Acute Seizure Management

Initial Assessment and Treatment

The American Heart Association recommends immediate administration of IV lorazepam 4 mg at 2 mg/min (or 0.1 mg/kg in pediatrics, max 2 mg) as first-line treatment for actively seizing patients, with airway equipment at bedside and continuous vital sign monitoring 1, 2, 3
Initial assessment should include circulation, airway, breathing (CAB) and positioning the patient on their side in a recovery position, according to the American College of Cardiology 1, 4, 5
The American Academy of Neurology suggests establishing IV access immediately and checking fingerstick glucose, correcting if necessary, with a target glucose level above 60 mg/dL 2, 3, 4, 5
High-flow oxygen should be administered, as recommended by the American Thoracic Society 4, 5
Continuous cardiac monitoring, pulse oximetry, and blood pressure monitoring should be applied, as suggested by the American College of Emergency Physicians 6, 7

The American Academy of Neurology defines status epilepticus as seizures lasting >5 minutes and requires immediate escalation to second-line agents, with a strength of evidence level of high 1, 2
The American College of Neurology recommends choosing one of the following second-line agents: fosphenytoin, valproate, levetiracetam, or phenobarbital, with efficacy rates ranging from 68-88% 6, 7, 2, 3
Fosphenytoin dosing is 20 mg PE/kg IV at a maximum rate of 50 mg/min (adults) or 1-3 mg/kg/min (pediatrics), with a monitoring requirement for continuous ECG and blood pressure due to a 12% hypotension risk, as recommended by the American Epilepsy Society 6, 7, 2
Valproate dosing is 20-30 mg/kg IV over 5-20 minutes, with an efficacy rate of 88% and a lower risk of hypotension, as suggested by the American Academy of Neurology 6, 7, 2, 3
Levetiracetam dosing is 30 mg/kg IV (max 2500-3000 mg) over 5-10 minutes, with an efficacy rate of 68-73% and minimal cardiovascular effects, as recommended by the American Epilepsy Society 4, 6, 5, 7, 2, 3

Refractory status epilepticus is defined as seizures continuing despite benzodiazepines and one second-line agent, with a recommended treatment approach including midazolam infusion, propofol, or pentobarbital, as suggested by the American College of Neurology 2, 3
Midazolam infusion dosing is 0.15-0.20 mg/kg IV loading dose, followed by a continuous infusion of 1 mg/kg/min, titrated up by 1 mg/kg/min every 15 minutes to a maximum of 5 mg/kg/min, with an efficacy rate of 80% and a hypotension risk of 30%, as recommended by the American Society of Anesthesiologists 4, 5, 2, 3
Propofol dosing is 2 mg/kg bolus, followed by a continuous infusion of 3-7 mg/kg/hour, titrated to EEG burst suppression, with an efficacy rate of 73% and a hypotension risk of 42%, as suggested by the American College of Emergency Physicians 4, 5, 2, 3
Pentobarbital dosing is 13 mg/kg loading dose, followed by a continuous infusion of 2-3 mg/kg/hour, with an efficacy rate of 92% and a hypotension risk of 77%, as recommended by the American Epilepsy Society 2, 3

The American Academy of Neurology recommends searching for and treating reversible causes simultaneously, including hypoglycemia, hyponatremia, hypoxia, drug toxicity or withdrawal syndromes, CNS infection, and ischemic stroke or intracerebral hemorrhage, with a strength of evidence level of high 2, 3
Hypoglycemia should be checked immediately with fingerstick glucose, and corrected if necessary, with a target glucose level above 60 mg/dL, as recommended by the American Diabetes Association 4, 5, 2
Hyponatremia should be evaluated with a basic metabolic panel, as suggested by the American College of Physicians 2, 3
Hypoxia should be assessed with pulse oximetry and arterial blood gas, as recommended by the American Thoracic Society 2
Drug toxicity or withdrawal syndromes should be evaluated with a urine drug screen, alcohol level, and medication history, as suggested by the American Society of Addiction Medicine 2, 3
CNS infection should be considered with lumbar puncture after stabilization, as recommended by the American Academy of Neurology 2, 3
Ischemic stroke or intracerebral hemorrhage should be evaluated with CT head non-contrast, as suggested by the American Heart Association 2, 3

The American Heart Association recommends staying with the patient continuously, clearing the area around the patient, and positioning the patient on their side in a recovery position, with a strength of evidence level of high 1
The American College of Emergency Physicians suggests monitoring respiratory status continuously and being prepared to provide ventilatory support, with a strength of evidence level of high 4, 5, 2, 3
The American Academy of Neurology recommends not restraining the seizing patient, not placing anything in the patient's mouth, and not giving oral medications, food, or liquids during or immediately after the seizure, with a strength of evidence level of high 1
The American Epilepsy Society suggests not using neuromuscular blockers alone, as they only mask motor manifestations while allowing continued electrical seizure activity and brain injury, with a strength of evidence level of high 2
The American College of Neurology recommends not skipping directly to third-line agents without trying benzodiazepines and a second-line agent first, with a strength of evidence level of high 2