What is the appropriate acute and chronic treatment plan for an adult with seizures and no known contraindications?

Treatment for Seizures

Acute Management of Active Seizures

For any patient actively seizing, immediately administer IV lorazepam 4 mg at 2 mg/min—this terminates seizures in 65% of cases and is superior to all other first-line options. 1, 2

First-Line Treatment (0-5 minutes)

• Lorazepam 4 mg IV at 2 mg/min is the definitive first-line agent, with 65% efficacy and longer duration of action than diazepam (65% vs 56% success rate). 1, 2, 3
• Have airway equipment (bag-valve-mask, intubation set) immediately available before administering any benzodiazepine, as respiratory depression requiring intervention is predictable. 1, 3
• Check fingerstick glucose immediately and correct hypoglycemia while administering lorazepam—this is a rapidly reversible cause. 1
• Maintain continuous oxygen saturation monitoring throughout treatment, as apnea can occur up to 30 minutes after the last dose. 1
• If seizures continue after 10-15 minutes, repeat lorazepam 4 mg IV once. 1, 3

Second-Line Treatment (5-20 minutes after benzodiazepines)

If seizures persist after adequate benzodiazepine dosing, immediately escalate to valproate 20-30 mg/kg IV over 5-20 minutes—it achieves 88% efficacy with 0% hypotension risk, making it safer than phenytoin. 1, 2, 4

Alternative second-line agents in order of preference:

• Valproate 20-30 mg/kg IV (maximum 3000 mg) over 5-20 minutes: 88% efficacy, 0% hypotension risk, superior safety profile. 1, 2, 4
• Levetiracetam 30 mg/kg IV (maximum 2500-3000 mg) over 5 minutes: 68-73% efficacy, minimal cardiovascular effects, no cardiac monitoring required. 1, 2, 4
• Fosphenytoin 20 mg PE/kg IV at maximum 150 PE/min: 84% efficacy but 12% hypotension risk, requires continuous ECG and blood pressure monitoring. 1, 2, 4
• Phenobarbital 20 mg/kg IV over 10 minutes: 58.2% efficacy but higher respiratory depression and hypotension risk. 1, 5

Critical point: Valproate is absolutely contraindicated in women of childbearing potential due to fetal teratogenic risk—use levetiracetam instead. 1

Refractory Status Epilepticus (20+ minutes)

For seizures continuing despite benzodiazepines and one second-line agent, initiate midazolam continuous infusion with loading dose 0.15-0.20 mg/kg IV followed by 1 mg/kg/min—this achieves 80% seizure control with only 30% hypotension risk. 1, 2

• Midazolam infusion: Load 0.15-0.20 mg/kg IV, then 1 mg/kg/min continuous infusion, titrate up by 1 mg/kg/min every 15 minutes to maximum 5 mg/kg/min. 80% efficacy, 30% hypotension risk. 1
• Propofol: 2 mg/kg bolus, then 3-7 mg/kg/hour infusion. 73% efficacy, 42% hypotension risk, requires mechanical ventilation but shorter duration (4 days vs 14 days with barbiturates). 1, 2, 4
• Pentobarbital: 13 mg/kg bolus, then 2-3 mg/kg/hour infusion. 92% efficacy but 77% hypotension risk requiring vasopressors. 1

Before tapering midazolam, load with a long-acting anticonvulsant (phenytoin/fosphenytoin, valproate, levetiracetam, or phenobarbital) to ensure adequate levels are established. 1

Essential Monitoring for Refractory Cases

• Initiate continuous EEG monitoring when progressing to anesthetic agents—25% of patients with apparent seizure cessation have continuing electrical seizures. 1, 2
• Continue EEG for minimum 48 hours after complete anesthetic discontinuation, as late seizure recurrence is common and often nonconvulsive. 1
• Maintain continuous blood pressure monitoring and have vasopressors immediately available. 1
• Ensure mechanical ventilation capability is established before initiating anesthetic agents. 1

Simultaneous Management of Underlying Causes

While administering anticonvulsants, immediately search for and correct reversible causes:

• Hypoglycemia (check fingerstick glucose immediately) 1, 3
• Hyponatremia (most common electrolyte disturbance causing seizures) 1
• Hypoxia 1, 4
• Drug toxicity or withdrawal syndromes (especially alcohol) 1, 4
• CNS infection (meningitis, encephalitis) 1, 4
• Acute stroke or intracerebral hemorrhage 1

Do not delay anticonvulsant administration to obtain neuroimaging—CT scanning can be performed after seizure control is achieved. 1

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Chronic Seizure Management

After First Unprovoked Seizure

Do not initiate antiepileptic drug therapy after a first unprovoked seizure—observe the patient and arrange outpatient EEG and neurology follow-up. 1

• Patients who return to baseline in the emergency department can be safely discharged without admission. 1
• Arrange outpatient EEG for every patient after first unprovoked seizure, as abnormal EEG predicts higher recurrence risk. 1
• Consider treatment only after a second seizure or if specific high-risk features are present. 1

Maintenance Therapy for Established Epilepsy

For adults with recurrent partial seizures, begin monotherapy with either carbamazepine or phenytoin; for seizures with secondary generalization, valproate is equally effective. 6

• Start with monotherapy at adequate doses before considering combination therapy. 1, 6
• For breakthrough seizures on current regimen, first optimize current medication dosing and check serum drug levels to assess compliance before adding a second agent. 1
• If adding a second agent to levetiracetam, valproate is a reasonable combination with no significant pharmacokinetic interactions, but avoid in women of childbearing potential. 1

Maintenance Dosing After Status Epilepticus

• Levetiracetam: 30 mg/kg IV every 12 hours (maximum 1500 mg per dose) for convulsive status epilepticus; 15 mg/kg every 12 hours for non-convulsive status epilepticus. 1
• Phenytoin: Transition to oral phenytoin 300-400 mg per day divided into multiple doses after IV loading. 1
• Adjust doses in renal dysfunction for levetiracetam and in elderly patients for valproate (reduced protein binding increases free fraction). 1

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Critical Pitfalls to Avoid

• Never skip directly to third-line anesthetic agents (propofol, pentobarbital) until benzodiazepines and a second-line agent have been tried. 1, 2
• Never use neuromuscular blockers alone—they only mask motor manifestations while allowing continued electrical seizure activity and brain injury. 1, 2
• Do not delay escalation—if seizures continue after 5-10 minutes at any stage, immediately progress to the next treatment step. 1, 2
• Do not attribute altered mental status solely to post-ictal state—obtain urgent EEG if patient does not awaken within expected timeframe, as nonconvulsive status epilepticus occurs in >50% of cases. 1
• Avoid phenytoin in favor of valproate when possible—valproate has superior safety profile (0% vs 12% hypotension) with similar or better efficacy (88% vs 84%). 1, 2, 4