What is the management of an active seizure (convulsion)?

From the Guidelines

Management of an active seizure requires immediate administration of lorazepam 0.1 mg/kg (maximum 2 mg) i.v. to control seizures, as per the most recent guidelines. When managing an active seizure, it is crucial to prioritize the patient's safety and well-being. The first step is to assess the patient's airway, breathing, and circulation (CAB) and provide airway protection interventions, administer high-flow oxygen, and check blood glucose levels 1.

Initial Management

• Ensure patient safety by placing them on their side to prevent aspiration and removing dangerous objects from the area
• Administer lorazepam 0.1 mg/kg (maximum 2 mg) i.v.; repeat dose after at least 1 minute (to a maximum of 2 doses) to control seizures, as recommended by the guidelines 1
• Consider levetiracetam 40 mg/kg (maximum 2,500 mg) i.v. bolus (in addition to maintenance dose) if seizures persist

Ongoing Management

• If seizures continue, add phenobarbital i.v. at a loading dose of 10–20 mg/kg (maximum 1,000 mg) 1
• Administer corticosteroids as per the guidelines (see Table 3 in 1)
• Maintain airway patency, provide supplemental oxygen if needed, and continuously monitor vital signs
• Check blood glucose levels and administer 50 mL of 50% dextrose if hypoglycemia is present

Refractory Seizures

• If seizures persist, consider continuous electroencephalography monitoring and transfer the patient to the intensive care unit (ICU) for further management 1
• Maintenance doses after resolution of status epilepticus include lorazepam 0.05 mg/kg (maximum 1 mg) i.v. every 8 hours for 3 doses, levetiracetam 30 mg/kg i.v. every 12 hours, and phenobarbital 1–3 mg/kg i.v. every 12 hours 1

From the FDA Drug Label

For the treatment of status epilepticus, the usual recommended dose of lorazepam injection is 4 mg given slowly (2 mg/min) for patients 18 years and older. If seizures cease, no additional lorazepam injection is required. If seizures continue or recur after a 10- to 15-minute observation period, an additional 4 mg intravenous dose may be slowly administered

• The management of an active seizure with lorazepam (IV) involves administering 4 mg slowly over 2 mg/min for patients 18 years and older.
• If the seizure stops, no additional dose is needed.
• If the seizure continues or recurs after 10-15 minutes, an additional 4 mg dose may be given slowly. 2

From the Research

Management of Active Seizure

• The first-line treatment for status epilepticus is benzodiazepines, which act on the GABAA receptor to promote a state of central nervous system depression 3.
• Time to treatment is crucial, and clinical response to benzodiazepines is lost with prolonged status epilepticus 3.
• Non-intravenous routes of midazolam, such as intramuscular or rectal administration, can be considered as equally efficacious alternatives to intravenous lorazepam 3, 4.
• Intramuscular midazolam has been shown to be effective in treating acute seizures, with a faster time to maximum concentration compared to other antiepileptic drugs 4.
• Rectal diazepam is also an effective treatment for acute seizures, with rapid absorption and a short time to maximum concentration 4.

Treatment Options

• Benzodiazepines, such as clonazepam and clobazam, can be used for seizure prophylaxis in patients with epilepsy refractory to multiple antiepileptic drugs 3.
• Other treatment options, such as fosphenytoin and phenobarbital, can be used after treatment with benzodiazepines 5.
• Newer antiepileptic drugs, such as valproate and levetiracetam, may be as effective and safe as traditional treatments, with faster infusion times and better pharmacokinetic profiles 5, 6.
• Intranasal and intrapulmonary administration of benzodiazepines are also being developed as potential treatment options 7.

Importance of Timely Treatment

• Timely administration of appropriate antiepileptic drugs is crucial in stopping seizures early and improving outcomes 5.
• Delays in treatment can lead to poor outcomes, and care protocols should be implemented to minimize treatment delays 5.
• More research is needed to understand how different treatment options modify prognosis in status epilepticus 5.