What is the management of seizures in a hospital setting?

Management of Seizures in the Hospital

Administer benzodiazepines immediately as first-line therapy for any actively seizing patient, followed by levetiracetam, fosphenytoin, or valproate as equally effective second-line agents if seizures persist after adequate benzodiazepine dosing. 1, 2

Initial Assessment and Stabilization

Immediate Actions

• Secure airway, breathing, and circulation—equipment for airway management must be immediately available before administering any antiseizure medications 3
• Check fingerstick glucose and correct hypoglycemia immediately 2
• Establish intravenous access and obtain vital signs with continuous cardiac monitoring 4
• Search for and treat underlying causes including hyponatremia, hypoxia, ischemic stroke, intracerebral hemorrhage, and withdrawal syndromes 2

Status Epilepticus Definition

• Status epilepticus is defined as a seizure lasting longer than 5 minutes or multiple seizures without return to neurologic baseline 1
• This is a medical emergency requiring immediate treatment to reduce morbidity and mortality 5

Treatment Algorithm

First-Line: Benzodiazepines

Intravenous Route (Preferred):

• Lorazepam 4 mg IV slowly (2 mg/min) for adults 3
• If seizures continue after 10-15 minutes, administer an additional 4 mg IV dose 3
• Alternative: Diazepam IV if lorazepam unavailable 6

Alternative Routes When IV Access Unavailable:

• Intramuscular midazolam 10 mg (shown to be non-inferior to IV lorazepam in prehospital studies) 1, 7
• Rectal diazepam 6
• Intranasal or buccal midazolam 8, 9

Critical Pitfall: Do NOT use intramuscular diazepam due to erratic absorption 6

Second-Line: Antiseizure Medications (After Benzodiazepine Failure)

All three agents have equivalent efficacy—approximately 45-47% seizure cessation at 60 minutes—so selection should be based on patient-specific contraindications and side effect profiles: 1, 2

Levetiracetam:

• Dose: 60 mg/kg IV (maximum 4500 mg) over 10 minutes 1
• Hypotension risk: 0.7% 1, 2
• Intubation rate: 20% 1
• Preferred in patients with liver disease or cardiac conduction abnormalities 8

Fosphenytoin:

• Dose: 20 mg phenytoin equivalents/kg IV at maximum rate of 150 mg/min 4
• Hypotension risk: 3.2% 1, 2
• Intubation rate: 26.4% 1
• Requires continuous cardiac monitoring during infusion 4
• Avoid in patients with cardiac conduction abnormalities or hypotension 8

Valproate:

• Dose: 40 mg/kg IV (maximum 3000 mg) over 10 minutes 1
• Hypotension risk: 1.6% 1, 2
• Intubation rate: 16.8% 1
• Contraindicated in pregnancy, liver disease, and mitochondrial disorders 8

Important Note: The patient's home antiseizure medication does not affect the probability of stopping status epilepticus when used as a second-line agent 1, 2

Third-Line: Refractory Status Epilepticus

If seizures persist after adequate first and second-line therapy (refractory status epilepticus), consider: 2

• Phenobarbital loading dose 2
• Continuous infusions: propofol, pentobarbital, or midazolam 2
• Ketamine (emerging evidence supports earlier use) 5, 8

Critical consideration: Pentobarbital has 92% efficacy but 77% of patients require vasopressor support 2

Monitoring and Ongoing Management

EEG Monitoring

• Consider continuous EEG monitoring for patients with persistent altered consciousness to rule out nonconvulsive status epilepticus 2
• This is particularly important as transition to nonconvulsive status epilepticus is common 8
• If patient is not fully awake after apparent seizure cessation, continue EEG for at least 24 hours 8

Medication Administration Details

Phenytoin/Fosphenytoin Specific:

• Must dilute in normal saline to final concentration ≥5 mg/mL 4
• Use in-line filter (0.22-0.55 microns) 4
• Complete infusion within 1-4 hours of preparation 4
• Maximum rate: 50 mg/min in adults, 1-3 mg/kg/min in pediatrics (whichever is slower) 4

Lorazepam Specific:

• Contains benzyl alcohol—use caution in neonates 3
• Maintain patent airway equipment immediately available 3
• For intramuscular use as preanesthetic: administer at least 2 hours before procedure 3

Common Pitfalls to Avoid

• Failing to recognize nonconvulsive status epilepticus in patients with persistent altered mental status—obtain EEG 2
• Not addressing underlying causes while treating the seizure itself (hypoglycemia, hyponatremia, withdrawal, toxins) 2
• Inadequate benzodiazepine dosing before moving to second-line agents—ensure "optimal dosing" has been achieved 1
• Using intramuscular diazepam instead of other routes due to erratic absorption 6
• Delaying treatment to obtain antiseizure medication levels—treat empirically and check levels later 1
• Administering phenytoin too rapidly without cardiac monitoring—can cause fatal arrhythmias 4
• Using intramuscular phenytoin for status epilepticus—peak levels may take up to 24 hours 4

Special Considerations

Medication Interactions and Precipitants

• Prescribed medications (tramadol) and illicit substances (cocaine) can lower seizure threshold 1
• Noncompliance with antiseizure medications is a common precipitant of ED seizure presentations 1

Disposition

• Approximately 16-26% of patients with status epilepticus require endotracheal intubation 1, 2
• Mortality is higher (22.2% vs 6.9%) in patients without prior seizure history who develop status epilepticus 10