REMSTARBC.ca    Rural Emergency Medicine Simulation Training and Resource - British Columbia

This page will not cover the whole topic of seizure and epilepsy
but rather the acute presentation of

seizures in the ER and status epilepticus. 

Management of Seizures – Adult

  1. ABCDE’s
  2. IV lines
  3. Do finger prick glucose and take Temperature.
  4. Draw blood for CBC, LFT, Calcium, Magnesium, Sodium
  5. If glucose < 3, give Glucose 50 ml of 50% (25 gms)over 5 minutes IV
  6. Thiamine 100 mg IV, IM
  7. Ativan 2 – 4 mg IV or Valium 2 – 10 mg IV or Midazolam 0.1 – 0.2 mg/kg IV (5 – 10 mg)
  8. If unable to establish IV, use Midazolam 0.05 – 0.2mg/Kg IM (10 mg IM may be more effective than Ativan)

  9. For Status Epilepticus/Persistent generalized seizure:
    a. Assess airway, breathing, circulation. If intubation needed go to G.
    b. Benzodiazepine as above.
    c. Get antiepileptic drug – Levetiracetam (Keppra) 60 mg/kg IV over 10 min,
        or Valproic acid 40 mg/kg IV over 10 min
    d. Exclude Hypoglycemia – if needed give IV glucose
    e. Exclude Hyponatremia – if needed 100-150 ml 3% NaCL
    f. If seizure stops, still give Keppra or Valproic acid
    g. If seizure continues – intubate. Propofol 1.5 mg/kg + Ketamine 2 mg/kg + paralytic.
        Watch for hypotension, have pressors ready.
    h. Start Propofol infusion 50-80 mcg/kg/min
    i. Consider Narcan or IV lipid emulsion therapy for drug overdoses
    j. Consider empiric IV antibiotics (Ceftriaxone 2 gm) for suspected infecion

                                                                  IV Antiepileptic Drugs 

                                           Onset                      Peak Action          Half life

                   Lorazepam:           2 - 3 min                       40 - 60 min                   6 - 8 hrs
                   Diazepam:             1 – 3 min.                     15 – 30 min                   3 – 4 hrs.
                   Midazolam:           1 –5 min.                                                           

Management of Seizures – Pediatric

  1. ABCDE’s: oxygen,suction secretions, recovery position
  2. IV line/intraosseous access.
  3. glucose, CBC, lytes
  4. If glucose < 3, give 25% glucose 2 – 4 ml/Kg IV.
  5. Lorazepam 0.1 mg/kg (max 4 mg/dose) IV/IO/IN 
  6. Or Diazepam 0.2 mg/kg IV/IO/PR (max 10 mg/dose) or Midazolam 0.1 – 0.2 mg/kg IV/IO/IM/IN
  7. Phenytoin (Dilantin) 20 mg/kg IV/IO at 50 mg/min (max 1000mg)
    Have patient on cardiac monitor, watch BP.
  8. Phenobarbital 20 mg/kg IV/IO/IM (note IM takes 2 hours for onset)

For Refractory Status Epilepticus
   9. Status Epilepticus:
       A. Phenytoin (Dilantin) 20-30 mg/Kg IV at max. 50 mg/min.
            Patient should be on cardiac monitor to watch for QRS width. 
           Stop drug is QRS > 50% baseline width.  Watch also for hypotension.
           May repeat 10 min after loading dose. Not for use in alcohol withdrawal seizures.
       B. Valproic Acid 20-60 mg/kg IV bolus at 2 mg/min. May repeat 10 Min. after loading dose
       C. Phenobarbital 20-30 mg/Kg IV at no faster than 60 mg/min.
       D. Propofol 1-2 mg/kg at 20 mcg/kg/min, followed by infusion at 30-200mcg/kg/min
            (requires mechanical ventilation)