Management of Active Seizures

Initial Treatment

For a 45-year-old patient actively having seizures, immediate administration of intravenous benzodiazepines is the first-line treatment, followed by second-line antiepileptic drugs if seizures persist, as recommended by the American Academy of Emergency Medicine 1, 2
Administer IV lorazepam 0.1 mg/kg (typically 4-8 mg) over 2 minutes, as suggested by the American Academy of Pediatrics 3
If IV access is not immediately available, consider IM midazolam 0.2 mg/kg (maximum 10 mg per dose), as recommended by the American Academy of Pediatrics 4
Rectal diazepam 0.5 mg/kg up to 20 mg may also be considered, as suggested by the American Academy of Pediatrics 3, 5

Administer one of the following IV medications if seizures continue after 10-20 minutes: fosphenytoin, valproate sodium, or levetiracetam, as recommended by the American Academy of Emergency Medicine 2, 4
Valproate sodium 30 mg/kg over 10 minutes (not exceeding 20 mg/min) has shown similar efficacy to phenytoin (88% seizure control in both groups) with fewer cardiovascular side effects, as reported by the American Academy of Emergency Medicine 2
Levetiracetam 30 mg/kg IV over 15 minutes may also be considered, as suggested by the American Academy of Emergency Medicine 1, 6

Consider one of the following options for refractory status epilepticus: IV midazolam, IV propofol, or IV phenobarbital, as recommended by the American Academy of Emergency Medicine 1, 4, 6, 7
IV midazolam loading dose 0.15-0.2 mg/kg, followed by continuous infusion starting at 1 mg/kg/min, increasing by 1 mg/kg/min every 15 minutes (maximum 5 mg/kg/min) until seizures stop, as suggested by the American Academy of Pediatrics 4, 7

Treat any identified precipitating factors, such as hypoglycemia, by administering 50 ml of 50% dextrose IV, as recommended by the American Academy of Emergency Medicine 2

Continuous cardiac monitoring and pulse oximetry throughout treatment, as recommended by the American Academy of Pediatrics 4, 7
Be prepared to provide respiratory support, as benzodiazepines may cause respiratory depression, as reported by the American Academy of Pediatrics 4, 7
Consider EEG monitoring if seizures persist despite treatment, as suggested by the American Academy of Emergency Medicine 2

Do not delay treatment while waiting for laboratory results in an actively seizing patient, as recommended by the American Academy of Emergency Medicine 2
Benzodiazepines may cause respiratory depression, especially when combined with other sedative agents, as reported by the American Academy of Pediatrics 4, 7
If using propofol, monitor for propofol infusion syndrome (metabolic acidosis, rhabdomyolysis, cardiac dysfunction), as suggested by the American Academy of Emergency Medicine 6