Management of Seizures

Immediate Stabilization and First-Line Treatment

The American College of Emergency Physicians recommends benzodiazepines as the definitive first-line therapy for active seizures, with Level A evidence supporting their use 3, 1
Lorazepam 4 mg IV at 2 mg/min is the preferred benzodiazepine, demonstrating 65% efficacy in terminating status epilepticus and superior performance compared to diazepam (59.1% vs 42.6%) 1, 2
Have airway equipment immediately available before administering any benzodiazepine, as respiratory depression can occur 1
Check fingerstick glucose immediately and correct hypoglycemia while administering treatment—this is a rapidly reversible cause 1, 2

Status epilepticus is operationally defined as seizures lasting ≥5 minutes, requiring immediate escalation to second-line agents 1, 2
All three second-line agents have equivalent efficacy (45-47% seizure cessation at 60 minutes), so selection should be based on safety profile and patient-specific contraindications 2, 4
Levetiracetam 60 mg/kg IV (maximum 4500 mg) over 10 minutes is a recommended second-line agent, with a hypotension risk of 0.7% and intubation rate of 20% 2, 4
Valproate 40 mg/kg IV (maximum 3000 mg) over 10 minutes is another recommended second-line agent, with a hypotension risk of 1.6% and intubation rate of 16.8% 2, 4
Fosphenytoin 20 mg PE/kg IV at maximum rate of 150 mg/min is also a recommended second-line agent, with a hypotension risk of 3.2% and intubation rate of 26.4% 2, 4

Refractory status epilepticus is defined as seizures continuing despite benzodiazepines and one second-line agent 1
Initiate continuous EEG monitoring at this stage to guide therapy and detect non-convulsive seizure activity 1, 2
Midazolam infusion is a recommended anesthetic agent, with a loading dose of 0.15-0.20 mg/kg IV and continuous infusion of 1 mg/kg/min, titrate up by 1 mg/kg/min every 15 minutes to maximum 5 mg/kg/min 1
Propofol is another recommended anesthetic agent, with a loading dose of 2 mg/kg bolus and continuous infusion of 3-7 mg/kg/hour 4
Pentobarbital is a recommended anesthetic agent, with a loading dose of 13 mg/kg and continuous infusion of 2-3 mg/kg/hour 4

Search for and treat underlying causes while administering anticonvulsants, including metabolic, structural, toxic, and medication-related causes 3, 2, 4
Obtain neuroimaging (CT head) after seizure control is achieved—do not delay anticonvulsant administration for imaging 1

Mortality from status epilepticus ranges from 5-22%, reaching 65% in refractory cases 3, 5
Approximately 16-26% of patients with status epilepticus require endotracheal intubation 2, 4
Continuous vital sign monitoring is essential, particularly respiratory status and blood pressure, regardless of administration route 1