Guidelines for Seizure Management

Immediate First Aid and Emergency Response

For any actively seizing patient, immediately administer IV lorazepam 4 mg at 2 mg/min—this terminates status epilepticus in 65% of cases and is superior to diazepam (59.1% vs 42.6% seizure cessation). 1

First Aid Provider Actions (Non-Medical Personnel)

Help the seizing person to the ground, place them on their side in recovery position, and clear the surrounding area to minimize injury risk. 2
Stay with the person throughout the seizure and do not restrain them. 2
Never put anything in the person's mouth or give food, liquids, or oral medications during or immediately after a seizure. 2
Activate EMS for: first-time seizure, seizures lasting >5 minutes, multiple seizures without return to baseline, seizures in water, traumatic injuries, difficulty breathing, choking, seizures in infants <6 months, pregnant individuals, or failure to return to baseline within 5-10 minutes after seizure stops. 2

Medical Provider Pre-Treatment Preparation

Have airway equipment (bag-valve-mask and intubation set) immediately available before administering any benzodiazepine, as respiratory depression requiring intervention is predictable. 1
Check fingerstick glucose immediately and correct hypoglycemia while administering anticonvulsants. 1
Establish IV access and start fluid resuscitation simultaneously with benzodiazepine administration to prevent hypotension. 1

Status Epilepticus Treatment Algorithm

Status epilepticus is defined operationally as any seizure lasting ≥5 minutes or recurrent seizures without return to baseline consciousness—treatment must begin immediately at this threshold, not at the traditional 30-minute definition. 1, 3

Stage 1: First-Line Treatment (0-5 minutes)

Benzodiazepines

IV lorazepam 4 mg at 2 mg/min is the preferred first-line agent with 65% efficacy and longer duration of action than diazepam. 1, 4
May repeat once after 5 minutes if seizures continue. 1
Alternative routes when IV access unavailable:
- IM midazolam 0.2 mg/kg (maximum 6 mg), may repeat every 10-15 minutes. 1
- Intranasal midazolam with onset in 1-2 minutes, peak effect at 3-4 minutes. 1
- Rectal diazepam 0.5 mg/kg if buccal/intranasal routes not feasible. 1
- Never use IM diazepam due to erratic absorption. 1
Continuously monitor oxygen saturation and respiratory status for at least 30 minutes, as apnea can occur up to 30 minutes after the last dose. 1

Stage 2: Second-Line Treatment (5-20 minutes)

If seizures persist after adequate benzodiazepine dosing, immediately escalate to one of the following second-line agents—do not delay. 1

Recommended agents in order of safety profile:

Valproate (Preferred for Safety)

Dose: 20-30 mg/kg IV (maximum 3000 mg) over 5-20 minutes. 1, 5
Efficacy: 88% seizure cessation with 0% hypotension risk—superior safety profile to phenytoin. 1
Absolute contraindication: Women of childbearing potential due to fetal teratogenicity and neurodevelopmental risks. 1, 6
No cardiac monitoring required. 1

Levetiracetam (Preferred for Minimal Side Effects)

Dose: 30 mg/kg IV (maximum 2500-3000 mg) over 5 minutes. 1
Efficacy: 68-73% seizure cessation with minimal cardiovascular effects (≈0.7% hypotension risk). 1
20% intubation rate, no continuous cardiac monitoring required. 1
Maintenance: 30 mg/kg IV every 12 hours (maximum 1500 mg/dose) for convulsive SE; 15 mg/kg every 12 hours for non-convulsive SE. 1
Renal dosing required: Reduce dose by 50% if CrCl 30-50 mL/min; reduce to 250-500 mg every 12 hours if CrCl <30 mL/min. 1

Fosphenytoin (Traditional Agent)

Dose: 20 mg PE/kg IV at maximum rate of 150 PE/min (not to exceed 50 mg/min in elderly). 1
Efficacy: 84% seizure cessation but 12% hypotension risk. 1
Requires continuous ECG and blood pressure monitoring due to cardiovascular toxicity. 1
26.4% intubation rate. 1
95% of neurologists recommend phenytoin/fosphenytoin for benzodiazepine-refractory seizures, making it the most widely available option. 1

Phenobarbital (Highest Respiratory Risk)

Dose: 20 mg/kg IV over 10 minutes (maximum 1000 mg). 1
Efficacy: 58.2% as initial second-line agent—lowest efficacy of the four options. 1
Higher risk of respiratory depression and hypotension due to vasodilatatory and cardiodepressant effects. 1

Key principle: Valproate appears superior to phenytoin in head-to-head trials (88% vs 84% efficacy, 0% vs 12% hypotension), making it the preferred second-line agent when not contraindicated. 1

Stage 3: Refractory Status Epilepticus (20+ minutes)

Refractory SE is defined as seizures continuing despite benzodiazepines and one second-line agent—initiate continuous EEG monitoring at this stage. 1

Anesthetic agents (in order of preference):

Midazolam Infusion (First Choice)

Loading dose: 0.15-0.20 mg/kg IV. 1
Maintenance: 1 mg/kg/min continuous infusion, titrate up by 1 mg/kg/min every 15 minutes to maximum 5 mg/kg/min. 1
Efficacy: 80% overall success rate with 30% hypotension risk—significantly lower than pentobarbital (77%). 1
Critical: Load with phenytoin/fosphenytoin, valproate, levetiracetam, or phenobarbital during the midazolam infusion to ensure adequate long-acting anticonvulsant levels before tapering. 1

Propofol (Second Choice)

Dose: 2 mg/kg bolus, then 3-7 mg/kg/hour infusion. 1
Efficacy: 73% seizure control with 42% hypotension risk. 1
Requires mechanical ventilation but shorter duration than barbiturates (4 days vs 14 days). 1
Continuous blood pressure monitoring essential. 1

Pentobarbital (Highest Efficacy, Highest Risk)

Dose: 13 mg/kg bolus, then 2-3 mg/kg/hour infusion. 1
Efficacy: 92% seizure control—highest of all agents. 1
77% hypotension risk requiring vasopressors (norepinephrine or phenylephrine). 1
Prolonged mechanical ventilation (mean 14 days). 1
Reserve for cases refractory to midazolam and propofol. 1

Ketamine (Fourth-Line for Super-Refractory SE)

Dose: 0.45-2.1 mg/kg/hour infusion. 1
Efficacy: 64% when administered early (within 3 days); drops to 32% when delayed to mean 26.5 days. 1
Mechanistically distinct NMDA receptor antagonist—useful when GABA-ergic agents fail. 1
Use with caution in patients with depleted catecholamine reserves. 1

Critical Monitoring for Refractory SE

Continuous EEG monitoring is mandatory throughout anesthetic infusion and for at least 24-48 hours after discontinuation—breakthrough seizures occur in >50% of patients and are often only detectable by EEG without clinical manifestations. 1
Titrate anesthetic agents to achieve seizure suppression on EEG, not just clinical cessation. 1
Never use neuromuscular blockers alone (e.g., rocuronium)—they only mask motor manifestations while allowing continued electrical seizure activity and brain injury. 1

Simultaneous Evaluation for Underlying Causes

While administering anticonvulsants, promptly identify and treat reversible causes—do not postpone anticonvulsant therapy to obtain neuroimaging. 1

Immediate Laboratory Assessment

Fingerstick glucose (hypoglycemia is rapidly reversible). 1
Serum sodium (hyponatremia is the most common electrolyte disturbance precipitating seizures). 1
Pregnancy test in women of childbearing potential. 1

Other Reversible Causes to Address

Hypoxia, drug toxicity or withdrawal syndromes, CNS infection (meningitis/encephalitis), ischemic stroke, intracerebral hemorrhage. 1

Chronic Seizure Management: Medication Selection

Focal Seizures

Levetiracetam and lamotrigine are preferred first-choice agents for focal epilepsy due to efficacy and overall good tolerability. 6

Levetiracetam

Initial dose: 500 mg twice daily. 6
Target dose: 1000-1500 mg twice daily (30 mg/kg/day). 6
Increase by 500 mg/day every 1-2 weeks as tolerated, maximum 3000 mg/day. 6
Minimal drug interactions, no enzyme induction. 6
Monitor for psychiatric side effects: depression, irritability, behavioral changes. 6

Lacosamide (Alternative)

Reasonable second-line alternative if levetiracetam not tolerated or ineffective. 6
Proven efficacy as add-on therapy for focal seizures. 6

Agents to Avoid

Enzyme-inducing anticonvulsants (phenytoin, carbamazepine, phenobarbital) should be avoided due to side-effect profiles and significant drug interactions with steroids, cytotoxic agents, and targeted therapies. 6
Valproate should be avoided in women of childbearing potential but remains an option for men and postmenopausal women. 6

Generalized Seizures

Valproate remains highly effective for generalized epilepsy but is contraindicated in women of childbearing potential. 6
Levetiracetam is an acceptable alternative for generalized seizures with favorable safety profile. 6

Special Populations

Pregnant Patients

Activate EMS immediately for any seizure in pregnancy. 2
Avoid valproate due to significantly increased risks of fetal malformations (neural tube defects, cardiac anomalies) and neurodevelopmental delay. 1, 6
Levetiracetam is the preferred anticonvulsant in women of childbearing potential and during pregnancy. 6
For acute seizure management, standard benzodiazepine and second-line protocols apply—maternal stabilization is the priority. 1

Elderly Patients

Levetiracetam is particularly suitable for elderly patients due to minimal cardiovascular effects and no cardiac monitoring requirements. 1
Fosphenytoin infusion rate should not exceed 50 mg/min in elderly (vs 150 PE/min in younger adults) due to increased cardiovascular risk. 1
Both levetiracetam and valproate require dose adjustments in renal dysfunction, common in elderly. 1
Valproate protein binding is reduced in elderly, increasing free fraction and potential toxicity. 1

Pediatric Patients

Status Epilepticus Dosing

Lorazepam: 0.1 mg/kg IV (maximum 2 mg) for convulsive SE; 0.05 mg/kg IV (maximum 1 mg) for non-convulsive SE, may repeat up to 2-4 doses respectively. 1
Fosphenytoin: 20 mg PE/kg IV at rate not exceeding 1-3 mg/kg/min or 50 mg/min, whichever is slower. 1
Levetiracetam: 40 mg/kg IV (maximum 2500 mg) loading dose; maintenance 30 mg/kg IV every 12 hours (maximum 1500 mg) for convulsive SE, 15 mg/kg every 12 hours for non-convulsive SE. 1
Valproate: 20 mg/kg IV over 10 minutes (maximum 1000 mg initial dose) per American Academy of Pediatrics. 5
Phenobarbital: 20 mg/kg IV over 10 minutes (maximum 1000 mg); maintenance 1-3 mg/kg IV every 12 hours. 1

Febrile Seizures

Antipyretics (acetaminophen, ibuprofen, paracetamol) are not effective for stopping a febrile seizure or preventing subsequent febrile seizures. 2
Febrile seizures occur in 2-4% of children, most commonly between 6 months and 2 years of age. 2

Monitoring and Follow-Up

Breakthrough Seizures on Current Regimen

Verify medication compliance by checking serum drug levels before escalating therapy. 6
Question patients about seizure occurrences at each follow-up visit. 6
Search for precipitating factors: sleep deprivation, alcohol use, medication non-compliance, intercurrent illness. 1
Optimize monotherapy at maximum tolerated doses before adding a second agent. 6
Consider EEG to distinguish true epileptic seizures from psychogenic seizures or detect subclinical activity. 6
Obtain repeat neuroimaging if seizures worsen, as this often heralds disease progression in structural epilepsy. 6

Prognosis and Outcomes

Overall mortality for status epilepticus ranges from 5-22%; in refractory cases mortality can reach 65%. 1
Delayed treatment beyond 5-10 minutes increases risk of subsequent prolonged seizure activity, epileptogenesis, memory deficits, and learning difficulties. 3
Emergency department personnel fail to recognize status epilepticus in children in 34% of cases—emphasizing the need for heightened awareness. 3
Approximately 25% of patients with generalized convulsive status epilepticus have ongoing non-convulsive electrical seizures detectable only by EEG. 1

What are the current guidelines for acute and chronic management of seizures, including status epilepticus treatment, medication selection for focal and generalized seizures, and special considerations for pregnant and elderly patients?

Help us tailor your experience