What is the management of an acute seizure?

From the Guidelines

To manage an acute seizure, benzodiazepines should be administered as first-line treatment, with lorazepam (Ativan) 2-4 mg IV/IM, diazepam (Valium) 5-10 mg IV/PR, or midazolam (Versed) 5-10 mg IM/intranasal being suitable options, as recommended by the American College of Emergency Physicians (ACEP) in their 2024 clinical policy 1. When managing an acute seizure, it is crucial to prioritize the patient's safety above all, by moving objects away, placing them on their side, and not restraining them or putting anything in their mouth. Key considerations include:

• Calling emergency services if the seizure lasts more than 5 minutes, if multiple seizures occur without recovery, if the person is injured, pregnant, or has no known seizure history.
• Administering benzodiazepines as first-line treatment, with options including lorazepam (Ativan) 2-4 mg IV/IM, diazepam (Valium) 5-10 mg IV/PR, or midazolam (Versed) 5-10 mg IM/intranasal.
• Using second-line treatments, such as fosphenytoin (20 mg PE/kg IV), valproate (40 mg/kg IV), or levetiracetam (60 mg/kg IV, max 4500 mg), if seizures persist. The ACEP's 2024 clinical policy provides evidence-based recommendations for the management of adult emergency department patients presenting with seizure, including the use of benzodiazepines as first-line treatment 1. After the seizure stops, it is essential to:
• Monitor the person's breathing and consciousness
• Place them in recovery position
• Stay until they are fully alert
• Document the seizure duration, characteristics, and any potential triggers to help with future management. Benzodiazepines work by enhancing GABA activity in the brain, which inhibits excessive neuronal firing that causes seizures, as noted in the ACEP's clinical policy 1.

From the FDA Drug Label

The use of benzodiazepines, like lorazepam injection, is ordinarily only an initial step of a complex and sustained intervention which may require additional interventions (e.g., concomitant intravenous administration of phenytoin). For the treatment of status epilepticus, the usual recommended dose of lorazepam injection is 4 mg given slowly (2 mg/min) for patients 18 years and older. If seizures cease, no additional lorazepam injection is required If seizures continue or recur after a 10- to 15-minute observation period, an additional 4 mg intravenous dose may be slowly administered.

To manage acute seizure or status epilepticus, the recommended initial dose of lorazepam is 4 mg given slowly (2 mg/min) for patients 18 years and older. If seizures cease, no additional dose is required. If seizures continue or recur after a 10- to 15-minute observation period, an additional 4 mg intravenous dose may be slowly administered 2.

• Key considerations:
  • Ventilatory support must be readily available
  • Intravenous infusion should be started
  • Vital signs should be monitored
  • Unobstructed airway should be maintained
  • Artificial ventilation equipment should be available
• Additional interventions may be required, such as concomitant intravenous administration of phenytoin.

From the Research

Managing Acute Seizures

To manage acute seizures, several treatment options are available, including:

• Sublingual lorazepam oral concentrate solution, which has been shown to be effective in interrupting prolonged and repetitive seizures 3
• Rectal diazepam, which is currently the only formulation approved by the US Food and Drug Administration (FDA) for out-of-hospital treatment of acute repetitive and prolonged seizures 4
• Intramuscular diazepam autoinjection, which has shown success against acute repetitive seizures in clinical trials 4
• Intranasal midazolam and diazepam, which are in testing for the treatment of acute repetitive and prolonged seizures 4

Benzodiazepines in Seizure Management

Benzodiazepines are commonly used in the treatment of epilepsy and are the first-line treatment for status epilepticus 5, 6. They act on the GABAA receptor to promote a state of central nervous system depression. Different benzodiazepines have different efficacy profiles and pharmacokinetic and pharmacodynamic properties, and the choice of benzodiazepine may depend on the specific patient and seizure type.

Routes of Administration

Different routes of administration are available for benzodiazepines, including:

• Intravenous administration, which is commonly used in the hospital setting 6, 7
• Intramuscular administration, which has been shown to be effective in clinical trials 4, 6
• Rectal administration, which is currently the only formulation approved by the US FDA for out-of-hospital treatment of acute repetitive and prolonged seizures 4
• Sublingual administration, which has been shown to be effective in interrupting prolonged and repetitive seizures 3
• Intranasal administration, which is in testing for the treatment of acute repetitive and prolonged seizures 4, 6

Efficacy and Safety

The efficacy and safety of benzodiazepines in the treatment of seizures have been established in several studies 3, 4, 5, 6, 7. Lorazepam, in particular, has been shown to be as efficacious and safe as diazepam-phenytoin combination in the treatment of convulsive status epilepticus in children 7. However, the choice of benzodiazepine and route of administration may depend on the specific patient and seizure type, and should be determined by a healthcare professional.