What is the treatment for seizures?

Treatment of Seizures

For acute seizures, immediately administer IV lorazepam 4 mg at 2 mg/min as first-line treatment, followed by a second-line agent (valproate 20-30 mg/kg IV, levetiracetam 30 mg/kg IV, or fosphenytoin 20 mg PE/kg IV) if seizures continue after adequate benzodiazepine dosing. 1

Immediate Management of Active Seizures

First-Line Treatment: Benzodiazepines

• Administer IV lorazepam 4 mg at 2 mg/min immediately for any actively seizing patient 1, 2
• Lorazepam demonstrates 65% efficacy in terminating status epilepticus and is superior to diazepam (59.1% vs 42.6% seizure termination) 1
• Have airway equipment immediately available before administration due to risk of respiratory depression 1
• Check fingerstick glucose simultaneously and correct hypoglycemia, a rapidly reversible cause 1

Second-Line Treatment (If Seizures Continue After Benzodiazepines)

Select one of the following agents if seizures persist after adequate benzodiazepine dosing:

• Valproate 20-30 mg/kg IV over 5-20 minutes: 88% efficacy with 0% hypotension risk—the safest cardiovascular profile 3, 1
• Levetiracetam 30 mg/kg IV over 5 minutes: 68-73% efficacy with minimal cardiovascular effects and no cardiac monitoring required 3, 1
• Fosphenytoin 20 mg PE/kg IV at maximum rate of 50 mg/min: 84% efficacy but 12% hypotension risk requiring continuous ECG and blood pressure monitoring 3, 1
• Phenobarbital 20 mg/kg IV over 10 minutes: 58.2% efficacy but higher risk of respiratory depression 1

Valproate appears to have the best safety-efficacy balance, causing significantly less hypotension than phenytoin while maintaining similar or superior efficacy. 1

Critical Pitfall to Avoid

• Never skip directly to third-line anesthetic agents (midazolam, propofol, pentobarbital) until both benzodiazepines and at least one second-line agent have been tried 1
• Never use neuromuscular blockers alone (e.g., rocuronium)—they only mask motor manifestations while allowing continued electrical seizure activity and ongoing brain injury 1

Refractory Status Epilepticus (Seizures Continuing Despite Benzodiazepines + One Second-Line Agent)

Initiate continuous EEG monitoring at this stage and select one of the following anesthetic agents: 1

Third-Line Anesthetic Agents

• Midazolam infusion (preferred first choice): Loading dose 0.15-0.20 mg/kg IV, then continuous infusion at 1 mg/kg/min, titrate up by 1 mg/kg/min every 15 minutes to maximum 5 mg/kg/min; 80% efficacy with 30% hypotension risk 1

• Propofol: 2 mg/kg bolus, then 3-7 mg/kg/hour infusion; 73% efficacy with 42% hypotension risk; requires mechanical ventilation but shorter ventilation time (4 days vs 14 days with pentobarbital) 1

• Pentobarbital (most effective but highest risk): 13 mg/kg bolus, then 2-3 mg/kg/hour infusion; 92% efficacy but 77% hypotension risk 1

All anesthetic agents require continuous blood pressure monitoring, continuous EEG monitoring to guide titration, and preparation for mechanical ventilation. 1

Loading Long-Acting Anticonvulsants During Anesthetic Infusion

• Load with phenytoin/fosphenytoin, valproate, levetiracetam, or phenobarbital during the midazolam infusion to ensure adequate levels of long-acting anticonvulsants are established before tapering 1

Management of Specific Seizure Contexts

Post-Stroke Seizures

• Treat new-onset seizures with short-acting medications (e.g., lorazepam IV) if not self-limiting 3
• Do NOT treat a single, self-limiting seizure occurring within 24 hours after ischemic stroke with long-term anticonvulsants 3
• Monitor for recurrent seizure activity during routine vital signs; treat recurrent seizures as per standard seizure protocols 3
• Prophylactic anticonvulsants are NOT recommended in ischemic stroke and may cause harm with negative effects on neurological recovery 3

First Unprovoked Seizure (Non-Emergency Setting)

• Do NOT initiate antiepileptic medications in the ED for patients with a single unprovoked seizure without evidence of brain disease or injury 3
• Do NOT initiate antiepileptic medications for provoked seizures—identify and treat precipitating medical conditions instead 3
• May initiate or defer antiepileptic medications for first unprovoked seizure with remote history of brain disease or injury (stroke, trauma, tumor) 3
• Delaying treatment until a second seizure does not affect 1-2 year remission rates 4
• Patients who have returned to clinical baseline in the ED do not require admission 3

Simultaneous Evaluation for Reversible Causes

While administering treatment, search for and correct the following reversible causes: 1

• Hypoglycemia (check fingerstick immediately)
• Hyponatremia and other electrolyte abnormalities
• Hypoxia
• Drug toxicity or withdrawal syndromes (alcohol, benzodiazepines, cocaine, tramadol)
• CNS infection (meningitis, encephalitis)
• Ischemic stroke or intracerebral hemorrhage
• Elevated intracranial pressure

Neuroimaging should not delay anticonvulsant administration in active status epilepticus—CT scanning can be performed after seizure control is achieved. 1

Chronic Epilepsy Management (Two or More Unprovoked Seizures)

Initiating Long-Term Treatment

• Start with monotherapy—using one antiepileptic drug (AED) at a time is the standard approach 5
• Treatment selection depends on seizure type: partial onset vs. generalized onset 2

First-Line Agents by Seizure Type

For partial onset seizures:

• Carbamazepine (blocks voltage-gated sodium channels) 2
• Levetiracetam or lamotrigine as alternatives 2

For generalized onset seizures:

• Valproate is the definitive first-line treatment 2
• Lamotrigine or levetiracetam are suitable alternatives for women of childbearing potential due to lower teratogenic risk 2

Critical Contraindications

• Avoid valproic acid in women of childbearing potential due to significant teratogenic risk 5
• Avoid enzyme-inducing anticonvulsants (phenytoin, carbamazepine, phenobarbital) when possible due to drug interactions and side-effect profiles 5
• Never use phenobarbital as first-line treatment—it performs significantly worse than all other options 2

Discontinuation of AEDs

• After 2 seizure-free years, consider discontinuation with involvement of the patient and family, weighing clinical, social, and personal factors 5

Monitoring Requirements

During Acute Treatment

• Continuous vital sign monitoring, particularly respiratory status and blood pressure 1
• Be prepared to provide respiratory support regardless of administration route 1
• Continuous EEG monitoring for refractory status epilepticus to detect ongoing electrical seizure activity and guide anesthetic titration 1

Chronic Management

• Routine monitoring of drug levels is NOT correlated with reduction in adverse effects or improvement in effectiveness and is NOT recommended 4