Seizure Management

Introduction to Seizure Management

The American College of Emergency Physicians recommends that emergency physicians need not initiate antiepileptic medication for patients who have had a provoked seizure, such as one caused by hyponatremia, which is a Level C recommendation 1
For a single provoked seizure, the number needed to treat (NNT) to prevent a single additional seizure in the following year is approximately 5, suggesting limited benefit of maintenance therapy when the underlying cause is addressed 1

Correcting the underlying hyponatremia is crucial, and maintenance anti-seizure medication is not required as long as the hyponatremia is corrected 1
The primary treatment should focus on addressing the cause of the seizure rather than starting maintenance anti-seizure medication for a single provoked seizure 1

Multiple seizures significantly increase recurrence risk from approximately one-third to about three-quarters of patients, indicating the need for maintenance therapy in such cases 1
The risk of seizure recurrence increases substantially with multiple unprovoked seizures, making maintenance anti-seizure medication indicated 1

Consider valproate as the first choice for maintenance anti-seizure medication, with a dosage of 20-40 mg/kg 1
Alternative options for maintenance anti-seizure medication include levetiracetam or phenytoin/fosphenytoin 2
The ESETT trial showed equal efficacy between levetiracetam, fosphenytoin, and valproate for status epilepticus 2
Some anti-seizure medications, such as carbamazepine, oxcarbazepine, and valproic acid, can cause hyponatremia, which should be considered when selecting maintenance therapy 2

Generalized tonic-clonic seizures affect large areas or both sides of the brain, manifesting as full-body rhythmic jerking with altered consciousness, and typically self-terminate within 1-2 minutes 3
Focal seizures affect only one area of the brain, presenting as jerking of one extremity/side, abnormal facial movements, repetitive movements, or staring spells, and may progress to generalized seizures 3
Most normal seizures typically last between 1 to 2 minutes and resolve spontaneously without intervention 3
A seizure is considered abnormal or potentially dangerous when the duration exceeds 5 minutes, when multiple seizures occur without return to baseline consciousness between episodes, or when the post-ictal state lasts longer than 5-10 minutes 3

During a seizure, help the person to the ground, place them on their side in the recovery position, clear the area around them to prevent injury, and stay with the person throughout the seizure 3
Do not restrain the person having a seizure, do not put anything in the mouth of someone having a seizure, and do not give food, liquids, or oral medicines during a seizure or when the person has decreased responsiveness 3
Administer an additional antiepileptic medication (Level A recommendation) for seizures lasting longer than 3 minutes 1
Options for antiepileptic medication include (Level B recommendation): IV valproate: 20-40 mg/kg (40 mg per minute) 1
Consider additional options (Level C recommendation): IV levetiracetam, Propofol, Barbiturates 1
First aid providers should activate EMS for individuals with seizures lasting >5 minutes or with multiple seizures without return to baseline mental status between episodes 3

Close monitoring for at least 24 hours is recommended for tardive seizures that may occur after the initial seizure 1
Watch for tardive seizures (late-onset seizures occurring after recovery) for 24-48 hours 4
Post-ictal confusion and amnesia are more common following prolonged seizures (>180 seconds) 4, 3
Side effects like headache, nausea, vomiting, muscle aches, confusion, and agitation typically do not persist beyond the day of treatment 4
The American Heart Association recommends monitoring vital signs and neurological status, and considering EEG monitoring for patients who do not follow commands after seizures 5

Complex febrile seizures in children may have longer post-ictal periods, and neuroimaging may be indicated in children with febrile status epilepticus (seizure lasting >30 minutes), as recommended by the American College of Radiology 6
In children with febrile seizures, antipyretics (acetaminophen, ibuprofen) are not effective for stopping or preventing seizures 3
Status epilepticus has a mortality rate of 5-22%, which can increase to 65% in cases refractory to first-line therapies 7