin equivalents) at maximum rate of 50 mg/minute 1, 9
• Efficacy of 84% in refractory seizures but inferior to lorazepam monotherapy (44% when used alone) 1
• Significant risk: 12% incidence of hypotension; use with extreme caution in hemodynamically unstable patients 1, 2
• Higher risk of cardiac dysrhythmias and soft tissue injury with extravasation 9

Evidence comparison: While all three second-line agents show similar efficacy (45-47% in established status epilepticus per recent trials), valproate's superior safety profile and 88% efficacy in earlier studies makes it the preferred choice unless contraindicated. 1, 5

Third-Line Treatment (Refractory Status Epilepticus)

If seizures persist despite benzodiazepines plus second-line agent, initiate propofol 2 mg/kg IV bolus followed by 5 mg/kg/hour infusion after securing the airway with endotracheal intubation. 1, 2

Propofol (Preferred Third-Line)

• Dose: 2 mg/kg bolus, then 5 mg/kg/hour continuous infusion 1, 2
• Requires fewer mechanical ventilation days (4 days) compared to pentobarbital (14 days) 1
• Lower incidence of hypotension requiring pressors (42%) versus barbiturates (77%) 1

Barbiturates (Alternative Third-Line)

• Phenobarbital or pentobarbital may be used but have fallen out of favor due to significant adverse effects including prolonged sedation and higher rates of hypotension 1, 2

Critical Monitoring and Pitfalls

• Delayed second-line treatment increases morbidity and mortality; do not wait beyond 10-15 minutes after adequate benzodiazepine dosing to initiate second-line agents. 2

• Consider continuous EEG monitoring in patients with altered mental status disproportionate to clinical presentation, as transition to non-convulsive status epilepticus is common. 2

• Sedation warning: Lorazepam's prolonged duration of action may add to post-ictal impairment; monitor for excessive sedation, especially after multiple doses. 3

• Patients should not operate machinery or drive for 24-48 hours after receiving lorazepam, or until drowsiness completely resolves. 3

• Overall, 25% of patients in established status epilepticus require intubation for respiratory compromise, independent of medication choice. 5