Patient is actively seizing in the emergency department (ED) for 30 seconds; what orders should I place?

Immediate Management of Active Seizure in the Emergency Department

Administer intravenous lorazepam 4 mg at 2 mg/min immediately—this is the single most important action for any patient actively seizing, with 65% efficacy in terminating seizures and superior performance compared to diazepam. 1

Critical First Steps (0-5 Minutes)

Immediate Benzodiazepine Administration

• Give IV lorazepam 4 mg at 2 mg/min as first-line treatment for the actively seizing patient 1
• Lorazepam demonstrates 59.1% seizure cessation versus 42.6% for diazepam, with longer duration of action 1
• Have airway equipment (bag-valve-mask, intubation supplies) immediately available before administering any benzodiazepine due to respiratory depression risk 1
• If IV access is unavailable, administer IM midazolam 10 mg, which has equivalent efficacy to IV lorazepam 1

Simultaneous Rapid Assessment

• Check fingerstick glucose immediately—hypoglycemia is the most common rapidly reversible cause 1
• Establish continuous oxygen saturation monitoring with supplemental oxygen available 1
• Obtain vital signs and prepare for potential respiratory support 1

If Seizure Continues After 30 Seconds to 5 Minutes

Definition and Escalation Threshold

• Any seizure lasting ≥5 minutes meets the operational definition of status epilepticus and requires immediate escalation to second-line therapy 1
• Do not wait—early treatment prevents benzodiazepine pharmacoresistance that develops within minutes 2

Second-Line Agent Selection (Choose One)

Valproate is the preferred second-line agent based on superior safety profile:

• Administer valproate 30 mg/kg IV (maximum 3000 mg) over 5-20 minutes 1, 3
• Achieves 88% seizure control with 0% hypotension risk 1, 3
• Absolute contraindication in women of childbearing potential due to teratogenicity 1

Alternative second-line options if valproate is contraindicated:

• Levetiracetam 30 mg/kg IV (maximum 2500-3000 mg) over 5 minutes 1

  • 68-73% efficacy with minimal cardiovascular effects (0.7% hypotension) 1
  • Excellent choice for elderly patients and those with cardiovascular instability 1
  • No cardiac monitoring required 1

• Fosphenytoin 20 mg PE/kg IV at maximum rate of 150 PE/min 1

  • 84% efficacy but 12% hypotension risk 1
  • Requires continuous ECG and blood pressure monitoring 1
  • Traditional agent with widest availability 1

• Phenobarbital 20 mg/kg IV over 10 minutes 1

  • 58.2% efficacy as initial second-line agent 1
  • Higher risk of respiratory depression and hypotension 1
  • Reserve for cases where other agents are unavailable 1

Essential Concurrent Orders

Laboratory Evaluation

• Serum glucose and sodium—the only labs that consistently change acute ED management 1
• Pregnancy test in all patients of childbearing potential 1
• Antiepileptic drug levels if patient has known epilepsy 1

Search for Reversible Causes (Do Not Delay Treatment)

• Hypoglycemia, hyponatremia, hypoxia 1
• Drug toxicity or withdrawal (alcohol, benzodiazepines, barbiturates) 1
• CNS infection, ischemic stroke, intracerebral hemorrhage 1

Neuroimaging Decision

• Emergent non-contrast head CT if any high-risk features present: 1
  • Age >40 years
  • Recent head trauma
  • Focal seizure onset
  • Fever or persistent headache
  • Anticoagulation use
  • Known malignancy or immunocompromised state
  • Focal neurologic deficit
  • Persistent altered mental status
• CT abnormalities found in 23-41% of first-time seizure presentations 1
• Do not delay anticonvulsant administration to obtain neuroimaging 1

Critical Pitfalls to Avoid

• Never use neuromuscular blockers alone (e.g., rocuronium)—they only mask motor manifestations while allowing continued electrical seizure activity and brain injury 1
• Do not use phenytoin for drug-induced seizures—there is no role for this agent in toxicologic seizures 4
• Do not skip to third-line anesthetic agents (pentobarbital, propofol, midazolam infusion) until benzodiazepines and one second-line agent have been tried 1
• Do not use intramuscular diazepam—absorption is erratic; use rectal route instead if IM administration is being considered 1

Prognosis Context

• Overall mortality for status epilepticus ranges from 5-22%, increasing to 65% in refractory cases 1
• Early seizure recurrence occurs in >85% of cases within 360 minutes (mean 121 minutes) 5
• Patients with alcoholism and history of seizures have highest early recurrence rate at 25.2% 5