Managing Active Seizures

December 4, 2020

Seizures seen in the emergency department usually meet criteria for status epilepticus, which is associated with mortality rates as high as 43 percent. The longer the seizure, the more refractory to medications it becomes, and the poorer the likely outcomes.

Review “Tips for Managing Active Seizures in the Emergency Department” in ACEP Now before you answer the question.

Which of the following is not in line with the key goal of treating such seizures swiftly, aggressively, and effectively?

Benzodiazepines are first-line agents for seizure control, ideally IV lorazepam if an IV line is available. It’s imperative that patients not be underdosed (lorazepam 0.1 mg/kg IV up to 4 mg or midazolam 0.2 mg/kg intramuscular up to 10 mg).

Use of a paralytic agent is recommended if advanced airway management is necessary, specifically with long-term neuromuscular blockade.

After the administration of two adequate doses of IV lorazepam (given two to four minutes apart), propofol should be considered, concurrently with a traditional second-line agent such as levetiracetam, fosphenytoin, or valproic acid.

Concurrent with treatment, it’s essential to search for a potential underlying seizure trigger, including extremes of vital signs, metabolic or toxicologic causes, and eclampsia, among others.

If seizure cessation is not achieved after a second-line medication, some treatment options are propofol, midazolam, ketamine, lacosamide, and phenobarbital.

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