What are the orders for acute seizure management?

Acute Seizure Management Orders

For any actively seizing patient, immediately administer IV lorazepam 4 mg at 2 mg/min (or 0.1 mg/kg in pediatrics, max 2 mg) as first-line treatment, with airway equipment at bedside and continuous vital sign monitoring. 1, 2, 3

Immediate Actions (First 0-5 Minutes)

Initial Assessment & Stabilization:

• Assess circulation, airway, breathing (CAB) and position patient on side in recovery position 1
• Establish IV access immediately 2, 3
• Check fingerstick glucose and correct if <60 mg/dL 1, 2
• Apply continuous cardiac monitoring, pulse oximetry, and blood pressure monitoring 1, 4
• Have airway equipment and bag-valve-mask immediately available at bedside 5
• Administer high-flow oxygen 1

First-Line Anticonvulsant (Benzodiazepines):

• IV lorazepam 4 mg at 2 mg/min (adults) or 0.1 mg/kg (max 2 mg) in pediatrics 1, 2, 3
• May repeat once after 5-10 minutes if seizure continues 2, 3
• Alternative if no IV access: Intramuscular midazolam 10 mg (adults) or 0.2 mg/kg (pediatrics) 1
• Alternative: Intranasal midazolam or buccal midazolam (0.2-0.5 mg/kg) 1, 6

Second-Line Treatment (If Seizures Continue After 10-15 Minutes)

Status epilepticus is defined as seizures lasting >5 minutes and requires immediate escalation to second-line agents. 1, 2

Choose ONE of the following second-line agents (all have similar efficacy 68-88%): 1, 2, 3

Option 1: Fosphenytoin (Traditional Choice)

• Dose: 20 mg PE/kg IV at maximum rate of 50 mg/min (adults) or 1-3 mg/kg/min (pediatrics) 1, 2, 4
• Efficacy: 84% seizure control 2
• Monitoring: Requires continuous ECG and blood pressure monitoring due to 12% hypotension risk and cardiac arrhythmia risk 1, 2, 4
• Infusion requirements: Use 0.22-0.55 micron in-line filter, dilute in normal saline to ≥5 mg/mL concentration 4

Option 2: Valproate (Preferred for Cardiovascular Safety)

• Dose: 20-30 mg/kg IV over 5-20 minutes 1, 2, 3
• Efficacy: 88% seizure control with 0% hypotension risk 2, 3
• Advantage: Less hypotension than fosphenytoin while maintaining similar efficacy 2

Option 3: Levetiracetam (Preferred for Elderly/Cardiac Patients)

• Dose: 30 mg/kg IV (max 2500-3000 mg) over 5-10 minutes 1, 2, 3
• Efficacy: 68-73% seizure control 2, 3
• Advantage: Minimal cardiovascular effects, no cardiac monitoring required 2, 3

Option 4: Phenobarbital

• Dose: 20 mg/kg IV over 10 minutes 1, 2
• Efficacy: 58.2% seizure control 2
• Caution: Higher risk of respiratory depression 2

Third-Line Treatment: Refractory Status Epilepticus (If Seizures Continue After 30-40 Minutes)

Refractory status epilepticus is defined as seizures continuing despite benzodiazepines and one second-line agent. 2, 3

Immediate Actions:

• Transfer to ICU 1, 3
• Initiate continuous EEG monitoring 1, 2, 3
• Prepare for intubation and mechanical ventilation 2, 3

Choose ONE anesthetic agent:

Option 1: Midazolam Infusion (First Choice)

• Loading dose: 0.15-0.20 mg/kg IV 1, 2, 3
• Continuous infusion: Start at 1 mg/kg/min, titrate up by 1 mg/kg/min every 15 minutes to max 5 mg/kg/min 2, 3
• Efficacy: 80% seizure control 2, 3
• Hypotension risk: 30% 2, 3

Option 2: Propofol (For Intubated Patients)

• Loading dose: 2 mg/kg bolus 1, 2, 3
• Continuous infusion: 3-7 mg/kg/hour, titrate to EEG burst suppression 2, 3
• Efficacy: 73% seizure control 2, 3
• Hypotension risk: 42% 2
• Advantage: Shorter ventilation time (4 days vs 14 days with pentobarbital) 2

Option 3: Pentobarbital (Most Effective but Highest Risk)

• Loading dose: 13 mg/kg 2, 3
• Continuous infusion: 2-3 mg/kg/hour 2, 3
• Efficacy: 92% seizure control (highest) 2, 3
• Hypotension risk: 77% (highest) 2

Concurrent Diagnostic Workup

Search for and treat reversible causes simultaneously: 2, 3

• Hypoglycemia (check fingerstick glucose immediately) 1, 2
• Hyponatremia (send basic metabolic panel) 2, 3
• Hypoxia (pulse oximetry, arterial blood gas) 2
• Drug toxicity or withdrawal syndromes (urine drug screen, alcohol level, medication history) 2, 3
• CNS infection (consider lumbar puncture after stabilization) 2, 3
• Ischemic stroke or intracerebral hemorrhage (CT head non-contrast) 2, 3

EMS Activation Criteria

Activate emergency response system for: 1

• First-time seizure 1
• Seizure lasting >5 minutes 1
• Multiple seizures without return to baseline between episodes 1
• Seizure in infant <6 months of age 1
• Seizure in pregnant patient 1
• Seizure with traumatic injury, difficulty breathing, or choking 1
• Seizure occurring in water 1
• Patient does not return to baseline within 5-10 minutes after seizure stops 1

Critical Safety Measures

DO NOT: 1

• Restrain the seizing patient 1
• Place anything in the patient's mouth 1, 5
• Give oral medications, food, or liquids during or immediately after seizure 1, 5
• Use neuromuscular blockers alone (they only mask motor manifestations while allowing continued electrical seizure activity and brain injury) 2
• Skip directly to third-line agents without trying benzodiazepines and a second-line agent first 2

DO: 1

• Stay with the patient continuously 1
• Clear area around patient to prevent injury 1
• Position patient on side in recovery position 1
• Monitor respiratory status continuously and be prepared to provide ventilatory support 1, 2, 3

Maintenance Therapy After Seizure Control

After resolution of status epilepticus, administer maintenance doses: 1

• Lorazepam 0.05 mg/kg (max 1 mg) IV every 8 hours for 3 doses 1
• Levetiracetam 15-30 mg/kg IV every 12 hours 1
• Phenobarbital 1-3 mg/kg IV every 12 hours (if used) 1
• Continue the second-line agent that was effective at appropriate maintenance dosing 3

Special Considerations

Pediatric Dosing Adjustments:

• Lorazepam: 0.05-0.1 mg/kg IV (max 2 mg per dose) 1
• Fosphenytoin: 1-3 mg/kg/min or 50 mg/min, whichever is slower 4
• All second-line agents: Use weight-based dosing as specified above 1

Post-Ictal Period:

• Expect confusion and sedation for several minutes to hours after seizure cessation 1
• Continue monitoring until patient returns to baseline mental status 1, 7
• Distinguish between post-ictal sedation and continued non-convulsive status epilepticus if consciousness does not improve 1