In the acute setting, seizures are initially treated with benzodiazepines (lorazepam or midazolam), followed by phenytoin or phenobarbital. Antiepileptic drugs (AEDs) are commonly used in treating focal and generalized epilepsies.

Treatment of seizures in the emergency department may include:^[1]

Patient stabilization by:

• Secure airway
• Oxygen
• Monitor vital signs
• Cardiac monitoring
• Obtain IV access
• Thiamine/ 250 mg/ IV, followed by 50% glucose/ 50 ml/ IV/ over 10 minutes (glucagon/ 1 mg/ IM if IV access is not available)
  • If suspicion of hypoglycemia, alcohol abuse, and poor nutrition

Treatment with the following should be started if the seizure persists after 5 minutes:

• 5–20 minutes:
  • Lorazepam/ 0.1 mg/kg (max 4 mg)/ IV over a few seconds
  • Diazepam/ 10 mg /IV (0.15 mg/kg) (if lorazepam is not available)
  • Midazolam/ 10mg/ buccal (if IV access is not possible)
  • If there is no response, repeat this after 10 min
• If no response, 20–40 minutes:
  • Phenytoin 20/ mg/kg/ IV
  • or:
    • Phenobarbital 10–15/ mg/kg/ IV
    • Sodium valproate 30–40/ mg/kg, max dose 3,000 mg/ IV
    • Leveracetam 40–60/ mg/kg, max dose 4,500 mg/ IV
• If no response, 40–60 minutes:
  • Refractory status epilepticus:
    • Intubate
    • General anaesthesia
    • Admit to intensive care unit (ICU)

Antiepileptic drugs (AEDs) commonly used in treating focal and generalized epilepsies include:^[2]

• Focal epilepsy:
  • Carbamazepine
  • Eslicarbazepine
  • Gabapentin
  • Lacosamide
  • Oxcarbazepine
  • Phenytoin

• Focal and generalized epilepsies (broad spectrum):
  • Clobazam
  • Clonazepam
  • Lamotrigine
  • Levetiracetam
  • Perampanel
  • Topiramate
  • Valproate
  • Zonisamide

• Generalized epilepsy:
  • Ethosuximide in absence seizures

For more information about antiepileptic drugs (AEDs) in the therapy of epilepsies, click here.

For more information about antiepileptic drugs (AEDs), click here.