What are the steps to manage a seizure code?

Seizure Code Management Protocol

For an active seizure emergency, immediately secure the airway with 100% oxygen, establish IV/IO access, check blood glucose at bedside, and administer lorazepam 0.1 mg/kg IV (maximum 4 mg) slowly over 2 minutes as first-line therapy. 1, 2, 3

Immediate Stabilization (First 0-2 Minutes)

Airway and Positioning:

• Position patient on their side to prevent aspiration 2
• Never restrain the seizing patient or place anything in their mouth 2
• Provide high-flow oxygen (100%) to prevent hypoxemia from seizure-induced respiratory compromise 4, 1, 2
• Have equipment ready to maintain patent airway and provide ventilatory support 4, 3

Critical Initial Assessments:

• Check blood glucose immediately at bedside—hypoglycemia is a rapidly reversible cause that must be identified urgently 1, 2, 5
• Establish IV or intraosseous access if not already present 1, 2
• Begin continuous monitoring of vital signs, ECG, oxygen saturation, blood pressure, and temperature 2, 6

First-Line Seizure Termination (Minutes 2-5)

Benzodiazepine Administration:

• Adults: Administer lorazepam 0.1 mg/kg IV (maximum 4 mg) slowly over 2 minutes 2, 3
• Pediatrics: Administer lorazepam 0.1 mg/kg IV (maximum 2 mg) slowly over 2 minutes, may repeat once after at least 1 minute (maximum 2 doses) 4, 1
• If IV access unavailable, intramuscular midazolam 0.2 mg/kg (maximum 10 mg) is an acceptable alternative 7
• Intranasal midazolam 0.2 mg/kg can be used when other routes are not immediately available 7

Repeat Dosing:

• If seizure continues after 1 minute, repeat lorazepam 0.1 mg/kg (maximum 4 mg in adults, 2 mg in pediatrics) 2, 3
• Maximum of 2 doses of lorazepam for initial treatment 4, 1, 3

Second-Line Therapy (Minutes 5-10)

If Seizures Persist After Benzodiazepines:

• Pediatrics: Immediately administer levetiracetam 40 mg/kg IV bolus (maximum 2,500 mg) 4, 1
• Adults: Administer phenytoin loading dose 18 mg/kg IV at rate not exceeding 50 mg/minute (approximately 20 minutes for 70 kg patient) 2, 6
• Pediatrics (alternative): Phenytoin 15-20 mg/kg IV at rate not exceeding 1-3 mg/kg/min or 50 mg/minute, whichever is slower 6

Critical Monitoring During Phenytoin:

• Continuous ECG and blood pressure monitoring is essential during phenytoin administration 6
• Observe for signs of respiratory depression 6
• Use in-line filter (0.22 to 0.55 microns) if giving as infusion 6

Third-Line Therapy for Refractory Status Epilepticus (After 10-15 Minutes)

Escalation Protocol:

• Add phenobarbital 10-20 mg/kg IV loading dose (maximum 1,000 mg) over 10 minutes 4, 6
• Consider transfer to ICU/PICU for refractory seizures 4
• Prepare for possible intubation and mechanical ventilation 4, 3
• Consider continuous EEG monitoring for refractory seizures 4

Alternative Agents for Refractory Cases:

• Propofol infusion may be considered for refractory status epilepticus 8
• Avoid propofol if cardiovascular instability is present 4

Maintenance Therapy After Seizure Control

Post-Seizure Medication Dosing:

• Lorazepam 0.05 mg/kg (maximum 1 mg) IV every 8 hours for 3 doses 4, 1
• Levetiracetam 30 mg/kg IV every 12 hours or increase prophylaxis dose to 20 mg/kg IV every 12 hours (maximum 1,500 mg) 4, 1
• Phenobarbital 1-3 mg/kg IV every 12 hours if used for seizure termination 4

Post-Ictal Management

Ongoing Monitoring:

• Continue oxygen supplementation and lateral positioning during postictal period 2
• Monitor vital signs continuously including heart rate, blood pressure, oxygen saturation, and temperature 2
• Reassess neurological status including level of consciousness and focal deficits 2
• Maintain aspiration precautions and elevated head of bed 4

Diagnostic Workup:

• Neuroimaging (MRI with and without contrast or CT if MRI not available) for grade ≥2 neurotoxicity or unexplained altered mental status 4
• EEG evaluation for unexplained altered mental status to assess for nonconvulsive seizures 4
• Lumbar puncture for grade ≥3 neurotoxicity and may consider for grade 2 4
• Investigate possible infection (pneumonia, urinary tract infection, meningitis/encephalitis) 4, 2
• Monitor and correct severe hyponatremia 4

Context-Specific Considerations

Stroke-Related Seizures:

• A single self-limiting seizure occurring at onset or within 24 hours after ischemic stroke should NOT be treated with long-term anticonvulsant medications 4
• Recurrent seizures in stroke patients should be treated as per standard seizure management 4
• Prophylactic anticonvulsants are not recommended and may negatively affect neurological recovery 4

Pediatric-Specific Scenarios:

• Simple febrile seizures require no prophylactic anticonvulsant therapy 1
• Complex febrile seizures require observation within inpatient setting and investigations including blood tests and lumbar puncture as appropriate 1
• Neonatal seizures follow the same CAB assessment, oxygen administration, and glucose checking protocol 1

First Unprovoked Seizure:

• Do NOT routinely initiate antiepileptic drugs after a first unprovoked seizure 4, 1
• Patients with first unprovoked seizure who have returned to clinical baseline do not require admission 4
• Consider initiating treatment for first unprovoked seizure with remote history of brain disease or injury 4

Critical Pitfalls to Avoid

Medication Safety:

• Inadequate respiratory monitoring when using benzodiazepines, particularly with combination therapy, can lead to respiratory arrest 1
• Reduce doses of other CNS depressants when using benzodiazepines 3
• Never exceed 50 mg/minute phenytoin infusion rate in adults or 1-3 mg/kg/min in pediatrics to minimize cardiovascular adverse reactions 6

Diagnostic Errors:

• Failure to check glucose early leads to missed diagnosis of easily reversible hypoglycemia 1, 5
• Delaying second-line therapy beyond 5-10 minutes worsens seizure outcomes and increases risk of permanent neurological impairment 1, 3
• Not considering nonconvulsive status epilepticus in patients with unexplained altered mental status or coma 5

Treatment Errors:

• Using prophylactic anticonvulsants for simple febrile seizures causes unnecessary toxicity without benefit 1
• Intramuscular phenytoin should NOT be used for status epilepticus because peak serum levels may require up to 24 hours 6
• Avoid vasopressin, calcium channel blockers, and β-blockers in local anesthetic toxicity-induced seizures 4