New Guidance for Prolonged Seizure Treatment

Prolonged seizure treatment guidelines released by American Epilepsy Society

/ Author:  / Reviewed by: Beth Bolt, RPh

(RxWiki News) When seizures go on for too long, they can put patients' lives at risk. And doctors now have some new guidance on how to treat patients with prolonged seizures.

New guidelines from the American Epilepsy Society lay out effective phases of prolonged seizure treatment and identify when doctors should modify those phases to best serve patients.

A seizure results from irregular electrical activity in the brain and can cause body spasms, convulsions and loss of consciousness. A prolonged seizure occurs when the episode lasts for more than 30 minutes. Although seizures are often not fatal, prolonged seizures can significantly up patients' risk of severe health problems.

The new guidelines may help doctors give patients the correct treatments to lower this risk.

"This is a valuable new guideline for both children and adults that could change the approach many clinicians take in treating these seizure emergencies," said guideline author Tracy Glauser, MD, of Cincinnati Children's Hospital's Comprehensive Epilepsy Center, in a press release. "The goal of therapy is the rapid termination of the seizure activity to reduce neurological injuries and deaths."

In forming the new guidelines, Dr. Glauser and colleagues reviewed all available research related to epilepsy treatment. They found that four phases of prolonged seizure treatment are effective for most patients.

Within the first five minutes of seizure activity in the brain — called the stabilization phase — doctors should provide first aid and monitor the patient, Dr. Glauser and team found.

After the doctor determines whether the seizure requires medical attention, which should occur within the first five to 20 minutes, he or she is recommended to administer an injectable benzodiazepine (intramuscular midazolam, intravenous lorazepam or diazepam). These medications appeared effective and relatively safe in this context in the evidence Dr. Glauser and colleagues reviewed.

Between 20 and 40 minutes of seizure activity, and after the patient doesn't respond to the initial phases of treatment, doctors should administer the drugs fosphenytoin, valproic acid or levetiracetam. If those medications don't appear to work, phenobarbital may be an acceptable alternative treatment, although it may cause more adverse events.

After seizure activity has continued for more than 40 minutes, evidence on effective treatments become less clear. Dr. Glauser and team found that repeating the second-line therapy of administering anesthetic doses of either thiopental, midazolam, pentobarbital or propofol may be effective.

The researchers behind the new guidelines also noted that doctors should be flexible. Prolonged seizures can occur for various reasons, and their severity can vary. Doctors should keep that in mind, feeling free to skip the second phase of treatment in favor of the stronger third-phase treatments if the patient appears to require it, these researchers said.

"In treating status epilepticus there is an overriding urgency to stop seizures before the 30-minute mark when seizure-associated neurologic injury can occur," said guideline author Shlomo Shinnar, MD, PhD, of Albert Einstein College of Medicine and Montefiore Medical Center, in a press release. "This guideline supports an aggressive approach to treating status epilepticus and seeks to bring some structure to what can often be a chaotic and dire medical situation."

The new guidelines were published Feb. 9 in the journal Epilepsy Currents.

Several study authors were involved in other epilepsy-related projects. Some study authors received funding from various, research-related sources.

Reviewed by: 
Review Date: 
February 10, 2016
Last Updated:
February 10, 2016