What are the initial steps for managing seizures in an Intensive Care Unit (ICU) patient?

From the Guidelines

The initial steps for managing an ICU patient having a seizure include ensuring patient safety, maintaining airway patency, and administering appropriate medications, with first-line treatment being intravenous benzodiazepines, as recommended by the most recent clinical policy 1. The management of seizures in ICU patients is critical to prevent morbidity, mortality, and to maintain quality of life.

Key Initial Steps

• Protect the patient from injury by padding side rails and removing any potentially harmful objects.
• Position the patient on their side if possible to prevent aspiration.
• Administer oxygen and ensure continuous monitoring of vital signs, including oxygen saturation, blood pressure, and cardiac rhythm.
• For medication management, give intravenous benzodiazepines as first-line therapy: lorazepam 2-4 mg IV, diazepam 5-10 mg IV, or midazolam 5-10 mg IV, which can be repeated once after 5-10 minutes if seizures persist, as per the latest guidelines 1.

Further Management

If seizures continue despite benzodiazepines, proceed to second-line agents such as fosphenytoin, valproic acid, or levetiracetam.

• Simultaneously, obtain rapid laboratory studies including electrolytes, glucose, calcium, magnesium, complete blood count, and toxicology screen to identify potential causes.
• Hypoglycemia should be corrected immediately with 50 mL of 50% dextrose IV if present. Additionally, considering the ICU setting, EEG monitoring may be useful to monitor nonconvulsive seizure activity or to titrate electrosuppressive medication, as suggested by earlier guidelines 1. However, the most recent and highest quality study 1 prioritizes the initial steps of ensuring patient safety and administering benzodiazepines as first-line treatment.

From the FDA Drug Label

The treatment of status, however, requires far more than the administration of an anticonvulsant agent. It involves observation and management of all parameters critical to maintaining vital function and the capacity to provide support of those functions as required. Ventilatory support must be readily available 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). Because status epilepticus may result from a correctable acute cause such as hypoglycemia, hyponatremia, or other metabolic or toxic derangement, such an abnormality must be immediately sought and corrected.

The initial steps for an ICU patient having a seizure include:

• Observation and management of all parameters critical to maintaining vital function
• Ensuring ventilatory support is readily available
• Identifying and correcting any underlying acute cause of the seizure, such as hypoglycemia or hyponatremia
• Considering the use of benzodiazepines, like lorazepam, as an initial step in a complex and sustained intervention, which may require additional interventions, such as concomitant intravenous administration of other anticonvulsants 2

From the Research

Initial Steps for ICU Patient Having a Seizure

• The initial steps for an ICU patient having a seizure involve prompt recognition and treatment to prevent further brain damage and other complications 3.
• According to the study by 4, early termination of prolonged seizures with intravenous administration of benzodiazepines, such as lorazepam, improves outcomes.
• The use of intramuscular midazolam has been shown to be at least as safe and effective as intravenous lorazepam for prehospital seizure cessation 4, 5.
• In the ICU setting, the selection of optimally effective therapy for seizures or status epilepticus depends on multiple factors, making collaboration between neurophysiologists and the ICU team crucial 3.
• The study by 6 found that intranasal midazolam was comparable to intravenous lorazepam for seizure termination and prevention of seizure clusters in the adult epilepsy monitoring unit.
• Continuous intravenous infusions of lorazepam or midazolam can be used for sedation in ICU patients, with the choice of medication depending on various factors, including the patient's condition and the desired level of sedation 7.

Treatment Options

• Intravenous lorazepam is a commonly used treatment for seizures in the ICU setting 4, 7.
• Intramuscular midazolam is a viable alternative to intravenous lorazepam, particularly in situations where intravenous access is not available or is difficult to establish 4, 5.
• Intranasal midazolam has been shown to be effective for seizure termination and prevention of seizure clusters in the adult epilepsy monitoring unit 6.

Important Considerations

• Accurate diagnosis and efficient treatment of seizures in the ICU are challenging due to patient factors, complexities of antiepileptic drug therapy, and the required expertise for EEG interpretation 3.
• The use of EEG monitoring can help identify patients at risk of seizures and guide treatment decisions 3.