What is the initial management of seizure-like activity in a long-term care setting?

Initial Management of Seizure-Like Activity in Long-Term Care

For active, non-self-limiting seizures in long-term care residents, immediately administer IV lorazepam 4 mg slowly (2 mg/min) after ensuring airway patency and stabilizing vital signs. 1, 2, 3

Immediate Stabilization (First 5 Minutes)

• Ensure airway, breathing, and circulation are secured first before any medication administration 2
• Position the patient to prevent aspiration and maintain airway patency 3
• Monitor oxygen saturation continuously, as hypoxia exacerbates both seizures and any underlying cerebral pathology 2
• Establish IV access if not already present 1, 3
• Check fingerstick glucose immediately to rule out hypoglycemia as a reversible cause 1, 4

First-Line Pharmacologic Treatment

Administer IV lorazepam 4 mg at a rate not exceeding 2 mg/min for patients 18 years and older with ongoing seizure activity 3

• If seizures cease after the initial dose, no additional lorazepam is required 3
• If seizures continue or recur after a 10-15 minute observation period, administer an additional 4 mg IV dose slowly 3
• Critical warning: The most important risk with lorazepam is respiratory depression—ventilatory support equipment must be immediately available 3
• Monitor for excessive sedation, particularly in elderly long-term care residents who may have prolonged effects 3

Second-Line Agent Selection (If Seizures Persist After Benzodiazepines)

If seizures continue despite optimal benzodiazepine dosing, immediately administer one of three equally effective second-line agents: fosphenytoin, levetiracetam, or valproate. 1

Agent-Specific Dosing:

• Fosphenytoin: 15-20 mg PE/kg IV at maximum rate of 150 mg PE/min, with continuous cardiac monitoring 1, 5
• Levetiracetam: 60 mg/kg IV (up to 4500 mg) over 15 minutes 1
• Valproate: 40 mg/kg IV (up to 3000 mg) over 10 minutes 1

Selection Considerations:

• All three agents have similar efficacy for terminating seizures (approximately 45-47% success rate) 1
• Levetiracetam has the lowest risk of hypotension (0.7% vs 3.2% for fosphenytoin vs 1.6% for valproate) 1
• Fosphenytoin requires cardiac monitoring due to arrhythmia risk and must not exceed 50 mg/min in adults 5
• Intubation rates are similar across all three agents (16.8-26.4%) 1

Critical Decision Point: Long-Term Anticonvulsant Therapy

Do NOT initiate long-term anticonvulsant therapy for a single, self-limiting seizure occurring within 24 hours of an acute medical event (such as stroke, infection, or metabolic derangement). 1, 2

• A single seizure in the context of acute illness does not constitute epilepsy and prophylactic treatment may impair neurological recovery 1, 2
• Only initiate maintenance anticonvulsants if: recurrent seizures occur beyond the acute period, or if seizures continue despite treatment of the underlying cause 1, 4

Diagnostic Workup During Active Management

While managing the seizure, simultaneously investigate reversible causes:

• Obtain stat basic metabolic panel to identify electrolyte abnormalities (hyponatremia, hypocalcemia, hypomagnesemia) 4
• Check renal and hepatic function, as organ failure commonly provokes seizures in long-term care residents 4
• Review medication list for proconvulsant drugs or recent medication changes/withdrawals 4
• Measure temperature every 4 hours—fever >37.5°C requires investigation as infection is a common seizure precipitant in this population 2
• Consider non-contrast head CT if new focal neurological deficits are present or if the patient has fall risk/anticoagulation 2
• Obtain EEG monitoring if the patient has unexplained reduced consciousness after apparent seizure termination to rule out non-convulsive status epilepticus 1, 2

Common Pitfalls in Long-Term Care Settings

• Avoid intramuscular phenytoin—absorption is erratic and peak levels may not occur for 24 hours, making it inappropriate for acute seizure management 5
• Do not delay treatment waiting for IV access; buccal or intranasal benzodiazepines can be used if IV access is not immediately available 6
• Propylene glycol toxicity can occur with high-dose diazepam (>900 mg/day), particularly in residents with renal dysfunction or alcoholism—monitor for metabolic acidosis 7
• Elderly patients are at higher risk for prolonged sedation and respiratory depression with benzodiazepines—have reversal agents and airway equipment ready 3

Post-Seizure Monitoring and Care

• Continue vital sign monitoring every 15-30 minutes for at least 2 hours after seizure termination, watching specifically for recurrent seizure activity 1, 2
• Assess swallowing function before allowing any oral intake, as aspiration risk is significantly elevated in the post-ictal period 2
• Document seizure characteristics (duration, focal vs generalized, post-ictal state) to guide further workup 1
• Avoid aggressive blood pressure lowering if cerebrovascular ischemia is suspected, as this may worsen perfusion 2

When to Transfer to Acute Care

Transfer to the emergency department is indicated if:

• Seizures do not terminate after appropriate first- and second-line therapy 1
• Respiratory depression requiring mechanical ventilation occurs 3
• Underlying cause cannot be identified or corrected in the long-term care setting 4
• Recurrent seizures develop despite treatment 1