What is the management plan for seizures?

Management of Seizures

Immediate Stabilization and Assessment

Establish airway, breathing, and circulation while providing high-flow oxygen and securing IV or intraosseous access immediately. 1, 2

• Position the patient on their side in recovery position to prevent aspiration 2
• Check blood glucose immediately at bedside to rule out hypoglycemia as the cause 1, 2
• Search for and treat reversible causes including hypoglycemia, hyponatremia, hypoxia, drug toxicity, CNS infection, ischemic stroke, intracerebral hemorrhage, and withdrawal syndromes 3, 1
• Never restrain the patient or place anything in their mouth during active seizure 2

First-Line Treatment: Benzodiazepines

Administer benzodiazepines as first-line therapy, with IV lorazepam preferred over diazepam when IV access is available. 4, 5, 6, 7

When IV Access Available:

• Lorazepam 4 mg IV slowly (2 mg/min) is the preferred benzodiazepine 5, 7
• If seizures continue after 10-15 minutes, repeat lorazepam 4 mg IV 5
• Diazepam 5-10 mg IV (at 5 mg/min) is an alternative, though lorazepam is superior due to longer duration of action 4, 7, 8

When IV Access NOT Available:

• Diazepam rectal 10-20 mg is effective 2, 4
• Midazolam intramuscular is equally efficacious to IV lorazepam 6, 9
• Phenobarbital IM may be considered when rectal diazepam is not feasible 2

Second-Line Treatment for Status Epilepticus

If seizures persist despite optimal benzodiazepine dosing, immediately administer fosphenytoin, levetiracetam, or valproate—all three agents have equivalent efficacy (45-47% seizure cessation at 60 minutes) per the 2024 ACEP Level A recommendation. 3, 1

Dosing for Second-Line Agents:

• Fosphenytoin: 18-20 mg/kg IV over 20 minutes 1, 2

  • Hypotension risk: 3.2% 1
  • Less preferred in cardiac patients due to cardiovascular effects 2

• Levetiracetam: 20-60 mg/kg IV (typically 1000-3000 mg in adults) 1, 2

  • Hypotension risk: 0.7% (lowest of the three) 1
  • Preferred in patients with cardiac disease 2

• Valproate: 20-40 mg/kg IV (typically 30 mg/kg at 5 mg/kg/min) 3, 1, 2

  • Hypotension risk: 1.6% 1, 2
  • Avoid in pregnancy and hepatic disease

The ESETT trial (2019) definitively established that no single agent is superior—choose based on patient-specific contraindications and side effect profiles. 3

• The patient's home antiseizure medication does not affect second-line agent efficacy 1
• Median time to seizure termination ranges from 7-11.7 minutes across all three agents 3

Third-Line Treatment for Refractory Status Epilepticus

For seizures continuing after benzodiazepines and second-line agents, administer phenobarbital IV or consider anesthetic agents with continuous EEG monitoring. 3, 1

• Phenobarbital IV for sustained control 3, 2
• Pentobarbital infusion has 92% efficacy but 77% require vasopressors for hypotension 1
• Propofol infusion or midazolam infusion are alternatives 3, 1
• Prepare for endotracheal intubation with rapid sequence induction—required in 16-26% of status epilepticus patients 1, 2

Critical Pitfall: Nonconvulsive Status Epilepticus

Consider emergent EEG in any patient with persistent altered mental status after seizure cessation, as nonconvulsive status epilepticus presents solely as inability to follow commands without motor manifestations. 10, 1

• Nonconvulsive seizures occur in 10-35% of post-cardiac arrest patients who don't follow commands 10
• Focal seizures with maintained awareness allow patients to respond to commands, while generalized seizures cause loss of consciousness 10
• Failing to recognize nonconvulsive status epilepticus is a major treatment pitfall 1, 2

Special Considerations

• Respiratory assistance equipment must be immediately available before administering any IV benzodiazepine 4, 5
• Status epilepticus is defined as seizure lasting >5 minutes or multiple seizures without return to baseline 3
• Treatment delay increases mortality—initiate therapy when seizures last 5-7 minutes 7
• Do not routinely prescribe antiepileptic drugs after a first unprovoked seizure 2