What are the steps to manage a seizure code?

Seizure Code Management Protocol

For an active seizure lasting >5 minutes (status epilepticus), immediately administer benzodiazepines as first-line therapy, followed by second-line agents (fosphenytoin, levetiracetam, or valproic acid) if seizures persist, while simultaneously securing airway, establishing IV access, checking glucose, and identifying reversible causes. 1

Immediate Actions (First 0-5 Minutes)

Airway, Breathing, Circulation

• Protect the airway and position patient to prevent aspiration (lateral decubitus if possible) 2
• Administer supplemental oxygen and monitor oxygen saturation 3
• Establish IV access immediately 3
• Check fingerstick glucose immediately in all seizure patients, as hypoglycemia is a common reversible cause 4, 5

Initial Assessment During Seizure

• Note seizure duration from onset (critical for determining status epilepticus) 1
• Document seizure semiology: focal versus generalized onset 5
• Monitor vital signs continuously 3

Pharmacologic Management Algorithm

First-Line Treatment (If Seizure >5 Minutes)

Administer benzodiazepines immediately: 1, 2

• Lorazepam 0.1 mg/kg IV (preferred due to longer duration of action), OR
• Diazepam 0.15-0.2 mg/kg IV 2

Second-Line Treatment (If Seizure Continues After Benzodiazepines)

Choose ONE of the following (all have similar 45-47% efficacy): 4, 1

• Fosphenytoin: 18-20 mg PE/kg IV at 150 mg/min (preferred over phenytoin due to faster infusion rate and less hypotension risk) 1
• Levetiracetam: 30 mg/kg IV at 5 mg/kg/min (no hypotension risk, efficacy 67-73%) 1
• Valproate: 30 mg/kg IV at 6 mg/kg/hour (efficacy 68-88%, minimal hypotension) 1

Clinical Pearl: Phenytoin/fosphenytoin causes hypotension in 12% of cases versus 0% with valproate 1

Third-Line Treatment (Refractory Status Epilepticus)

If seizures persist after second-line agents: 1

• Propofol: 1-2 mg/kg IV bolus, then 2-10 mg/kg/hour infusion, OR
• Phenobarbital: 20 mg/kg IV at 50-100 mg/min 1
• Consider ICU transfer and continuous EEG monitoring 1

Concurrent Diagnostic Workup

Identify and Correct Precipitating Factors

Search for reversible causes immediately: 6, 4, 1

Metabolic causes to check:

• Hypoglycemia (check immediately) 4, 5
• Hyponatremia (most common electrolyte cause) 4, 5
• Hypocalcemia (can trigger seizures at any age) 4, 5
• Hypomagnesemia (especially in alcohol-related seizures) 5
• Uremia, hyperglycemia 5

Other acute causes:

• Hypoxia 1
• CNS infection (meningitis, encephalitis) 1, 5
• Stroke or intracranial hemorrhage 1, 5
• Medication non-compliance in known epilepsy patients 4
• Toxic ingestions (tramadol, theophylline, isoniazid) 4, 7
• Alcohol withdrawal 5, 7

Essential Laboratory Tests

• Serum glucose (immediate) 4, 5
• Complete metabolic panel: sodium, calcium, magnesium, renal function 4, 5
• Consider toxicology screen if ingestion suspected 5

Post-Seizure Management

Neuroimaging Decisions

Obtain head CT in the emergency department for: 5

• First-time seizure patients (34% have CT abnormalities) 5
• Patients >60 years (highest yield) 5
• Focal neurologic deficits present (81% have focal lesions, but 17% with normal exams still have abnormalities) 5
• MRI is preferred when neuroimaging is obtained (higher sensitivity for structural lesions) 5

EEG Monitoring Indications

Consider emergent EEG for: 1

• Persistent altered consciousness after seizure termination (rule out non-convulsive status epilepticus) 1
• Patients who received long-acting paralytics 1
• Patients in drug-induced coma 1

Disposition and Long-Term Management Decisions

When NOT to Start Antiepileptic Medications

Do not initiate long-term antiepileptics in the ED for: 6, 4

• Provoked seizures (treat the underlying cause instead) 6, 4
• Single unprovoked seizure without brain disease/injury (outpatient follow-up appropriate; NNT=14 to prevent one recurrence in 2 years) 6

When to CONSIDER Starting Antiepileptics

May initiate or defer to outpatient neurology for: 6

• First unprovoked seizure WITH remote history of brain disease/injury (stroke, trauma, tumor) 6
• These patients have higher recurrence risk and may benefit from treatment after single seizure 6

Admission Criteria

Patients do NOT require admission if: 6

• First unprovoked seizure
• Returned to clinical baseline in ED
• No ongoing acute medical issues 6

Admit patients with:

• Status epilepticus requiring multiple medications 1
• Persistent altered mental status 1
• Acute symptomatic causes requiring inpatient treatment 3
• Refractory seizures 1

Critical Pitfalls to Avoid

• Do not delay benzodiazepines if seizure exceeds 5 minutes—mortality increases significantly in refractory cases (65%) 1
• Phenytoin is ineffective for alcohol withdrawal seizures and certain toxic ingestions (theophylline, isoniazid) 7
• Do not assume epilepsy—most medically ill patients with secondary seizures do not have epilepsy; explain this to patients and families 7
• Do not miss non-convulsive status epilepticus—consider in any patient with unexplained confusion or coma 1, 7
• Do not start prophylactic anticonvulsants in stroke patients—may negatively affect neurological recovery 4