What is the management of an acute seizure at a nursing home?

Management of Acute Seizure at a Nursing Home

For an acute seizure in a nursing home, immediately administer intravenous lorazepam 4 mg at 2 mg/min if the seizure is not self-limiting, while simultaneously checking fingerstick glucose and ensuring airway equipment is available with continuous vital sign monitoring. 1, 2

Immediate Actions During Active Seizure

First-Line Treatment

• Administer IV lorazepam 4 mg at 2 mg/min as the only Level A first-line treatment for acute seizures, demonstrating 59.1% seizure termination efficacy 1
• Have airway equipment immediately available at bedside with continuous monitoring of vital signs, particularly respiratory status 1, 2
• If seizures continue after 10-15 minutes, administer an additional 4 mg IV lorazepam slowly 2

Simultaneous Diagnostic Actions

• Check fingerstick glucose immediately in all seizure patients, as hypoglycemia is a common reversible cause 3, 1
• Assess for metabolic derangements including hyponatremia (most common electrolyte cause), hypocalcemia, and hypomagnesemia 3, 1
• Evaluate for drug toxicity or withdrawal syndromes, particularly alcohol withdrawal in nursing home populations 1, 4

Second-Line Treatment (If Seizure Persists)

If benzodiazepines fail to terminate the seizure, proceed to second-line agents 1:

• Valproate 20-30 mg/kg IV over 5-20 minutes (88% efficacy, 0% hypotension risk) 1
• Levetiracetam 30 mg/kg IV over 5 minutes (68-73% efficacy, minimal cardiovascular effects) 1
• Fosphenytoin 20 mg PE/kg IV at maximum 150 PE/min (84% efficacy but 12% hypotension risk) 1

Critical Pitfalls to Avoid

• Never use neuromuscular blockers alone (e.g., rocuronium) as they only mask motor manifestations while allowing continued electrical seizure activity and brain injury 1
• Do not skip directly to third-line anesthetic agents until benzodiazepines and at least one second-line agent have been tried 1
• Recognize that respiratory depression is the most important risk with lorazepam use, requiring airway patency assurance and close respiratory monitoring 2

Post-Seizure Management Decisions

For Single Self-Limiting Seizures

• A single self-limiting seizure should NOT be treated with long-term anticonvulsants 5, 1
• Monitor for recurrent seizure activity during routine vital sign checks 5
• Investigate underlying causes: infections (pneumonia, UTI), stroke, metabolic abnormalities, or toxic ingestions 3, 4

For Recurrent Seizures

• Treat recurrent seizures with long-term anticonvulsants as per treatment recommendations for seizures in other neurological conditions 5
• Levetiracetam is the most commonly prescribed maintenance ASM in nursing homes, followed by lamotrigine, valproic acid, and phenytoin 6

Special Considerations for Nursing Home Setting

Documentation Requirements

• Document whether the seizure is provoked (within 7 days of acute insult) or unprovoked, as this distinction is critical for diagnosis 3
• Record seizure semiology using International League Against Epilepsy classification (focal vs. generalized) 3
• Note any focal neurologic deficits, as 81% of patients with focal CT lesions have such deficits 3

Nursing Home-Specific Challenges

• Only 52% of nursing homes have seizure protocols, highlighting the need for standardized acute seizure action plans 6
• Nurses are responsible for protocol activation in the majority of cases 6
• Oral benzodiazepines are most commonly used in nursing homes, followed by IV then rectal formulations, though newer intranasal and intramuscular formulations are underutilized 6

Post-Acute Monitoring

• Continue vital sign monitoring, particularly respiratory status and blood pressure, after acute seizure management 1
• Patients over 50 years may have more profound and prolonged sedation with IV lorazepam 2
• Consider transfer to hospital for neuroimaging (CT or MRI) if this is a new-onset seizure, focal deficits are present, or the patient fails to return to baseline 3
• Patients with CT abnormalities are found in 34% overall, highest in those >60 years 3