What is the approach to managing a patient presenting with a seizure, considering their safety, potential underlying medical conditions, and past medical history of seizure disorders?

Approach to Managing a Patient Presenting with Seizure

Immediate Stabilization and Safety

For any seizure lasting >5 minutes, immediately administer benzodiazepines while simultaneously securing the airway, establishing IV access, and checking fingerstick glucose. 1, 2, 3

• Lorazepam 0.1 mg/kg IV (typically 4 mg for adults) is the preferred benzodiazepine due to its longer duration of action, administered slowly at 2 mg/min 3, 4
• If seizures persist after 10-15 minutes, repeat lorazepam 4 mg IV 4
• Maintain NPO status until swallowing ability is formally assessed to prevent aspiration 2
• Monitor vital signs continuously and have airway management equipment immediately available, as respiratory depression is the most important risk with benzodiazepine administration 4

Identify Reversible Causes Immediately

• Check serum glucose and sodium immediately—these are the only laboratory abnormalities that consistently alter acute management 5, 3
• Search for other metabolic derangements: hypocalcemia, hypomagnesemia 3
• Consider toxicology screen if ingestion is suspected 3
• Assess for withdrawal syndromes (alcohol, benzodiazepines) 1

Classify the Seizure Type

Determine whether this is a provoked or unprovoked seizure, as this fundamentally changes management. 1, 5

• Provoked seizures occur within 7 days of an acute insult: hyponatremia, other electrolyte abnormalities, withdrawal, toxic ingestions, encephalitis, CNS mass lesions, intracranial hemorrhage 1, 5
• Unprovoked seizures have no acute precipitating factors, including remote symptomatic seizures from events >7 days past 1, 5

Management of Refractory Status Epilepticus

If seizures persist despite optimal benzodiazepine dosing, immediately administer a second-line antiepileptic agent. 1, 2, 3

• Choose one of the following—all have similar efficacy: fosphenytoin, levetiracetam, or valproic acid 3
• Fosphenytoin is preferred over phenytoin due to faster infusion rate and lower hypotension risk 3
• Levetiracetam has 67-73% efficacy with no hypotension risk 3
• Valproate has 68-88% efficacy with minimal hypotension risk and may be superior to phenytoin 5, 3

Diagnostic Workup Based on Clinical Presentation

For first-time seizure patients, obtain head CT in the ED if the patient is >60 years old, has focal neurologic deficits, has not returned to baseline mental status, or has trauma/fever. 2, 3

• MRI is preferred when neuroimaging is obtained due to higher sensitivity for structural lesions, though CT is acceptable for emergency evaluation 3, 6
• EEG should be performed within 24 hours, particularly in children 6
• Consider emergent EEG for patients with persistent altered consciousness after seizure termination to rule out non-convulsive status epilepticus 3
• For patients with normal neurologic examination who have returned to baseline: only glucose and electrolytes are required 5, 7

Decision to Initiate Antiepileptic Therapy

For first unprovoked seizures in patients who have returned to baseline, do NOT routinely initiate antiepileptic drugs in the ED. 1, 5, 2

• Early treatment only prolongs time to next event without changing 5-year outcomes, with a number needed to treat of 14 to prevent one seizure recurrence in the first 2 years 5
• Exception: Consider initiating antiepileptic medication if the patient has remote history of brain disease or injury, or abnormal EEG with epileptiform abnormalities—these patients have 60-70% recurrence risk 5, 8
• For provoked seizures, treat the underlying cause; symptomatic antiepileptic therapy is not justified unless the seizure has characteristics of status epilepticus 6
• Patients with 2-3 recurrent unprovoked seizures have substantially increased recurrence risk and should receive antiepileptic therapy 5

Route of Administration for Known Seizure Disorder

For patients already on antiepileptic drugs who present with breakthrough seizure, consider intravenous loading with fosphenytoin or valproate. 5

• Check antiepileptic drug levels if patient is on phenytoin, valproate, carbamazepine, or phenobarbital to assess for subtherapeutic levels 5

Admission Criteria

Admit patients with status epilepticus requiring multiple medications, persistent altered mental status, acute symptomatic causes, or refractory seizures. 3

• Patients with first unprovoked seizure who have returned to baseline, have normal neurologic examination, and normal laboratory results do not require hospitalization 7

Critical Pitfalls to Avoid

• Do not delay benzodiazepines if seizure exceeds 5 minutes—mortality increases significantly in refractory cases 3
• Do not miss non-convulsive status epilepticus—consider in any patient with unexplained confusion or coma 3
• Do not allow oral intake before proper swallowing assessment—aspiration risk persists in the immediate post-ictal period 2
• Do not start prophylactic anticonvulsants in stroke patients—they may negatively affect neurological recovery 3
• Patients over age 50 may have more profound and prolonged sedation with benzodiazepines 4