What is the initial management and treatment for a patient presenting with a seizure?

Initial Management and Treatment of Seizure Presentation

Immediately stabilize the airway, breathing, and circulation while simultaneously administering benzodiazepines if the seizure is ongoing or has lasted more than 5 minutes, then rapidly identify and correct reversible causes such as hypoglycemia, hyponatremia, or hypoxia. 1, 2

Immediate Stabilization (First 0-5 Minutes)

Airway and Vital Functions

• Ensure patent airway and have equipment for airway management immediately available before administering any medications 3
• Administer supplemental oxygen and monitor oxygen saturation 1
• Establish intravenous access and check fingerstick glucose immediately 1, 4
• Monitor vital signs continuously, including cardiac rhythm 1

First-Line Seizure Termination

• Administer benzodiazepines immediately for any seizure lasting >5 minutes or for status epilepticus 2, 5
• Lorazepam 4 mg IV at 2 mg/min is the preferred benzodiazepine due to longer duration of action 2, 3
• If seizures continue after 10-15 minutes, repeat lorazepam 4 mg IV slowly 3
• Alternative: diazepam 10 mg IV if lorazepam unavailable 1

Identify and Correct Underlying Causes (Concurrent with Seizure Management)

Critical Reversible Causes to Address Immediately

• Check and correct hypoglycemia (administer dextrose if glucose <60 mg/dL) 1, 4
• Assess for hyponatremia, hypoxia, and other electrolyte abnormalities 1, 4
• Consider drug toxicity (theophylline, isoniazid, cocaine) or alcohol withdrawal 4
• Evaluate for CNS infection, intracranial hemorrhage, or stroke 1, 5

Key History Elements to Obtain

• Known epilepsy diagnosis and current antiepileptic drug (AED) regimen with compliance history 1, 6
• Recent medication changes, particularly AED dose reductions or discontinuation 6
• Detailed seizure description: duration, focal vs. generalized features, post-ictal state 1, 7
• Recent head trauma, fever, or systemic illness 1, 4
• Substance use including alcohol and illicit drugs 4

Second-Line Treatment for Refractory Seizures (After Benzodiazepines)

If seizures persist after adequate benzodiazepine administration, immediately administer a second-line antiepileptic agent—valproate is preferred for its superior efficacy and safety profile. 1, 2

Medication Options (Choose One)

• Valproate 30 mg/kg IV at 6 mg/kg/hour (preferred: 88% efficacy, no hypotension risk) 1, 2
• Levetiracetam 30 mg/kg IV at 5 mg/kg/min (73% efficacy, excellent tolerability) 1, 2
• Fosphenytoin 20 mg PE/kg IV at 150 mg/min (84% efficacy but 12% hypotension risk) 1, 2
• Phenytoin 18-20 mg/kg IV at 50 mg/min (avoid if hemodynamically unstable) 1

Critical Pitfall to Avoid

• Do not delay second-line treatment—administer immediately if seizures persist after benzodiazepines 2
• Avoid valproate in women of childbearing potential due to teratogenic risk 2
• Avoid phenytoin in hypotensive patients (use valproate or levetiracetam instead) 1, 2

Management After Seizure Cessation

For Patients Who Return to Baseline

• Prophylactic anticonvulsants are NOT recommended for patients with no seizure history 1
• For known epilepsy patients with single typical seizure who return to baseline, hospital admission may not be required 1, 7
• Check AED levels if patient on chronic therapy and adjust dosing as needed 1, 6

Neuroimaging Indications

• Obtain emergent head CT for new-onset seizure with any of the following: 1
  • Persistent altered mental status beyond expected post-ictal period
  • Focal neurologic deficits on examination
  • Head trauma or anticoagulation use
  • Age >40 years with first seizure
  • Known malignancy (15-20% of brain metastases present with seizures) 1

Admission Criteria

• Seizure lasting >5 minutes requiring benzodiazepines 1, 2
• Status epilepticus or refractory seizures 1, 5
• New-onset seizure with identified structural lesion or acute metabolic cause 1, 4
• Persistent altered mental status (consider non-convulsive status epilepticus) 5
• Inability to identify and correct underlying cause 4

Third-Line Treatment for Continued Refractory Status

If seizures persist despite benzodiazepines and second-line agents, escalate to propofol or barbiturates with ICU-level care. 1, 2, 5

• Propofol 2 mg/kg bolus, then 5 mg/kg/hour infusion (preferred: fewer ventilator days than barbiturates) 1, 2
• Phenobarbital 20 mg/kg IV at 50-100 mg/min (effective but higher risk of hypotension and respiratory depression) 1, 5
• Continuous EEG monitoring is essential at this stage to detect non-convulsive seizures 5

Special Considerations

Cerebral Edema Management (If Brain Lesion Present)

• Dexamethasone 4-8 mg/day for mild edema, up to 16 mg/day in divided doses for significant mass effect 1
• Taper steroids rapidly once clinically stable due to toxicity with prolonged use 1

Anticonvulsant Selection for Ongoing Therapy

• Use non-enzyme-inducing agents (levetiracetam, valproate) when possible to avoid drug interactions with chemotherapy or steroids 1
• Single-agent therapy at lowest effective dose is preferred 1

Communication and Follow-Up

• Notify the patient's primary care physician or neurologist of all ED visit details 6
• Schedule outpatient follow-up appointment before discharge 6
• Explain to patients with provoked seizures that they likely do not have epilepsy 4