Management of Seizures in the Hospital

Initial Assessment and Treatment

The American College of Emergency Physicians recommends administering benzodiazepines immediately as first-line therapy for any actively seizing patient, followed by levetiracetam, fosphenytoin, or valproate as equally effective second-line agents if seizures persist after adequate benzodiazepine dosing 1, 2
Checking fingerstick glucose and correcting hypoglycemia immediately is crucial in the initial assessment of a seizing patient 2
Searching for and treating underlying causes, including hyponatremia, hypoxia, ischemic stroke, intracerebral hemorrhage, and withdrawal syndromes, is essential in the management of seizures 2

Status epilepticus is defined as a seizure lasting longer than 5 minutes or multiple seizures without return to neurologic baseline, and it requires immediate treatment to reduce morbidity and mortality 1, 3
The treatment of status epilepticus involves the use of benzodiazepines as first-line agents, followed by second-line agents such as levetiracetam, fosphenytoin, or valproate if seizures persist 1, 6, 2

Levetiracetam, fosphenytoin, and valproate have equivalent efficacy in stopping seizures, with approximately 45-47% seizure cessation at 60 minutes, and selection should be based on patient-specific contraindications and side effect profiles 1, 6, 2
Levetiracetam has a dose of 60 mg/kg IV (maximum 4500 mg) over 10 minutes, with a hypotension risk of 0.7% and an intubation rate of 20% 6, 2
Fosphenytoin has a dose of 20 mg phenytoin equivalents/kg IV at a maximum rate of 150 mg/min, with a hypotension risk of 3.2% and an intubation rate of 26.4% 6, 2
Valproate has a dose of 40 mg/kg IV (maximum 3000 mg) over 10 minutes, with a hypotension risk of 1.6% and an intubation rate of 16.8% 6, 2

If seizures persist after adequate first and second-line therapy, consider phenobarbital loading dose, continuous infusions of propofol, pentobarbital, or midazolam, and ketamine (emerging evidence supports earlier use) 2
Pentobarbital has 92% efficacy but 77% of patients require vasopressor support 2

Continuous EEG monitoring is recommended for patients with persistent altered consciousness to rule out nonconvulsive status epilepticus 2
Failing to recognize nonconvulsive status epilepticus in patients with persistent altered mental status can lead to delayed treatment, and obtaining an EEG is crucial 2

Prescribed medications (tramadol) and illicit substances (cocaine) can lower seizure threshold, and noncompliance with antiseizure medications is a common precipitant of ED seizure presentations 1, 3
Approximately 16-26% of patients with status epilepticus require endotracheal intubation, and mortality is higher in patients without prior seizure history who develop status epilepticus 6, 2