What is the immediate management for an inpatient with continuous seizures?

Management of Continuous Seizures (Status Epilepticus) in the Inpatient Setting

Administer IV lorazepam 4 mg slowly (2 mg/min) immediately as first-line treatment, and if seizures persist after 10-15 minutes, give a second 4 mg dose; patients who fail to respond to benzodiazepines must receive an additional antiepileptic medication—specifically IV fosphenytoin, phenytoin, or valproate as second-line agents. 1, 2

Immediate Stabilization (First 5 Minutes)

• Secure airway, breathing, and circulation before any medication administration—equipment for artificial ventilation must be immediately available at bedside, as respiratory depression is the most important risk with lorazepam 2, 3
• Start IV access, monitor vital signs continuously (heart rate, blood pressure, oxygen saturation, temperature), and maintain unobstructed airway 2, 1
• Check fingerstick glucose immediately and correct hypoglycemia if present, as this is a rapidly reversible cause 1, 4
• Draw blood for electrolytes, sodium, complete blood count, and toxicology screen while establishing IV access 3, 4

First-Line Treatment: Benzodiazepines

• Give lorazepam 4 mg IV slowly at 2 mg/min—this is the standard dose for adults 18 years and older 2, 1
• If seizures stop, no additional lorazepam is needed; observe for 10-15 minutes 2
• If seizures continue or recur after 10-15 minutes, administer a second 4 mg IV dose of lorazepam slowly 2
• Experience with further doses beyond 8 mg total is very limited and not recommended 2

Critical Pitfall to Avoid

Many patients receive inadequate benzodiazepine doses—ensure full 4 mg doses are given, as underdosing is a common cause of treatment failure 5

Second-Line Treatment: Refractory Status Epilepticus (After Benzodiazepine Failure)

Emergency physicians must administer an additional antiepileptic medication in patients with refractory status epilepticus who have failed benzodiazepines (Level A recommendation). 1

Preferred Second-Line Agents (Level B Evidence)

Choose one of the following three agents 1:

• Fosphenytoin: 18 PE/kg IV at maximum rate of 150 PE/min—fewer adverse events than phenytoin, requires filter and infusion pump 1
• Phenytoin: 18 mg/kg IV at maximum rate of 50 mg/min—requires cardiac monitoring for arrhythmias 1
• Valproate: up to 30 mg/kg IV at maximum rate of 10 mg/kg/min—shown to be at least as effective as phenytoin with potentially fewer adverse effects 1

The 2014 Annals of Emergency Medicine guidelines provide Level B evidence (moderate quality) supporting these three agents equally for refractory status epilepticus 1

Third-Line Treatment: Highly Refractory Status Epilepticus

If seizures persist after second-line agents, administer one of the following (Level C recommendations) 1:

• Levetiracetam IV 1
• Propofol infusion (adults only—requires ICU setting with mechanical ventilation) 1, 6
• Barbiturates: pentobarbital or phenobarbital infusion (requires ICU with invasive hemodynamic monitoring and EEG monitoring) 1, 6

Barbiturate Considerations

Pentobarbital has a 92% treatment success rate for refractory status epilepticus but causes hypotension requiring vasopressors in 77% of patients, compared to 42% with propofol and 30% with midazolam 1, 6

Concurrent Management During Seizure Treatment

• Search aggressively for treatable causes: hypoglycemia, hyponatremia, hypoxia, drug toxicity, CNS infection, intracranial hemorrhage, ischemic stroke, alcohol withdrawal 1, 4
• Obtain brain CT imaging urgently if any of the following: age >40, known malignancy, immunocompromised, fever, anticoagulation, new focal deficits 3
• Monitor temperature every 4 hours—treat fever >37.5°C promptly as hyperthermia worsens outcomes 7
• Do not delay imaging because of ongoing seizure activity—life-threatening pathology is present in nearly 1 in 4 patients with new-onset seizures 3

Special Considerations for Post-Stroke or Watershed Stroke Patients

• Avoid aggressive blood pressure lowering—maintain systolic BP <220 mmHg and diastolic <120 mmHg to preserve cerebral perfusion in watershed territories 7
• Elevate head of bed 20-30 degrees to improve venous drainage 7
• Do not start long-term anticonvulsants for a single, self-limiting seizure within 24 hours of acute stroke—no evidence supports prophylaxis and possible harm exists with negative effects on neural recovery 7, 3

Monitoring for Nonconvulsive Status Epilepticus

• Consider EEG monitoring if unexplained reduced consciousness persists after apparent seizure termination—25% of patients with generalized convulsive status epilepticus have continuing electrical seizures without motor activity 1, 3
• Ongoing electrical seizure activity causes neuronal injury even without convulsive movements 1

Critical Timing Considerations

Status epilepticus is defined as continuous seizure activity lasting ≥20 minutes or intermittent seizures without regaining consciousness, though treatment should begin at 5 minutes of continuous seizure activity 1

When to Initiate Long-Term Anticonvulsants

Start maintenance anticonvulsant therapy only if 7, 3:

• Recurrent seizures occur
• Status epilepticus develops
• Seizures occur in the early (24 hours to 7 days) or late (>7 days) post-stroke period
• Brain tumor or other structural lesion is identified

Do not start prophylactic anticonvulsants for single, self-limiting seizures—this may impair neural recovery without proven benefit 7, 3

Post-Seizure Management

• Assess swallowing function before allowing oral intake due to elevated aspiration risk 7
• Patients over 50 years may have more profound and prolonged sedation—advise no driving or operating machinery for 24-48 hours or until drowsiness subsides 2
• Premature ambulation may result in falls and injury 2