Management of Seizures in the Emergency Setting
Initial Assessment and Management
- The American College of Emergency Physicians recommends searching for and treating underlying causes of seizures, including hypoglycemia, hyponatremia, hypoxia, ischemic stroke or intracerebral hemorrhage, and withdrawal syndromes 2, 3
Treatment Algorithm for Seizures
Second-Line Treatment for Status Epilepticus
- The American College of Emergency Physicians guidelines state that fosphenytoin, levetiracetam, and valproate have similar efficacy as second-line agents for status epilepticus, with approximately 45-47% of patients achieving seizure cessation within 60 minutes 1, 3, 4
- Fosphenytoin, levetiracetam, and valproate are recommended as equally effective second-line agents for status epilepticus, according to the 2024 ACEP guidelines (Level A recommendation) 1, 4
Third-Line Treatment for Refractory Status Epilepticus
- Phenobarbital, propofol infusion, pentobarbital infusion, and midazolam infusion may be considered for refractory status epilepticus, with pentobarbital infusion having high efficacy (92%) but significant hypotension (77% requiring pressors) 2
Safety Considerations
- Fosphenytoin, valproate, and levetiracetam may cause hypotension, with risks of 3.2%, 1.6%, and 0.7%, respectively 1, 3, 4
- EEG monitoring may be considered for patients with persistent altered consciousness to rule out nonconvulsive status epilepticus 2
Special Considerations
- Endotracheal intubation may be required in approximately 16-26% of patients with status epilepticus 4
- The patient's home antiseizure medication does not affect the probability of stopping status epilepticus when used as a second-line agent 4