SEIZURE

Shibin El Kom Teaching Hospital

CRITICAL CARE DEPARTMENT
 Assessment of patients with recurrent seizures

This algorithm should be used in the management and assessment of patients with
repetitive or prolonged convulsive OR non-convulsive seizures.

Is the patient in tonic-clonic Refer to Status

status epilepticus? YES
Epilepticus

NO

Is the patient having Is the patient known to Are these more frequent
NO YES
repetitive or
have epilepsy? or prolonged than usual
prolonged seizures?

Usual supportive
care during seizure:
NO

NO
Secure airway
Senior review
Y Recovery position Y
E E
Monitor vital signs
S S
Oxygen if required

Senior review and prioritise patient safety whilst investigating for underlying
causes, treating the underlying cause and seizures as appropriate:
 Actions to consider

-IV access

-Oral / IV benzodiazepines

-Escalate AED treatment and consider loading dose

-Senior review

-Discuss with neurology and critical care colleagues

Investigations to consider

Glucose

electrolytes

KFTS

LFTS

ABG/oximetry

anticonvulsant drug levels - CBC (e.g. TTP) - urinalysis.

Lactate - CK - toxicology screen.

LP (suspicion of infection).

EEG and response on EEG to BZD especially in non-convulsive fits

Brain imaging (CT or MRI).

CXR

Lumbar puncture
Features of commonly used IV AEDs and IVAT for acute seizures and SE, after initial
single doses of IV BDZ have failed control.

Suggested IV Maintenance dose Side effects EEG or lab considerations

Initial IV dose

Fosphenytoin ≥ 20 mg/kg 100 mg q8h Hypotension Enzyme induction

(phenytoin) Cardiac EKG

Phenobarbital ≥ 20 mg/kg 30–60 mg q8h Hypotension BS on EEG

Resp depression Enzyme induction

Divalproex ≥ 20 mg/kg 1 g q8h Tremor Thrombocytopenia

sodium
Protein binding

Levetiracetam 60 mg/kg 1 g q8h Agitation Renal elimination

Lacosamide 200 mg 200 mg q12h Dizziness, cardiac EKG—conduction block,

arrhythmia

Brivaracetam 100 mg 100 q12h Mood Renal elimination

Midazolam 0.2–0.5 mg/kg 2–40 μg kg min Intubation Titrate to BS on EEG

Pentobarbital 5–15 mg/kg 0.5–5 mg/kg/h Intubation Titrate to BS on EEG

Propofol 1–2 mg/kg bolus q 1–15 mg/kg/h first, then Intubation, propofol Titrate to BS on EEG; Avoid
3 min up to 10 mg/kg up to 5 mg/kg/h infusion syndrome prolonged use

Ketamine 1–2.5 mg/kg 3–10 mg/kg/h Intubation Use with BDZ for psychosis

Psychosis (BDZ beta on EEG)

Hypertension
 Status epilepticus

Status epilepticus is when a seizure lasts for 5 minutes or

more or when a person does not regain consciousness between
seizures. It is a medical emergency and requires immediate
medical attention.

Seizures occur due to sudden, uncontrolled bursts of

electrical activity inside a person’s brain. These bursts of
electricity interrupt the signals between the brain cells, which can
cause involuntary changes in:

• movement

• sensations

• body functions

• behavior

• awareness
 Treatment algorithm for tonic-clonic status epilepticus in adults

Timeline Initial patient management 0-5 minutes Ongoing

• Protect the patient. Do not restrain. management
Give 150-200ml 10% glucose IV stat.
• Consider airway adjunct.
• Administer oxygen.
If seizures continue repeat this step AND Regular observations
• Place patient in a semi-prone position,
commence 10% glucose infusion at
head down 12 lead ECG
100ml/hr.
• Gain IV access
t=0 If suspicion of alcohol excess or Obtain FBC, U&Es, LFTs,
• Obtain BM. If hypoglycaemic malnutrition commence 1 pair Pabrinex IV Ca2+, Mg2+, clotting studies
BEFORE glucose replacement. and if applicable antiepileptic
drug levels and blood gas.

Treat acidosis if severe

1st line treatment 5-15 minutes (discuss with critical care)

Determine if diagnosed
If IV access If no IV access epilepsy, medication history
DOSE 1 – IV lorazepam 4mg bolus DOSE 1 – Buccal midazolam 10mg and acute seizure care plan
(Alternative IM midazolam 10mg)
t=5 Wait 5 minutes Consider neuroimaging and
Wait 5 minutes EEG
DOSE 2 – IV lorazepam 4mg bolus
DOSE 2 – Buccal midazolam 10mg
(Alternative IM midazolam 10mg) Consider possibility of non-
Wait 5 minutes epileptic seizures
Wait 5 minutes
Consider and treat potential
causes:
• Medication related (poor
2nd line treatment 15 minutes onwards compliance, poor
absorption, recent
IV or IO access antiepileptic drug changes,
Escalate to Critical Care as per local policy medication interactions or
subtherapeutic levels)
DOSE 3 • Infection
• Electrolyte disturbance
t=15 IV Levetiracetam 60mg/kg, maximum 4500mg (in 100ml sodium chloride
• Toxicity or drug withdrawal
t=15 0.9% over 10 minutes)
(including alcohol
OR IV Phenytoin 20mg/kg, maximum 2g (rate 50mg/min, 25mg/min for elderly or withdrawal)
patients with cardiac history, give undiluted)
• CNS pathology (tumour,
OR IV Valproate 40mg/kg, maximum 3000mg (in 100ml sodium chloride 0.9% stroke, encephalitis, PRES,
over 5 minutes) neurodegenerative diseases
etc.)
Caution – phenytoin administration requires cardiac monitoring and wide bore
IV access due to risk of extravasation and phlebitis.

Preferred if Avoid if
Levetiracetam - Polypharmacy (fewest - Mood or behavioural disorder (may worsen symptoms)
(Keppra) drug interactions) Seizure
Phenytoin - Cardiac monitoring not available terminated
- Known or suspected generalised epilepsy (genetic
epilepsy)
- Hypotension/bradycardia/heart block
- Porphyria
- Known or suspected overdose of recreational drugs / ABCDE assessment of
alcohol withdrawal.
patient at regular
Valproate - Known or suspected - Women of childbearing potential (consider pregnancy intervals.
idiopathic generalised test)
epilepsy (genetic - Liver disease
epilepsy) - Pancreatitis
Consider escalation to
- Co-morbid mood - Known or suspected metabolic disorder/mitochondrial Critical Care setting if
disorder/migraines disease (risk of hepatotoxicity) indicated

If ongoing seizures following the completion of the infusion consider 2nd IV Start supportive medical
antiepileptic drug infusion of a different drug from the same list (levetiracetam, care and look for
phenytoin, valproate as above) OR phenobarbital. underlying cause of
status epilepticus
Phenobarbital can be given 15mg/kg as a single dose, max. rate 100mg/min.
If at any point >30 minutes since seizure onset move to 3rd line treatment.

Caution when using multiple agents with similar mechanism of action in view of potential adverseReview Date:
effects. See May 2023
Appendix 2.
Version: 1.0
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 Treatment algorithm for tonic-clonic status epilepticus in adults (cont.)

The following stages must occur with anesthetic input, airway support and early Ongoing
arrangements for transfer to ITU.
management
in Critical Care
3rd line treatment 30 minutes onwards (Refractory Status) Unit
General anesthesia – induction and maintenance.
The properties of each drug should be considered when selecting induction At point of admission to
and maintenance agents (these may be different). ITU all patients should
have an up-to-date
t=30 Induction Maintenance ECG.
Propofol 1-2mg/kg bolus up to 4mg/kg/hour titrated to effect,
continuous infusion for min. 24 hours
Ensure regular
Thiopental 3-5mg/kg bolus 3-5mg/kg/hour titrated to effect, antiepileptic drugs are
sodium continuous infusion for min. 24 hours prescribed alongside
3mg/kg bolus 1mg/kg/hour titrated to effect any additional treatment
Ketamine
maximum 10mg/kg/hour, continuous as part of this pathway.
infusion for min. 24 hours
Midazolam 0.2mg/kg bolus 0.05-0.5mg/kg/hour titrated to effect,
It is important to
continuous infusion for min. 24 hours
document why treatment
decisions have been
• General anaesthesia maintenance is typically with propofol and/or made and ensure
midazolam in the first instance. detailed communication
with next of kin
• If first maintenance agent is unsuccessful at terminating seizures a regarding treatment plan
second anaesthetic agent should be used. and prognosis.
• As a minimum, intermittent EEG to be performed aiming for suppression
of electrographic epileptic activity.
t=24hrs+ • Maintenance doses of antiepileptic drugs (commence 10-14 hours after
loading dose to allow regular ongoing dosing).
Caution

midazolam exhibits
multiple drug
interactions which
24hrs+ 4th line treatment 24+ hours (Super-Refractory Status) should be considered:
See appendix 2

Seizures that continue or recur 24 hours after third line treatment are Patients on propofol
considered Super Refractory Status Epilepticus. Treatment at this stage should be monitored
should be guided by specialists using an MDT approach. There is no high for PRIS - propofol
quality randomised controlled trial evidence to guide treatment decisions. infusion syndrome
(metabolic acidosis,
rhabdomyolysis, renal
• Look for an underlying cause and treat (e.g. infectious/autoimmune failure,
encephalitis, systemic infection, electrolyte disturbance, toxicity) hypertriglyceridaemia,
• Neurosurgical intervention (e.g. lesional resection) refractory bradycardia
and cardiac failure)
• If no underlying cause identified in a first presentation of seizures,
immunotherapy can be considered: high dose steroids, IVIG and /or Interpretation of
therapeutic plasmapheresis processed EEG
monitoring such as
• Alternative treatments at this stage include therapeutic hypothermia, bispectral index (BIS)
ketogenic diet and magnesium infusion. may become unreliable
when using ketamine
Treatments considered to be ineffective should be discontinued to infusion.
minimise risk of adverse effects.

Caution when using multiple agents with similar mechanism of action in view of potential adverse effects. See Appendix 2.

Review Date: May 2023

Version: 1.0
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