Template:Seizure actively seizing management

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)
  • Midazolam IM 10 mg (> 40 kg), 5mg (13-40 kg), or 0.2 mg/kg
    • 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 2-4 mg or 0.1 mg/kg
  • Diazepam IV 0.15-0.2 mg/kg (up to 10 mg) or PR 0.2-0.5 mg/kg (up to 20 mg)
• Secondary medications
  • ESETT trial compared second line antiseizure medications and they all are equally efficacious. Therefor may be best to use the one with least side effects which is Levetiracetam
  • Levetiracetam IV 60 mg/kg, max 4500 mg/dose, or 1500 mg oral load (preferred in pregnancy)
  • Phenytoin IV 18 mg/kg at ≤ 50 mg/min
  • 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)
• Refractory medications
  • Propofol 2-5mg/kg, then infusion 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
  • Lacosamide IV 400 mg IV loading dose over 15 min, then maintenance dose of 200 mg q12hrs PO/IV
  • Phenobarbital IV 15-20 mg/kg at 50-75 mg/min
    • 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)
• 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

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.

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

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

PulmCrit- All 2nd line conventional anti-epileptics are equally good… or equally bad?

Legriel S, Oddo M, and Brophy GM. What’s new in refractory status epilepticus? Intensive Care Medicine. 2016:1-4.

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.

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.

Mirsattari SM et al. Treatment of refractory status epilepticus with inhalational anesthetic agents isoflurane and desflurane. Arch Neurol. 2004 Aug;61(8):1254-9.