Seizure Management Guidelines

Initial Assessment and Treatment

For an active seizure lasting >5 minutes (status epilepticus), immediately administer benzodiazepines as first-line therapy, followed by second-line agents if seizures persist, while simultaneously securing airway, establishing IV access, checking glucose, and identifying reversible causes 1
Check fingerstick glucose immediately in all seizure patients, as hypoglycemia is a common reversible cause 2, 3
Note seizure duration from onset, which is critical for determining status epilepticus 1
Document seizure semiology: focal versus generalized onset 3

Administer benzodiazepines immediately, with lorazepam 0.1 mg/kg IV being the preferred option due to its longer duration of action 1, 2
Choose one of the following second-line agents: fosphenytoin, levetiracetam, or valproic acid, all of which have similar efficacy 1, 2
Fosphenytoin is preferred over phenytoin due to its faster infusion rate and lower risk of hypotension 1
Levetiracetam has no hypotension risk and an efficacy of 67-73% 1
Valproate has an efficacy of 68-88% and minimal hypotension risk 1

Search for reversible causes immediately, including metabolic causes such as hypoglycemia, hyponatremia, hypocalcemia, and hypomagnesemia 2, 3, 4
Consider toxicology screen if ingestion is suspected 3
Obtain head CT in the emergency department for first-time seizure patients, patients >60 years, and those with focal neurologic deficits 3
MRI is preferred when neuroimaging is obtained due to its higher sensitivity for structural lesions 3

Consider emergent EEG for patients with persistent altered consciousness after seizure termination, those who received long-acting paralytics, and those in drug-induced coma 1
Do not initiate long-term antiepileptics in the ED for provoked seizures or single unprovoked seizures without brain disease/injury 2, 5
May initiate or defer to outpatient neurology for first unprovoked seizure with remote history of brain disease/injury 5
Admit patients with status epilepticus requiring multiple medications, persistent altered mental status, acute symptomatic causes, or refractory seizures 1, 5

Do not delay benzodiazepines if seizure exceeds 5 minutes, as mortality increases significantly in refractory cases 1
Do not miss non-convulsive status epilepticus, which should be considered in any patient with unexplained confusion or coma 1
Do not start prophylactic anticonvulsants in stroke patients, as they may negatively affect neurological recovery 2