What is the initial symptomatic treatment for a patient who is actively seizing?

Initial Symptomatic Treatment for Active Seizures

Administer intravenous lorazepam 4 mg at 2 mg/min as the immediate first-line treatment for any patient actively seizing. 1, 2, 3

First-Line Treatment: Benzodiazepines

Lorazepam is the preferred benzodiazepine due to its longer duration of action compared to other benzodiazepines and demonstrated 65% efficacy in terminating status epilepticus. 1, 4, 3

Dosing and Administration

• IV lorazepam 4 mg administered slowly at 2 mg/min for adults 1, 2, 3
• If seizures continue after 10-15 minutes of observation, administer an additional 4 mg IV dose slowly 3
• Underdosing lorazepam (less than 4 mg) significantly increases progression to refractory status epilepticus (87% vs 62%), so the full 4 mg dose is critical for patients over 40 kg 5

Alternative Routes When IV Access Unavailable

• IM midazolam is easier to administer than IV lorazepam in pre-hospital settings 6
• Intranasal midazolam is an acceptable alternative 2
• Rectal diazepam if other routes unavailable 7

Critical Immediate Actions

Before or simultaneously with benzodiazepine administration:

• Ensure airway patency and have equipment ready to maintain patent airway immediately available - this is mandatory before IV lorazepam administration 3, 4
• Be prepared for mechanical ventilation as benzodiazepines cause respiratory depression 2, 6
• Establish IV access immediately 4
• Monitor vital signs continuously (heart rate, rhythm, blood pressure, oxygen saturation) 4
• Check fingerstick glucose immediately and correct hypoglycemia - this is a rapidly reversible cause 1, 2

Second-Line Treatment (If Seizures Continue After Benzodiazepines)

If the patient continues seizing after adequate benzodiazepine dosing, immediately administer one of the following second-line agents: 1, 2

Preferred Second-Line Options (in order of recommendation):

1. Valproate 20-30 mg/kg IV over 5-20 minutes - 88% efficacy with 0% hypotension risk, superior safety profile 2, 4

2. Levetiracetam 30 mg/kg IV over 5 minutes - 68-73% efficacy with minimal cardiovascular effects and no drug interactions 2, 4

3. Fosphenytoin 20 mg PE/kg IV at maximum rate of 150 PE/min - 84% efficacy but 12% hypotension risk, requires continuous ECG and blood pressure monitoring 1, 2

4. Phenobarbital 20 mg/kg IV over 10 minutes - 58.2% efficacy but higher risk of respiratory depression 2

Valproate is preferred over fosphenytoin due to similar efficacy (88% vs 84%) but significantly lower hypotension risk (0% vs 12%). 2

Refractory Status Epilepticus (Third-Line)

If seizures persist despite benzodiazepines and one second-line agent, initiate continuous EEG monitoring and anesthetic agents: 2

1. Midazolam infusion: 0.15-0.20 mg/kg IV load, then 1 mg/kg/min continuous infusion (80% success rate, 30% hypotension risk) 2

2. Propofol: 2 mg/kg bolus, then 3-7 mg/kg/hour infusion (73% success rate, requires mechanical ventilation) 2

3. Pentobarbital: 13 mg/kg bolus, then 2-3 mg/kg/hour infusion (92% success rate but 77% hypotension risk) 2

Critical Pitfalls to Avoid

• Never use neuromuscular blockers (like rocuronium) alone - they only mask motor manifestations while allowing continued electrical seizure activity and ongoing brain injury 2
• Do not underdose lorazepam - doses less than 4 mg significantly increase progression to refractory status epilepticus 5
• Do not skip second-line agents and jump directly to third-line anesthetic agents like pentobarbital until benzodiazepines and at least one second-line agent have been tried 2
• Do not delay treatment to obtain labs - check glucose immediately but other tests should not delay benzodiazepine administration 4

Simultaneous Evaluation for Reversible Causes

While administering treatment, immediately search for and correct: 1, 2

• Hypoglycemia (check fingerstick glucose stat)
• Hyponatremia
• Hypoxia
• Drug toxicity or withdrawal syndromes
• CNS infection
• Ischemic stroke or intracerebral hemorrhage