What are the management and treatment options for a patient presenting with seizures?

Seizure Management and Treatment: Prescription Templates by Seizure Type

Status Epilepticus (Active Seizure ≥5 minutes)

For any patient actively seizing, immediately administer IV lorazepam 4 mg at 2 mg/min as first-line treatment, followed by fosphenytoin or valproate as second-line if seizures persist. 1, 2, 3

First-Line Treatment (0-5 minutes)

• Lorazepam 4 mg IV at 2 mg/min (preferred benzodiazepine due to longer duration of action) 1, 2, 3
• Alternative if no IV access: Midazolam 10 mg IM or intranasal 1, 4
• Check fingerstick glucose immediately and correct hypoglycemia 5
• Establish IV access, monitor vital signs, ensure airway equipment available 3

Prescription Template - Status Epilepticus First-Line:

Lorazepam 4 mg IV push at 2 mg/min
May repeat once after 10-15 minutes if seizures continue
Maximum total dose: 8 mg

Second-Line Treatment (5-20 minutes if seizures persist)

Choose ONE of the following agents 1, 2, 5:

Option 1: Fosphenytoin (most widely available, 95% of neurologists' choice)

• Dose: 20 mg PE/kg IV at maximum rate 150 mg PE/min 1, 2, 5
• Efficacy: 84% 2, 5
• Risk: 12% hypotension, requires continuous ECG and BP monitoring 2, 5

Prescription Template - Fosphenytoin:

Fosphenytoin 20 mg PE/kg IV (max rate 150 mg PE/min)
For 70 kg patient: 1400 mg PE IV over 10 minutes
Continuous cardiac monitoring required
Monitor BP every 5 minutes during infusion

Option 2: Valproate (preferred if hypotension concern)

• Dose: 30 mg/kg IV over 5-20 minutes 1, 2, 5
• Efficacy: 88% 2, 5
• Risk: 0% hypotension (superior safety profile) 2, 5

Prescription Template - Valproate:

Valproate 30 mg/kg IV over 10 minutes
For 70 kg patient: 2100 mg IV over 10 minutes
Infusion rate: 6 mg/kg/hour
Monitor liver function

Option 3: Levetiracetam (minimal cardiovascular effects)

• Dose: 30 mg/kg IV over 5 minutes 2, 5
• Efficacy: 68-73% 2, 5
• Advantage: Minimal adverse effects, no hypotension 5

Prescription Template - Levetiracetam:

Levetiracetam 30 mg/kg IV over 5 minutes
For 70 kg patient: 2100 mg IV over 5 minutes
Infusion rate: 5 mg/kg/min
No cardiac monitoring required

Option 4: Phenobarbital

• Dose: 20 mg/kg IV at 50-100 mg/min 2, 5
• Efficacy: 58% 2, 5
• Risk: Higher respiratory depression 2

Prescription Template - Phenobarbital:

Phenobarbital 20 mg/kg IV over 10 minutes
For 70 kg patient: 1400 mg IV over 10 minutes
Prepare for respiratory support
Monitor respiratory rate continuously

Refractory Status Epilepticus (Seizures continue after benzodiazepine + one second-line agent)

Initiate continuous EEG monitoring and choose ONE anesthetic agent 2, 5:

Option 1: Midazolam Infusion (first choice - 80% efficacy, 30% hypotension)

• Loading: 0.15-0.20 mg/kg IV 2, 5
• Infusion: 1 mg/kg/min, titrate up by 1 mg/kg/min every 15 minutes to max 5 mg/kg/min 2, 5

Prescription Template - Midazolam Infusion:

Midazolam 0.2 mg/kg IV bolus (14 mg for 70 kg patient)
Then continuous infusion starting at 1 mg/kg/min (70 mg/hour for 70 kg patient)
Titrate up by 1 mg/kg/min every 15 minutes as needed
Maximum rate: 5 mg/kg/min (350 mg/hour for 70 kg patient)
Requires mechanical ventilation
Continuous EEG monitoring
Load maintenance AED (phenytoin/valproate/levetiracetam) during infusion

Option 2: Propofol (73% efficacy, requires mechanical ventilation)

• Loading: 2 mg/kg IV bolus 2, 5
• Infusion: 3-7 mg/kg/hour 2, 5
• Advantage: Shorter ventilation time (4 days vs 14 days with pentobarbital) 5

Prescription Template - Propofol:

Propofol 2 mg/kg IV bolus (140 mg for 70 kg patient)
Then continuous infusion 3-7 mg/kg/hour (210-490 mg/hour for 70 kg patient)
Requires mechanical ventilation
Continuous BP monitoring (42% hypotension risk)
Continuous EEG monitoring to guide titration

Option 3: Pentobarbital (highest efficacy 92%, highest hypotension 77%)

• Loading: 13 mg/kg IV 2, 5
• Infusion: 2-3 mg/kg/hour 2, 5

Prescription Template - Pentobarbital:

Pentobarbital 13 mg/kg IV bolus (910 mg for 70 kg patient)
Then continuous infusion 2-3 mg/kg/hour (140-210 mg/hour for 70 kg patient)
Requires mechanical ventilation
Aggressive BP support (77% hypotension risk)
Continuous EEG monitoring
Expect prolonged ventilation (14 days average)

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First Unprovoked Seizure (Patient returned to baseline)

Do not initiate antiepileptic medication in the ED for patients with a first unprovoked seizure without evidence of brain disease or injury. 1

Decision Algorithm for First Seizure

DO NOT treat in ED if: 1

• Single unprovoked seizure
• No history of CNS injury (stroke, trauma, tumor)
• Patient returned to neurologic baseline
• Outpatient neurology follow-up arranged

Prescription Template - First Unprovoked Seizure (No Treatment):

No antiepileptic medication initiated
Discharge with neurology follow-up within 1-2 weeks
Seizure precautions counseling
Driving restrictions per state law
Return precautions for seizure recurrence

MAY initiate treatment if: 1

• Remote history of brain disease or injury (stroke, TBI, tumor)
• Abnormal EEG findings
• Abnormal neuroimaging
• Coordinate with neurology for outpatient initiation

Prescription Template - First Seizure with Risk Factors:

Option 1: Defer to outpatient neurology (preferred)
Option 2: If initiating in ED after neurology consultation:
  Levetiracetam 500 mg PO twice daily
  OR
  Lamotrigine 25 mg PO daily x 2 weeks, then 50 mg daily
  Neurology follow-up within 1 week

DO NOT admit to hospital: 1

• Patients with first unprovoked seizure who returned to baseline
• No evidence supporting admission reduces 24-hour adverse events 1

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Provoked Seizure (Acute Symptomatic Seizure)

Do not initiate antiepileptic medication in the ED for provoked seizures - identify and treat the underlying cause instead. 1, 5

Common Precipitating Causes to Address 1, 5:

• Hypoglycemia - correct with dextrose
• Hyponatremia - correct sodium cautiously
• Hypoxia - supplemental oxygen, treat underlying cause
• Drug toxicity - supportive care, specific antidotes
• Alcohol/drug withdrawal - benzodiazepines, supportive care
• CNS infection - antibiotics, antivirals
• Stroke/hemorrhage - neurosurgical consultation
• Metabolic derangements - correct underlying abnormality

Prescription Template - Provoked Seizure:

No antiepileptic medication for seizure prevention
Treat underlying cause:
  - If hypoglycemia: Dextrose 50% 50 mL IV
  - If hyponatremia: 3% saline per protocol
  - If alcohol withdrawal: Lorazepam 2 mg IV q15min PRN CIWA >10
  - If CNS infection: Appropriate antimicrobials
Admit for treatment of underlying condition

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Known Epilepsy with Breakthrough Seizure (Subtherapeutic Levels)

If Patient Takes Phenytoin/Fosphenytoin

Prescription Template - Phenytoin Reloading:

Check current phenytoin level
Calculate loading dose to achieve level 20 mcg/mL:
  Loading dose (mg) = (20 - current level) × 0.7 × weight (kg)
Administer fosphenytoin IV at max rate 150 mg PE/min
Resume home phenytoin dose
Ensure medication compliance counseling
Outpatient neurology follow-up

If Patient Takes Other AEDs

Prescription Template - Resume Home AED:

Administer one dose of home AED in ED:
  - If oral AED: Give home dose PO
  - If available IV formulation: Give IV equivalent
Ensure patient has adequate supply at home
Medication compliance counseling
Social work consult if financial barriers
Outpatient neurology follow-up within 1 week

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Focal Seizures (Outpatient Initiation)

For newly diagnosed focal epilepsy requiring outpatient treatment initiation 6, 7:

Prescription Template - Focal Seizures (Adults):

First-line options (choose ONE):
1. Levetiracetam 500 mg PO twice daily
   Titrate by 500 mg/day every 1-2 weeks
   Target: 1000-1500 mg twice daily
   
2. Lamotrigine 25 mg PO daily x 2 weeks
   Then 50 mg daily x 2 weeks
   Then 100 mg daily x 1 week
   Target: 100-200 mg twice daily
   (Slower titration reduces rash risk)
   
3. Carbamazepine 200 mg PO twice daily
   Titrate by 200 mg/day every week
   Target: 400-600 mg twice daily
   Check CBC, LFTs at baseline

Neurology follow-up in 2-4 weeks
Seizure diary
Driving restrictions per state law

Prescription Template - Focal Seizures (Elderly):

Preferred: Lamotrigine or Gabapentin (better tolerated)

Lamotrigine 25 mg PO daily x 2 weeks
Then 25 mg twice daily x 2 weeks
Then 50 mg twice daily
Target: 50-100 mg twice daily (lower than adults)

OR

Gabapentin 300 mg PO at bedtime x 3 days
Then 300 mg twice daily x 4 days
Then 300 mg three times daily
Target: 300-600 mg three times daily

Neurology follow-up in 2 weeks
Fall precautions

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Generalized Seizures (Outpatient Initiation)

Prescription Template - Generalized Seizures (Not Women of Childbearing Age):

Valproate 250 mg PO twice daily
Titrate by 250 mg/day every 3-7 days
Target: 500-1000 mg twice daily
Check LFTs, CBC, ammonia at baseline
Neurology follow-up in 2-4 weeks

Prescription Template - Generalized Seizures (Women of Childbearing Age):

AVOID valproate due to teratogenicity

Preferred: Levetiracetam 500 mg PO twice daily
Titrate by 500 mg/day every 1-2 weeks
Target: 1000-1500 mg twice daily

OR

Lamotrigine 25 mg PO daily x 2 weeks
Then 50 mg daily x 2 weeks
Then 100 mg daily x 1 week
Target: 100-200 mg twice daily

Contraception counseling
Folic acid 1-4 mg daily if pregnancy possible
Neurology follow-up in 2-4 weeks

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Critical Pitfalls to Avoid

• Never use neuromuscular blockers alone - they mask motor manifestations while electrical seizure activity continues causing brain injury 5
• Never skip directly to third-line agents without trying benzodiazepines and a second-line agent 5
• Never delay benzodiazepines - lorazepam has 65% efficacy as monotherapy for status epilepticus 2, 3
• Always search for reversible causes simultaneously with treatment initiation 1, 5
• Monitor for hypotension with phenytoin/fosphenytoin (12% risk) and pentobarbital (77% risk) 2, 5
• Prepare for mechanical ventilation before administering propofol or high-dose midazolam 5, 3
• Load maintenance AED during midazolam infusion to ensure adequate levels before tapering 5