Management of Seizure

Prehospital Care Care is mostly supportive, as most seizures are short duration, especially pediatric simple febrile seizures. ABCs, including oxygenation and airway assessment, temperature assessment, blood glucose assessment, and spinal precautions, should be performed as needed. Intravenous access should be obtained for almost all patients (may be deferred in those with simple febrile seizures). EMS protocols should include benzodiazepines (either IV, IM, or rectal) for prolonged seizures or status epilepticus. Emergency Department Care Care should be individualized for the patient presenting with seizure.

Sometimes, the most difficult part of the ED evaluation is differentiating whether the patient has had a seizure. Clues to the diagnosis include a clear history of tonic-clonic movements, urinary or bowel incontinence, post-episode confusion, and tongue biting. Attempt to obtain history from EMS providers, family, friends, or observers who may have been present during the episode. For those who present with a witnessed seizure who have stopped seizing, supportive care is adequate. o If antiepileptic medication levels are found to be low, then a loading dose given in the ED and discharge home is appropriate as long as there are no other concerning features to the presentation. o Phenytoin is an extremely common antiepileptic medication and is classically given as "one gram" in the ED, sometimes with the medication being delivered as half oral and half parenteral. Oral absorption of the drug can be erratic, but, when given in the appropriate doses (15-20 mg/kg PO either as a single dose or divided into 400-600 mg per dose every 2 h), it can achieve therapeutic serum levels o Both valproic acid and phenobarbital can also be given parenterally as a loading dose at 20 mg/kg. o Carbamazepine has proven to be effective for oral loading, but it is associated with a high rate of adverse effects. Therefore, oral loading is not recommended at this time. o Newer antiepileptic drugs, such as lamotrigine and levetiracetam, have varying drug profiles and are still being studied. Doses of these medications should be given in consultation with a neurologist.

In the event that the patient's seizure activity has not abated at ED presentation, ABCs should be addressed, as detailed below:

Airway management o Administer oxygen. o For patients who are in status epilepticus or cyanotic, endotracheal intubation using rapid sequence intubation (RSI) should be strongly considered.

If using RSI, short-acting paralytics should be used to ensure that ongoing seizure activity is not masked. Consider EEG monitoring in the ED if the patient has been paralyzed because there is no other method to determine if seizure activity is still present. Establish large-bore intravenous access. Initiate rapid glucose determination and treat appropriately. Consider antibiotics with or without antiviral agents, depending on the clinical situation. The goal of treatment is to control the seizure before neuronal injury occurs (theoretically between 20 min to 1 h). CNS infections and anoxic injury are the leading causes of mortality associated with status epilepticus.

Seizure management in the emergency department is as follows: Initial therapies:

Benzodiazepines - Considered first-line therapy o Intravenous options include lorazepam, diazepam, and midazolam. o If intravenous access cannot be obtained, then IM lorazepam or midazolam, or rectal diazepam can be considered. o Intravenous lorazepam was found to be superior to intravenous diazepam in both seizure cessation and preventing recurrent seizures. o A common regimen is 0.1 mg/kg of lorazepam (Ativan) IV given at 2 mg/min or 0.2 mg/kg diazepam IV given at 5-10 mg/min. o Very large doses of benzodiazepines may be needed. Note: There is no specific upper limit to benzodiazepine dose when used for acute seizure control. As with all sedatives, monitor the patient for respiratory or cardiovascular depression. Phenytoin - Usually considered the second-line agent for patients who continue to seize despite aggressive benzodiazepine therapy o The recommended dose is 20 mg/kg IV and can be augmented with another 10 mg/kg IV if the patient is still seizing. o Care should be taken with the administration of parenteral phenytoin because the propylene glycol diluent may cause hypotension, cardiac arrhythmias, and death if given too quickly. o Fosphenytoin is a phenytoin precursor that is considered to be safer than phenytoin by some authors as it does not contain a propylene glycol diluents Other authors have disputed a safety advantage for fosphenytoin, and it is much more expensive than phenytoin. Fosphenytoin may be administered intramuscularly, and this is an advantage for patients without intravenous access. Valproic acid Effective in treating all forms of seizure o Recommended dose of valproic acid is 15-20 mg/kg. o Valproic acid has an excellent safety profile. o It is contraindicated in hepatic dysfunction because of the extremely rare occurrence of fatal idiosyncratic hepatotoxicity.

Phenobarbital Similar efficacy to lorazepam o Recommended dose of phenobarbital is 20 mg/kg, but, like phenytoin, it can be given up to 30 mg/kg for severe refractory seizures. o Phenobarbital may cause hypotension and respiratory depression.

Continuous infusions:

If 2 or more of the initial drug therapies fail to control the seizures, then the next line of treatment includes continuous infusions of antiepileptic medications. The major side effects are hypotension and respiratory depression, and the patient should be intubated (if not already completed up to this point) and preparation made to support the patient's cardiovascular status. o Pentobarbital Pentobarbital is shorter acting than phenobarbital, but it is more sedating. Pentobarbital should be administered in a bolus at 5-15 mg/kg, then continuous infusion of 0.5-10 mg/kg/h as tolerated. o Midazolam: Midazolam is administered as a 0.2 mg/kg bolus, then continuous infusion of 0.05-2 mg/kg/h. o Propofol Limited data are available, but propofol appears to be very effective at terminating seizures. Propofol is administered in a bolus at 2-5 mg/kg, then continuous infusion of 20-100 mcg/kg/min. It is limited by infusion syndrome of hypotension, metabolic acidosis, and hyperlipidemia seen with prolonged infusions. There is very little evidence to guide use of these medications. Midazolam is slightly less effective at stopping seizures versus propofol or pentobarbital, but treatment with midazolam has a lower frequency of occurrence of hypotension.

Consultations Many patients with seizure may be managed without consultation. Consultation should be considered in the following circumstances:

Status epilepticus: Consider consulting a neurologist or an intensivist. Breakthrough seizure in a compliant patient with therapeutic levels: Consider consulting the physician who is chronically managing the patient's seizure disorder. Medication changes may be needed and ideally should be coordinated with a physician providing ongoing care.