ED Seizure tips


  • Precipitating event
  • Staring, Jerks
  • Loss of consciousness, fall
  • Post seizure confusion
  • Incontinence, Tongue bite
  • Injuries from fall

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Acute treatment of seizure

  • Lorazepam 2-4 mg iv
  • Draw: CMP, CBC, drug level. Urine drug screen, UA
  • Give loading dose:
    • Levetiracetam (Keppra) 40-60 mg/kg, max 4500 mg iv, or
    • Fosphenytoin (Dilantin) 20 mg/kg, if not on Phenytoin, or
    • Valproate (Depacon) 20-40 mg/kg iv, if not on Valproate
    • Adjust loading dose if already on above
  • Monitor vital signs, respiratory status, suction
  • CT head to check for acute brain disease
  • Chest x ray for pneumonia
  • X ray if fracture suspected
  • NPO, Bed rest
  • If still has seizure, or in status

Status epilepticus

  • Give a loading dose of second med
  • if still has seizure:
  • Intubate
  • Midazolam 0.2 mg/kg iv blous, then 0.1 mg/kg/hr, titrate, or
  • Propofol 2 mg/kg load, then continuous infusion
  • Continuous EEG monitoring
  • CT head if not done already
  • LP if fever, or history suggestive of infection
  • Get more history: consider withdraw from alcohol, sedative

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New Onset seizure

  • Review above test results
  • Review past history: head injury, stroke, craniotomy
  • Review current med: that may increase chance of seizure
  • MRI head wo and w contrast, ck tumor, avm
  • EEG to define seizure type
  • Decide on need and choice of seizure med
  • Explain: Precautions and restrictions on activity, driving

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Recurrent seizure

  • Check for infection, UA, CHEST X RAY
  • Metabolic problems
  • Compliance with medication, by history and level
  • Adjust med based on compliance and drug level
  • Past test results seizure type, nonepileptic events
  • Explain: Precautions and restrictions on activity, driving

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Common Seizure Med

following available in iv and po

Levitiracetam (Keppra)

  • Usual start dose 500-1000 mg bid
  • Excreted by urine
  • Pros: safe, effective for all seizure type
  • cons: may cause drowsiness

Phenytoin (Dilantin)

  • Start dose: 100 mg 3 hs, ck level in 5 days.
  • NOT effective for generalized onset seizure
  • Pros: inexpensive, effective
  • Cons: severe allergic reaction, nonlinear pharmakokinetics
  • May cause liver problem, hirsutism

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Valproaic (Depakote)

Lacosamide (Vimpat)

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