What is a standing order for a patient in case of an acute seizure?

Standing Orders for Acute Seizure Management

For any patient with active seizures lasting beyond 5 minutes or recurrent seizures, the standing order should be intravenous lorazepam 4 mg administered at 2 mg/min, with airway equipment immediately available and continuous monitoring of vital signs. 1, 2

Immediate First-Line Treatment Protocol

Benzodiazepines are the only Level A (strongest evidence) first-line treatment for acute seizures, with lorazepam demonstrating superior efficacy over diazepam (59.1% vs 42.6% seizure termination). 2, 3

Lorazepam Administration Details:

• Dose: 4 mg IV administered slowly at 2 mg/min 1, 2
• Repeat dosing: If seizures continue after 10-15 minutes, administer an additional 4 mg IV slowly 3
• Duration of action: Up to 72 hours, significantly longer than diazepam (<2 hours) or midazolam (3-4 hours) 4
• Success rate: 80% efficacy in terminating status epilepticus with initial 4 mg dose 3

Critical Safety Measures Required:

• Airway equipment must be immediately available before administration, as respiratory depression is the most important risk 3
• Continuous monitoring of respiratory status and blood pressure 2
• Intravenous access established with repeated aspiration to avoid intra-arterial injection 3
• Must dilute with equal amount of compatible diluent prior to IV use 3

Simultaneous Actions During Acute Seizure

While administering lorazepam, immediately address reversible causes:

• Check fingerstick glucose and correct hypoglycemia 2
• Assess for hyponatremia, hypocalcemia, hypomagnesemia 1, 5, 6
• Evaluate for drug toxicity or withdrawal syndromes 5, 2
• Consider CNS infection if fever present 5
• Rule out stroke, intracerebral hemorrhage, or CNS mass lesions 5, 2

Second-Line Treatment (If Seizures Continue After Benzodiazepines)

If seizures persist after adequate benzodiazepine dosing (two 4 mg doses of lorazepam), immediately escalate to one of these second-line agents 2:

Preferred Second-Line Options:

• Valproate 20-30 mg/kg IV over 5-20 minutes: 88% efficacy, 0% hypotension risk 2
• Levetiracetam 30 mg/kg IV over 5 minutes: 68-73% efficacy, minimal cardiovascular effects 2
• Fosphenytoin 20 mg PE/kg IV at maximum rate of 150 PE/min: 84% efficacy but 12% hypotension risk requiring continuous ECG and blood pressure monitoring 2
• Phenobarbital 20 mg/kg IV over 10 minutes: 58.2% efficacy but higher respiratory depression risk 2

Valproate appears superior to fosphenytoin with similar efficacy but significantly lower hypotension risk (0% vs 12%), making it an excellent first choice among second-line agents. 2

Alternative Routes When IV Access Unavailable

If intravenous access cannot be established:

• Intramuscular midazolam: Easier than IV lorazepam in pre-hospital settings, 93-100% efficacy 4, 7
• Rectal diazepam gel: FDA-approved for out-of-hospital acute repetitive seizures, 0.2-0.5 mg/kg depending on age/weight 8
• Sublingual lorazepam oral concentrate: 66-70% efficacy for stopping prolonged/repetitive seizures, doses 0.5-2 mg 9
• Intranasal midazolam: 79% efficacy where available 4

Refractory Status Epilepticus Protocol

If seizures continue despite benzodiazepines and one second-line agent, initiate continuous EEG monitoring and anesthetic therapy 2:

Third-Line Anesthetic Agents:

• Midazolam infusion: 0.15-0.20 mg/kg IV load, then 1 mg/kg/min continuous infusion (titrate up by 1 mg/kg/min every 15 minutes to max 5 mg/kg/min): 80% efficacy, 30% hypotension risk 2
• Propofol: 2 mg/kg bolus, then 3-7 mg/kg/hour infusion: 73% efficacy, 42% hypotension risk, requires mechanical ventilation 2
• Pentobarbital: 13 mg/kg bolus, then 2-3 mg/kg/hour infusion: 92% efficacy but 77% hypotension risk 2

All anesthetic agents require mechanical ventilation support, continuous EEG monitoring, and aggressive blood pressure management. 2

Special Considerations for Stroke Patients

• Single self-limiting seizure within 24 hours of ischemic stroke should NOT be treated with long-term anticonvulsants 1
• Treat acute seizure with short-acting medications (lorazepam IV) if not self-limiting 1
• Monitor for recurrent seizure activity during routine vital signs 1
• Prophylactic anticonvulsants are NOT recommended and may harm neurological recovery 1

Critical Pitfalls to Avoid

• Never use neuromuscular blockers alone (e.g., rocuronium)—they only mask motor manifestations while allowing continued electrical seizure activity and brain injury 2
• Never skip directly to third-line anesthetic agents until benzodiazepines and at least one second-line agent have been tried 2
• Never delay anticonvulsant administration for neuroimaging in active status epilepticus—CT can be performed after seizure control 2
• Do not administer lorazepam without airway equipment immediately available 3
• Ensure proper dilution of lorazepam with equal volume of compatible diluent before IV administration 3

Post-Seizure Monitoring Requirements

• Continuous vital sign monitoring, particularly respiratory status and blood pressure 2
• Monitor for excessive sedation, especially after multiple doses, as sedative effects may add to post-ictal impairment of consciousness 3
• Patients over 50 years may have more profound and prolonged sedation 3
• No driving or operating machinery for 24-48 hours or until drowsiness subsides, whichever is longer 3