Template:Seizure actively seizing management: Difference between revisions

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#Protect patient from injury
===Seizure Precautions===
#*If possible place patient in left lateral position to reduce risk of aspiration
*Protect patient from injury
#*Do not place bite block
**If possible, place patient in left lateral position to reduce risk of aspiration
#*Ensure clear airway after seizure stops
**Do not place bite block!
#[[Benzodiazepine]]
*Jaw thrust, a NPA and [[oxygen]] may be required
#*[[Lorazepam]] 2mg IV (first line)<ref>Treiman D, Meyers P, Walton N, et al. A comparison of four treatments for generalized convulsive status epilepticus. New Engl J Med 1998; 339; 792-798</ref>
*An IV line should be placed
#*IM Options:
 
#**[[Midazolam]] IM 0.2mg/kg<ref>McMullan J, Sasson C, Pancioli A, Silbergleit R: Midazolam versus diazepam for the treatment of status epilepticus in children and young adults: A meta-analysis. Acad Emerg Med 2010; 17:575-582</ref> OR
===Medications===
#**[[Diazepam]] PR 0.5-1.0mg/kg (up to 20mg)
*[[Benzodiazepine]] (Initial treatment of choice)<ref>Glauser T, et al. Evidence-based guideline: treatment of convulsive status epilepticus in children and adults: report of the guideline committee of the American Epilepsy Society. Epilepsy Curr. 2016; 16(1):48-61.</ref>
#Secondary medications
**[[Midazolam]] IM 10 mg (> 40 kg), 5mg (13-40 kg), or 0.2 mg/kg<ref>McMullan J, Sasson C, Pancioli A, Silbergleit R: Midazolam versus diazepam for the treatment of status epilepticus in children and young adults: A meta-analysis. Acad Emerg Med 2010; 17:575-582</ref>
#*[[Lorazepam]] 2mg IV (up to 0.1mg/kg) OR [[diazepam]] 5-10mg IV (up to 0.15mg/kg); AND
***May also be given IN at 0.2 mg/kg, max 10 mg
#*[[Phenytoin]] 20-30mg/kg at 50mg/min OR [[fosphenytoin]] 20-30mg/kg/PE at 150mg/min
***OR buccal at 0.3 mg/kg, max 10 mg
#**[[Phenytoin]]/[[fosphenytoin]] contraindicated in pts w/ 2nd or 3rd degree AV block
**[[Lorazepam]] IV 4 mg or 0.1 mg/kg; may repeat one dose<ref>Glauser T, Shinnar S, Gloss D, et al. Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society. Epilepsy Curr. 2016;16(1):48-61. doi:10.5698/1535-7597-16.1.48</ref>
#**[[Phenytoin]] may cause hypotension due to propylene glycol diluent
**[[Diazepam]] IV 0.15-0.2 mg/kg (up to 10 mg); may repeat one dose or PR 0.2-0.5 mg/kg (up to 20 mg) once <ref>Glauser T, Shinnar S, Gloss D, et al. Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society. Epilepsy Curr. 2016;16(1):48-61. doi:10.5698/1535-7597-16.1.48</ref>
#**[[Fosphenytoin]] may be given IM
*Secondary medications
#Refractory medications
**ESETT trial<ref>[https://www.nejm.org/doi/10.1056/NEJMoa1905795 Kapur J, Elm J, Chamberlain J, et al. Randomized Trial of Three Anticonvulsant Medications for Status Epilepticus. N Engl J Med. 2019;381(22):2103-2113. doi:10.1056/NEJMoa1905795]</ref> compared second line antiseizure medications and they all are equally efficacious. Therefore may be best to use the one with least side effects <ref>[https://emcrit.org/pulmcrit/esett/ PulmCrit- All 2nd line conventional anti-epileptics are equally good… or equally bad?]</ref> which is [[Levetiracetam]]
#*[[Valproic acid]] 20-40mg/kg at 5mg/kg/min OR
**[[Levetiracetam]] IV 60 mg/kg, max 4500 mg/dose, or 1500 mg oral load <span style="color:#008000"> ('''preferred in pregnancy''')</span><ref>Macri E, Greene-Chandos D. Neurological Emergencies During Pregnancy. Neurol Clin. 2021 May;39(2):649-670. doi: 10.1016/j.ncl.2021.02.008. PMID: 33896537</ref>
#*[[Phenobarbital]] 20mg/kg at 50-75mg/min (be prepared to intubate) OR
**[[Phenytoin]] IV 18 mg/kg at ≤ 50 mg/min <span style="color:red"> ('''avoid in pregnancy''')</span><ref>Macri E, Greene-Chandos D. Neurological Emergencies During Pregnancy. Neurol Clin. 2021 May;39(2):649-670. doi: 10.1016/j.ncl.2021.02.008. PMID: 33896537</ref>
#*[[Propofol]] 2-5mg/kg, then infusion of 2-10mg/kg/hr OR
**[[Fosphenytoin]] IV 20-30 mg/kg at 150 mg/min (may also be given IM)
#*[[Midazolam]] 0.2mg/kg then inusion of 0.05-2mg/kg/hr OR
***Contraindicated in pts w/ 2nd or 3rd degree AV block
#*[[Ketamine]] 1.5mg/kg then 0.01-0.05mg/kg/hr
***Avoid phenytoin or fosphenytoin in suspected toxicology case due to sodium channel blockade
#**Contraindicated in pts w/ intracranial masses
**[[Valproic acid]] IV 20-40 mg/kg at 5 mg/kg/min, max 3000 mg <span style="color:red"> ('''avoid in pregnancy''')</span><ref>Macri E, Greene-Chandos D. Neurological Emergencies During Pregnancy. Neurol Clin. 2021 May;39(2):649-670. doi: 10.1016/j.ncl.2021.02.008. PMID: 33896537</ref>
#Consider
*Refractory medications
#*Secondary causes of seizure (e.g. [[hyponatremia]], hypoglycemia, INH overdose, [[ecclampsia]])
**[[Propofol]] 2-5mg/kg load, then infusion of 30-200mcg/kg/min (equivalent of 2-10mg/kg/hr) '''OR'''
#*EEG to rule-out nonconvulsive status
**[[Midazolam]] 0.2mg/kg, then infusion of 0.05-2mg/kg/hr '''OR'''
#*Prophylactic intubation
**[[Ketamine]] loading dose 0.5 to 3 mg/kg, followed by infusion of 0.3 to 4 mg/kg/hr<ref>Legriel S, Oddo M, and Brophy GM. What’s new in refractory status epilepticus? Intensive Care Medicine. 2016:1-4.</ref>
#*Anesthesia consult for inhaled anesthetics in OR for refractory status epilepticus<ref>Mirsattari SM et al. Treatment of refractory status epilepticus with inhalational anesthetic agents isoflurane and desflurane. Arch Neurol. 2004 Aug;61(8):1254-9.</ref>
**[[Lacosamide]] IV 400 mg IV loading dose over 15 min, then maintenance dose of 200 mg q12hrs PO/IV<ref>Legros B et al. Intravenous lacosamide in refractory seizure clusters and status epilepticus: comparison of 200 and 400 mg loading doses. Neurocrit Care. 2014 Jun;20(3):484-8.</ref>
**[[Phenobarbital]] IV 15-20 mg/kg at 50-75 mg/min<ref>Pugin D et al. Is pentobarbital safe and efficacious in the treatment of super-refractory status epilepticus: a cohort study. Critical Care 2014. DOI: 10.1186/cc13883.</ref>
***Then continuous infusion at 0.5-4.0 mg/kg/hr
***Dose adjusted to suppression-burst pattern on continuous EEG
**Consider consulting anesthesia for inhaled anesthetics (potent anticonvulsants)<ref>Mirsattari SM et al. Treatment of refractory status epilepticus with inhalational anesthetic agents isoflurane and desflurane. Arch Neurol. 2004 Aug;61(8):1254-9.</ref>
*Others
**[[Carbamazepine]] 8 mg/kg oral suspension, single oral load
**[[Gabapentin]] 900 mg/day oral at 300 mg tid for 3 days
**[[Lamotrigine]] 6.5 mg/kg single oral load
 
===Other Considerations===
*Secondary causes of seizure (e.g. [[hyponatremia]], [[hypoglycemia]], [[INH toxicity]], [[ecclampsia]])
*Nonconvulsive seizures or [[status epilepticus]] - get EEG

Latest revision as of 09:08, 5 October 2025

Seizure Precautions

  • Protect patient from injury
    • If possible, place patient in left lateral position to reduce risk of aspiration
    • Do not place bite block!
  • Jaw thrust, a NPA and oxygen may be required
  • An IV line should be placed

Medications

  • Benzodiazepine (Initial treatment of choice)[1]
    • Midazolam IM 10 mg (> 40 kg), 5mg (13-40 kg), or 0.2 mg/kg[2]
      • May also be given IN at 0.2 mg/kg, max 10 mg
      • OR buccal at 0.3 mg/kg, max 10 mg
    • Lorazepam IV 4 mg or 0.1 mg/kg; may repeat one dose[3]
    • Diazepam IV 0.15-0.2 mg/kg (up to 10 mg); may repeat one dose or PR 0.2-0.5 mg/kg (up to 20 mg) once [4]
  • Secondary medications
    • ESETT trial[5] compared second line antiseizure medications and they all are equally efficacious. Therefore may be best to use the one with least side effects [6] which is Levetiracetam
    • Levetiracetam IV 60 mg/kg, max 4500 mg/dose, or 1500 mg oral load (preferred in pregnancy)[7]
    • Phenytoin IV 18 mg/kg at ≤ 50 mg/min (avoid in pregnancy)[8]
    • Fosphenytoin IV 20-30 mg/kg at 150 mg/min (may also be given IM)
      • Contraindicated in pts w/ 2nd or 3rd degree AV block
      • Avoid phenytoin or fosphenytoin in suspected toxicology case due to sodium channel blockade
    • Valproic acid IV 20-40 mg/kg at 5 mg/kg/min, max 3000 mg (avoid in pregnancy)[9]
  • Refractory medications
    • Propofol 2-5mg/kg load, then infusion of 30-200mcg/kg/min (equivalent of 2-10mg/kg/hr) OR
    • Midazolam 0.2mg/kg, then infusion of 0.05-2mg/kg/hr OR
    • Ketamine loading dose 0.5 to 3 mg/kg, followed by infusion of 0.3 to 4 mg/kg/hr[10]
    • Lacosamide IV 400 mg IV loading dose over 15 min, then maintenance dose of 200 mg q12hrs PO/IV[11]
    • Phenobarbital IV 15-20 mg/kg at 50-75 mg/min[12]
      • Then continuous infusion at 0.5-4.0 mg/kg/hr
      • Dose adjusted to suppression-burst pattern on continuous EEG
    • Consider consulting anesthesia for inhaled anesthetics (potent anticonvulsants)[13]
  • Others

Other Considerations

  1. ↑ Glauser T, et al. Evidence-based guideline: treatment of convulsive status epilepticus in children and adults: report of the guideline committee of the American Epilepsy Society. Epilepsy Curr. 2016; 16(1):48-61.
  2. ↑ McMullan J, Sasson C, Pancioli A, Silbergleit R: Midazolam versus diazepam for the treatment of status epilepticus in children and young adults: A meta-analysis. Acad Emerg Med 2010; 17:575-582
  3. ↑ Glauser T, Shinnar S, Gloss D, et al. Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society. Epilepsy Curr. 2016;16(1):48-61. doi:10.5698/1535-7597-16.1.48
  4. ↑ Glauser T, Shinnar S, Gloss D, et al. Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society. Epilepsy Curr. 2016;16(1):48-61. doi:10.5698/1535-7597-16.1.48
  5. ↑ Kapur J, Elm J, Chamberlain J, et al. Randomized Trial of Three Anticonvulsant Medications for Status Epilepticus. N Engl J Med. 2019;381(22):2103-2113. doi:10.1056/NEJMoa1905795
  6. ↑ PulmCrit- All 2nd line conventional anti-epileptics are equally good… or equally bad?
  7. ↑ Macri E, Greene-Chandos D. Neurological Emergencies During Pregnancy. Neurol Clin. 2021 May;39(2):649-670. doi: 10.1016/j.ncl.2021.02.008. PMID: 33896537
  8. ↑ Macri E, Greene-Chandos D. Neurological Emergencies During Pregnancy. Neurol Clin. 2021 May;39(2):649-670. doi: 10.1016/j.ncl.2021.02.008. PMID: 33896537
  9. ↑ Macri E, Greene-Chandos D. Neurological Emergencies During Pregnancy. Neurol Clin. 2021 May;39(2):649-670. doi: 10.1016/j.ncl.2021.02.008. PMID: 33896537
  10. ↑ Legriel S, Oddo M, and Brophy GM. What’s new in refractory status epilepticus? Intensive Care Medicine. 2016:1-4.
  11. ↑ Legros B et al. Intravenous lacosamide in refractory seizure clusters and status epilepticus: comparison of 200 and 400 mg loading doses. Neurocrit Care. 2014 Jun;20(3):484-8.
  12. ↑ Pugin D et al. Is pentobarbital safe and efficacious in the treatment of super-refractory status epilepticus: a cohort study. Critical Care 2014. DOI: 10.1186/cc13883.
  13. ↑ Mirsattari SM et al. Treatment of refractory status epilepticus with inhalational anesthetic agents isoflurane and desflurane. Arch Neurol. 2004 Aug;61(8):1254-9.
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