What is the appropriate management for a patient presenting with a seizure in the ED (Emergency Department)?

Emergency Department Management of Seizures

For any actively seizing patient in the ED, immediately administer benzodiazepines as first-line therapy, followed by levetiracetam, fosphenytoin, or valproate as equally effective second-line agents if seizures persist beyond 5 minutes. 1, 2

Immediate Stabilization (First 5 Minutes)

Active Seizure Management

• Administer lorazepam 4 mg IV at 2 mg/min as the preferred benzodiazepine (65% efficacy in terminating status epilepticus, superior to diazepam's 42.6%) 2
• Have airway equipment immediately available before giving any benzodiazepine due to respiratory depression risk 2
• If no IV access, use rectal diazepam (avoid IM route due to erratic absorption) 3
• Check fingerstick glucose immediately and correct hypoglycemia while administering treatment 1, 2

Critical Concurrent Actions

• Search for and treat underlying causes: hyponatremia, hypoxia, ischemic stroke, intracerebral hemorrhage, withdrawal syndromes, medication noncompliance 1
• Recognize that prescribed medications (tramadol) and illicit substances (cocaine) can lower seizure threshold 1

Second-Line Treatment (If Seizures Persist ≥5 Minutes)

Status epilepticus is operationally defined as seizures lasting ≥5 minutes, requiring immediate escalation. 2

Equivalent Second-Line Options (45-47% efficacy at 60 minutes)

All three agents have equivalent efficacy; select based on safety profile and patient-specific contraindications 1, 2:

• Levetiracetam 60 mg/kg IV (maximum 4500 mg) over 10 minutes

  • Hypotension risk: 0.7%
  • Intubation rate: 20% 1, 2

• Valproate 40 mg/kg IV (maximum 3000 mg) over 10 minutes

  • Hypotension risk: 1.6%
  • Intubation rate: 16.8% 1, 2

• Fosphenytoin 20 mg phenytoin equivalents/kg IV at maximum rate of 150 mg/min

  • Hypotension risk: 3.2%
  • Intubation rate: 26.4% 1, 2

Third-Line Treatment (Refractory Status Epilepticus)

Refractory status epilepticus is defined as seizures continuing despite benzodiazepines and one second-line agent. 2

Anesthetic Agents

• Midazolam: Loading dose 0.15-0.20 mg/kg IV, then continuous infusion 1 mg/kg/min, titrate up by 1 mg/kg/min every 15 minutes to maximum 5 mg/kg/min 2
• Propofol: Loading dose 2 mg/kg bolus, then continuous infusion 3-7 mg/kg/hour 2
• Pentobarbital: Loading dose 13 mg/kg, then continuous infusion 2-3 mg/kg/hour (92% efficacy but 77% require vasopressor support) 1, 2
• Ketamine: Emerging evidence supports earlier use 1

Essential Monitoring

• Initiate continuous EEG monitoring to guide therapy and detect nonconvulsive status epilepticus 1, 2
• Continuous vital sign monitoring, particularly respiratory status and blood pressure 2

Disposition Decisions After Seizure Control

Discharge Criteria (First Unprovoked Seizure)

Patients with a first unprovoked seizure who have returned to their clinical baseline in the ED need not be admitted. 4

Admission Considerations

• Age ≥40 years, alcoholism, hyperglycemia, or Glasgow Coma Scale <15 are associated with early seizure recurrence (85% of recurrences occur within 360 minutes) 4
• Alcoholic patients with seizure history have highest early recurrence rate (25.2%) 4
• Nonalcoholic patients with new-onset seizures have lowest early recurrence (9.4%) 4

Antiepileptic Medication Initiation Decisions

Do NOT Initiate AEDs in the ED for:

• Provoked seizures: Identify and treat precipitating medical conditions instead 4
• First unprovoked seizure without evidence of brain disease or injury: Waiting until a second seizure before initiating AEDs is appropriate (NNT=14 to prevent one recurrence within 2 years) 4

MAY Initiate AEDs in the ED for:

• First unprovoked seizure with remote history of brain disease or injury (stroke, trauma, tumor, CNS disease): These patients have higher recurrence rates, making treatment appropriate after one seizure (NNT=5 to prevent one seizure in first year) 4

Critical Pitfalls to Avoid

• Failing to recognize nonconvulsive status epilepticus in patients with persistent altered mental status—obtain EEG 1
• Delaying anticonvulsant administration for neuroimaging—obtain CT head after seizure control is achieved 2
• Missing hypoglycemia as a rapidly reversible cause 1, 2
• Approximately 16-26% of patients with status epilepticus require endotracheal intubation, with mortality ranging from 5-22% (65% in refractory cases) 1, 2