Approach to a Patient with Seizure

Initial Management and Stabilization

The American College of Emergency Physicians recommends timing the seizure duration, with status epilepticus defined as seizure lasting >5 minutes or multiple seizures without return to baseline 1, 2
Maintaining NPO status until swallowing ability is assessed to prevent aspiration is recommended 3

The American College of Emergency Physicians recommends administering benzodiazepines as first-line therapy for ongoing seizures or status epilepticus 1, 2
For second-line treatment in persistent status epilepticus, administering one of the following is recommended (Level B recommendation): phenytoin, fosphenytoin, or valproate 4
For refractory status epilepticus, considering levetiracetam, propofol, or barbiturates is recommended (Level C recommendation) 4

Laboratory tests based on clinical presentation, including basic metabolic panel to assess for electrolyte abnormalities, are recommended 5
Considering neuroimaging (CT or MRI) for patients with first unprovoked seizure, focal neurological deficits, persistent altered mental status, trauma, or fever is recommended 5, 6
Considering electroencephalography (EEG) for patients with unexplained altered mental status, suspected non-convulsive status epilepticus, or fluctuating level of consciousness is recommended 5, 7

For first unprovoked seizure, emergency physicians need not initiate antiepileptic medication in the ED without evidence of brain disease or injury (Level C recommendation) 6
For provoked seizure, identifying and treating the underlying cause is recommended 6
For status epilepticus, immediate treatment following the protocol outlined above is required 1, 2, 4
For seizures in intracerebral hemorrhage, administering antiseizure drugs to patients with impaired consciousness and confirmed electrographic seizures is recommended (Class 1, Level C-LD) 7

Maintaining NPO status until swallowing assessment confirms safe oral intake is recommended 3
Continuing monitoring for changes in swallowing ability as clinical status can change in the first hours following seizures is recommended 3

Failing to recognize status epilepticus and delaying appropriate treatment is a common pitfall to avoid 1, 2
Allowing oral intake too early before proper swallowing assessment is a common pitfall to avoid 3