Convulsion rx
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seizure management treatment guidelines
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Management of Convulsions (Seizures / Status Epilepticus)
Definitions & Timing
A single seizure that lasts >5 minutes (generalized tonic-clonic), or two or more seizures without full recovery of consciousness between them, is treated as status epilepticus (SE) - a neurological emergency. The old 30-minute threshold is no longer used clinically; most seizures terminate in 2-3 minutes, so treatment begins at 5 minutes.
Immediate General Measures (Any Convulsion)
- Protect the airway - position the patient on their side, suction secretions
- O₂ supplementation, monitor SpO₂
- IV access - draw blood glucose, electrolytes (Ca²⁺, Mg²⁺), lactate, AED levels, toxicology screen, pregnancy test if appropriate
- Treat hypoglycemia immediately with IV glucose if suspected/confirmed
- Continuous temperature monitoring - treat hyperthermia with passive cooling
- Do NOT perform lumbar puncture during active seizure
- If bacterial meningitis/encephalitis is clinically suspected, start empiric antibiotics/antivirals immediately
- If toxic ingestion is the cause, consider GI decontamination as appropriate
Stepwise Drug Treatment
PHASE 1 - First-Line: Benzodiazepines (0-5 min)
| Drug | Dose | Route | Notes |
|---|---|---|---|
| Lorazepam | 2-4 mg (adults); repeat once | IV | Preferred if IV access available; onset ~2-3 min, duration 12-24 h |
| Midazolam | 10 mg (adults >40 kg) | IM | Preferred if no IV access; non-inferior to IV lorazepam in trials; also intranasal option |
| Diazepam | 5-10 mg IV; or 0.2-0.5 mg/kg rectal gel | IV / PR | Shorter effective duration (15-60 min) due to rapid redistribution; used if lorazepam/midazolam unavailable |
| Buccal midazolam | 0.5 mg/kg up to 10 mg | Buccal | Superior to rectal diazepam in children |
- Lorazepam > diazepam for duration of action; IM midazolam = IV lorazepam when no IV access
- Risk: respiratory depression, hypotension - especially in children, and with alcohol/barbiturates/opioids
PHASE 2 - Second-Line: Long-Acting Antiepileptics (20-40 min, after benzodiazepine)
Start within 20 minutes of diagnosis if seizures persist. The major options are equally effective - no consensus on one preferred agent:
| Drug | Dose | Route | Notes |
|---|---|---|---|
| Fosphenytoin | 20 PE/kg at 150 PE/min | IV / IM | Preferred over phenytoin - water-soluble, fewer infusion-site reactions; can give IM |
| Phenytoin | 20 mg/kg at ≤50 mg/min | IV | Cardiac monitoring required; risk of hypotension + arrhythmia |
| Levetiracetam | 60 mg/kg (max 4500 mg) | IV | Well tolerated; no cardiac effects |
| Valproate | 40 mg/kg at 6 mg/kg/min | IV | Avoid in known mitochondrial disease, liver disease, pregnancy |
| Lacosamide | 200-400 mg | IV | ECG monitoring required (prolongs PR interval, risk of arrhythmia) |
| Phenobarbital | 20 mg/kg at 50-100 mg/min | IV | Highly effective but causes prolonged sedation, respiratory depression, hypotension |
PHASE 3 - Refractory SE (30+ min despite Phase 1+2)
Defined as seizures continuing ≥30 minutes after adequate first- and second-line treatment. Requires ICU admission + intubation + continuous EEG monitoring.
| Drug | Notes |
|---|---|
| Pentobarbital (anesthetic dose) | IV continuous infusion; titrate to burst suppression on EEG |
| Propofol | IV continuous infusion; risk of propofol infusion syndrome with prolonged use |
| Midazolam | IV continuous infusion |
| Ketamine | Emerging option in super-refractory SE |
Special Situations
| Scenario | Treatment |
|---|---|
| Eclampsia | IV/IM magnesium sulfate (4 g IV loading dose) - drug of choice |
| Alcohol withdrawal | Benzodiazepines first-line; phenobarbital adjunct |
| Hypoglycemia-induced | IV dextrose alone may terminate seizure |
| Hyponatremia-induced | Hypertonic saline |
| Febrile convulsion (child) | Rectal diazepam / buccal midazolam acutely; usually self-limiting |
| Isoniazid toxicity | IV pyridoxine (B6) - gram for gram match to INH dose |
| TCA/cocaine overdose | IV sodium bicarbonate; avoid phenytoin |
Maintenance / Long-Term AED Selection (After Acute Control)
Once seizures are controlled, the underlying cause is sought and maintenance AED is chosen based on seizure type:
| Seizure Type | First-Line AEDs |
|---|---|
| Focal (partial) | Carbamazepine, oxcarbazepine, lamotrigine, levetiracetam, lacosamide |
| Generalized tonic-clonic | Valproate, levetiracetam, lamotrigine |
| Absence | Ethosuximide, valproate, lamotrigine |
| Juvenile myoclonic epilepsy | Valproate, levetiracetam, lamotrigine |
Key Monitoring Points
- Blood pressure, HR, SpO₂ continuously
- ECG when using phenytoin, fosphenytoin, lacosamide
- EEG mandatory in refractory SE and after neuromuscular blockade
- Avoid succinylcholine/paralytic agents without immediate EEG availability (masks ongoing seizure activity)
Sources:
- Katzung's Basic and Clinical Pharmacology, 16th Ed. - Status Epilepticus section
- Tintinalli's Emergency Medicine - Anticonvulsant Drugs in Status Epilepticus
- Bradley and Daroff's Neurology in Clinical Practice - Seizure Clusters and Status Epilepticus
Recent evidence note: A 2024 systematic review of clinical practice guidelines for SE management in adults (PMID 38606469, Epilepsia) confirms that no single second-line agent (levetiracetam vs. valproate vs. fosphenytoin) has demonstrated superiority, consistent with what the textbooks state above.
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Convulsion Quick Reference
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What's inside (single A4 page, colour-coded):
| Section | Content |
|---|---|
| Timeline bar | Visual 4-phase strip: 0-5 min → 5-20 min → 20-40 min → >40 min |
| Phase 1 - Benzodiazepines | Lorazepam, midazolam, diazepam, clonazepam - doses, routes, onset, duration |
| Phase 2 - Second-line AEDs | Fosphenytoin, phenytoin, levetiracetam, valproate, lacosamide, phenobarbital - loading doses + infusion rates |
| Phase 3 - Refractory SE | Pentobarbital, propofol, midazolam, ketamine - induction + maintenance doses |
| Special situations | Eclampsia, hypoglycaemia, alcohol withdrawal, INH toxicity, febrile convulsion, hyponatraemia, TCA OD |
| Immediate actions + monitoring | Side-by-side checklist boxes |
| Footer | Source citations + disclaimer |
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