What is the immediate management for a patient experiencing an acute seizure, considering their age, medical history, and potential underlying causes?

Immediate Management of Acute Seizure

For a patient actively seizing, immediately protect them from injury by helping them to the ground, placing them on their side in the recovery position, and clearing the surrounding area—then administer IV lorazepam 4 mg slowly (2 mg/min) if the seizure lasts longer than 5 minutes or does not self-terminate. 1, 2

Initial Safety Measures (First 0-2 Minutes)

• Position the patient on their side in the recovery position to reduce aspiration risk if vomiting occurs during or after the seizure 1, 3
• Help the patient to the ground if not already supine to minimize fall-related injuries 1
• Clear the area around the patient of any objects that could cause injury during seizure movements 1
• Stay with the patient throughout the entire episode 1
• Do NOT restrain the patient during seizure activity, as this can cause musculoskeletal injuries 1
• Do NOT place anything in the mouth or attempt to give oral medications, food, or liquids during the seizure or immediately after when consciousness is impaired 1

Pharmacological Intervention (If Seizure >5 Minutes)

Most seizures self-terminate within 1-2 minutes and require no medication. 1 However, seizures lasting beyond 5 minutes represent a medical emergency requiring immediate treatment:

• Administer lorazepam 4 mg IV slowly (2 mg/min) for adults ≥18 years if the seizure is not self-limiting 1, 2
• If seizures continue after 10-15 minutes of observation, give an additional 4 mg IV lorazepam slowly 2
• For recurrent seizures without return to baseline, treat immediately with benzodiazepines without waiting 5 minutes 3
• Ensure airway patency and have ventilatory support readily available, as respiratory depression is the most important risk with IV lorazepam 2

Critical Timing Note

The mean time to seizure recurrence is 121 minutes (median 90 minutes), with 85% of early recurrences occurring within 6 hours of the initial seizure. 1, 3 This window is critical for observation and decision-making.

Activate Emergency Medical Services (EMS) For:

• First-time seizure in any patient 1
• Seizure lasting >5 minutes 1, 3
• Multiple seizures without return to baseline between episodes 1, 3
• Seizure in pregnancy 1
• Seizure in infant <6 months of age 1
• Seizure occurring in water 1
• Seizure with traumatic injuries, difficulty breathing, or choking 1
• Patient does not return to baseline within 5-10 minutes after seizure stops 1

Immediate Diagnostic Evaluation (Emergency Department)

Essential Laboratory Tests

• Check serum glucose and sodium immediately in all first-time seizure patients, as these are the only laboratory abnormalities that consistently alter acute management 4, 3
• Obtain calcium, magnesium, and renal function to identify metabolic causes 4
• Pregnancy test for all women of childbearing age 4

Neuroimaging Indications

Perform brain CT or MRI in the ED for first-time seizures when any of the following are present: 4

• Age >40 years
• History of malignancy
• Immunocompromised state
• Anticoagulation therapy
• New focal neurological deficits

MRI is preferred over CT for non-emergent evaluation as it is more sensitive for detecting epileptogenic lesions. 3

Risk Stratification for Early Recurrence

High-Risk Features (Requiring Closer Observation):

• Age ≥40 years 1, 3
• Alcoholism (25.2% early recurrence rate vs 9.4% in non-alcoholic new-onset seizures) 1
• Hyperglycemia 1, 3
• Glasgow Coma Scale score <15 1, 3

Overall Recurrence Rates:

• 24-hour recurrence rate: 19% in all seizure patients 3
• Decreases to 9% when alcohol-related events and focal CT lesions are excluded 3

Disposition Decisions

Patients with a first unprovoked seizure can be safely discharged from the ED if they meet ALL of the following criteria: 1, 3

• Returned to clinical baseline neurological status
• Normal neurological examination
• No persistent altered mental status
• Glasgow Coma Scale score of 15

Special Considerations for Stroke Patients:

• A single self-limiting seizure within 24 hours of ischemic stroke should NOT be treated with long-term anticonvulsants 1
• Recurrent seizures in stroke patients should be treated as per standard seizure management protocols 1
• Prophylactic anticonvulsants are NOT recommended in ischemic stroke patients and may cause harm with negative effects on neurological recovery 1

Age-Specific Considerations

Pediatric Patients:

• For febrile seizures, antipyretics (acetaminophen, ibuprofen) are NOT effective for stopping seizures or preventing recurrent febrile seizures 1
• Enhanced EEG monitoring should be considered in neonates and children with stroke 1

Elderly Patients (>50 years):

• May experience more profound and prolonged sedation with IV lorazepam 2
• Higher index of suspicion for metabolic causes including hyponatremia, hypocalcemia, hypomagnesemia, and uremia 4

Common Pitfalls to Avoid

• Do not assume all shaking is seizure activity: 28-48% of suspected seizures have alternative diagnoses 3
• Do not allow oral intake before proper swallowing assessment: aspiration risk remains elevated in the immediate postictal period 3
• Do not start long-term anticonvulsants after a single self-limiting seizure: this is not indicated and may cause unnecessary harm 1
• Do not overlook correctable acute causes: hypoglycemia, hyponatremia, and other metabolic derangements must be immediately sought and corrected 2, 4