Seizure Management

All Content Status Epilepticus Medications ASM Flowcharts ASM Withdrawal Refractory Epilepsy
Status Epilepticus

Clinical Reference Cards

Courtesy of Dr. Gena Ghearing

Ictal Interictal Continuum (IIC) Card Management Protocol Status Epilepticus Pocket Reference Card

Management of Convulsive Status Epilepticus

Neurocritical Care Society Guidelines

The following table outlines the time‐based phases, interventions, and dosing regimens:

Phase Time Range Intervention & Dosing
Stabilization Phase 0–5 minutes
  • ABCs (Airway, Breathing, Circulation)
  • Record seizure onset and monitor vitals
  • Establish IV access
  • ECG monitoring
  • Finger stick blood glucose (if <60 mg/dL)
  • Administer 100 mg IV thiamine + 50 mL D50W
Initial Therapy Phase 5–20 minutes
  • IV Lorazepam: 0.1 mg/kg, max 4 mg (may repeat once)
  • OR IV Midazolam: 0.2 mg/kg, max 10 mg (IM if no IV access)
  • OR IV Diazepam: 0.15–0.2 mg/kg, max 10 mg (may repeat once)
Second-line Therapy 20–40 minutes
  • IV Fosphenytoin/Phenytoin: 20 mg/kg, single dose
  • OR IV Valproic Acid: 40 mg/kg, max 3000 mg/dose, single dose
  • OR IV Levetiracetam: 60 mg/kg, max 4500 mg/dose, single dose
  • If none available, consider IV Phenobarbital: 15 mg/kg, single dose
Refractory Therapy ≥ 40 minutes
  • Intubate the patient
  • Initiate continuous infusion therapy:
    • Midazolam: 0.2 mg/kg bolus, then infusion 0.2–2.9 mg/kg/h
    • OR/AND Propofol: 1 mg/kg bolus, then infusion 20–60 µg/kg/min
  • Add a second ASM (options: fosphenytoin, valproic acid, levetiracetam, lacosamide, or phenobarbital)
Breakthrough/Recurrence N/A
  • Up-titrate available drips or initiate propofol if not already started
  • Address underlying cause of seizures
  • If super refractory SE, consider additional continuous infusion:
    • Ketamine: 1–2 mg/kg bolus followed by 2–10 mg/kg/h (repeat bolus as needed)
Additional Therapies N/A
  • Ketogenic diet
  • Phenobarbital: 15–20 mg/kg
  • Pentobarbital: 5–15 mg/kg then 0.5–5 mg/kg/h
  • Hypothermia
  • Immunomodulation
  • Epilepsy surgery
  • ECT
Anti-Seizure Medications

Below is a list of anti-seizure medications (ASMs) with typical adult dosing ranges, common side effects, and their therapeutic ranges (if applicable) along with the metabolite measured:

Medication Typical Adult Dose Range Common Side Effects Therapeutic Range
Brivaracetam Oral or IV: 100–200 mg/day (in 2 divided doses) Drowsiness, dizziness, fatigue, irritability N/A
Carbamazepine Oral: 800–1200 mg/day (in 2 divided doses; range ~400–1600 mg) Dizziness, drowsiness, diplopia, ataxia Carbamazepine 4–12 µg/mL; CBZ‑10,11‑epoxide 0.4-4 μg/mL
Cannabidiol (rare, for Dravet/LGS) Oral: 10–20 mg/kg/day (in 2 doses) Diarrhea, fatigue, decreased appetite, somnolence N/A
Cenobamate (new) Oral: 200 mg/day (after gradual titration; max 400 mg/day) Dizziness, somnolence, fatigue, headache, nausea 3.8-54.6 mg/L
Clobazam (adjunct for LGS) Oral: 10–40 mg/day (usually divided BID) Sedation, drowsiness, drooling Clobazam 30-300 ng/mL; N-desmethylclobazam 300-3000 ng/mL/td
Clonazepam (rarely used long-term) Oral: 0.5 to 1.5 mg/day in 1 to 3 divided doses
Adjunctive therapy: 0.5 to 1 mg/day in 1 to 3 divided doses		 Sedation, drowsiness, cognitive impairment, tolerance N/A
Eslicarbazepine acetate Oral: 800–1600 mg/day (usually once daily) Dizziness, headache, diplopia, somnolence N/A
Ethosuximide Oral: 500–1500 mg/day (maximum ~60 mg/kg/day; for absence seizures only) Nausea, vomiting, lethargy, headache, weight loss 40–100 µg/mL
Felbamate (rarely used – toxicity) Oral: 1200–3600 mg/day (divided TID–QID) Sedation, nausea, vomiting, risk of aplastic anemia/liver failure NA
Fenfluramine Oral: 0.2-0.35 mg/kg BID Hypertension, pulmonary hypertension, valvular Heart Disease, weight loss <50 µg/L
Gabapentin (rarely effective for epilepsy) Oral: 900–3600 mg/day (divided TID) Dizziness, somnolence, peripheral edema, ataxia N/A
Lacosamide Oral or IV: 200–400 mg/day and maximum 600 mg/day (divided BID) Dizziness, headache, nausea 10-20 mg/L
Lamotrigine Oral: 100–400 mg/day (in 2 divided doses; slow titration. Note that dosing changes for patients taking drugs that alter metabolism) Rash (risk of Stevens–Johnson syndrome), dizziness, headache 3-15 µg/mL
Levetiracetam Oral or IV: 1000–4000 mg/day (divided BID) Drowsiness, dizziness, irritability, behavioral changes 10-40 µg/mL
Oxcarbazepine Oral: 600–2400 mg/day (divided BID) Dizziness, sedation, hyponatremia 3–35 µg/mL (MHD)
Perampanel Oral: 8–12 mg/day (once daily at bedtime) Dizziness, somnolence, hostility, irritability, falls 200–600 ng/mL
Phenobarbital Oral or IV: 60–200 mg/day (usually once at bedtime) Sedation, cognitive impairment, ataxia, dependence 10–40 µg/mL
Phenytoin Oral or IV: 300–400 mg/day (divided BID; ~5–7 mg/kg/day to maintain level 10–20 µg/mL) Nystagmus, ataxia, gingival hyperplasia, hirsutism, sedation 10–20 µg/mL (zero-order)
Primidone (rarely used) Oral: 750–1500 mg/day (divided BID–TID) Sedation, ataxia, nausea, dizziness N/A
Pregabalin (rarely used for epilepsy) Oral: 150–600 mg/day (divided BID) Dizziness, somnolence, weight gain, peripheral edema N/A
Rufinamide (rare, LGS) Oral: 1800–3200 mg/day (divided BID) Dizziness, fatigue, nausea, vomiting N/A
Stiripentol (rare, Dravet) Oral: 50 mg/kg/day (divided TID) Drowsiness, ataxia, loss of appetite N/A
Tiagabine (rarely used) Oral: 32–56 mg/day (divided BID–QID) Dizziness, nervousness, fatigue, tremor N/A
Topiramate Oral: 100–400 mg/day (divided BID) Cognitive slowing, weight loss, paresthesias, kidney stones 5-20 µg/mL
Valproate (Valproic acid) Oral or IV: 1000–3000 mg/day (divided BID–TID; ~15–60 mg/kg/day) GI upset, tremor, weight gain, hair loss, hepatotoxicity, thrombocytopenia 50-125 mcg/mL
Vigabatrin (rare – infantile spasms) Oral: 2000–3000 mg/day (divided BID) Visual field defects, sedation, irritability N/A
Zonisamide Oral: 100–400 mg/day (once daily or divided BID) Dizziness, somnolence, loss of appetite, weight loss 10–40 mcg/mL

*Note:* The doses listed are typical adult maintenance ranges. Actual prescribing should be individualized, and many medications require slow titration or weight‐based dosing in children. Always consult detailed references for specific dosing and monitoring recommendations.

References: Epilepsy Foundation; ILAE; UpToDate drug monographs.

ASM Flowcharts

These flow charts provide guidance on anti-seizure medication selection based on seizure type, mechanisms of action, and clinical applications:

Choice of Anti-Seizure Medications

Monotherapy and add-on therapy options for seizures in adults and children:

Anti-seizure medication choice flowchart

Mechanisms of Action

Neurobiological targets of commonly used anti-seizure medications:

Anti-seizure medication mechanisms of action

Clinical Spectrum of Anti-Seizure Medications

Treatment approaches for different types of epilepsy in adults and children:

Clinical spectrum of anti-seizure medications

Reference: Löscher, W., Klein, P. The Pharmacology and Clinical Efficacy of Antiseizure Medications: From Bromide Salts to Cenobamate and Beyond. CNS Drugs 35, 935–963 (2021). https://link.springer.com/article/10.1007/s40263-021-00827-8

ASM Withdrawal

ASM withdrawal should be performed gradually under medical supervision after careful consideration of seizure recurrence risk factors.

Key Considerations for ASM Withdrawal:

  • Minimum 2 years seizure-free before attempting withdrawal
  • Longer seizure-free period for patients with prior relapses or refractory epilepsy
  • Gradual tapering over months (typically 3-6 months)
  • Higher recurrence risk with multiple seizure types, abnormal EEG, or structural lesions
  • Consider driving restrictions during and after medication withdrawal

Use the prediction tool below to estimate seizure recurrence risk after medication withdrawal, but always consult your epilepsy specialist before making any medication changes.

Epilepsy Prediction Tools
Management of Refractory Epilepsy
Therapy Category Description/Details
Definition Drug-resistant epilepsy (DRE) is defined as failure to achieve sustained seizure freedom after trials of two appropriate ASMs. Approximately one-third of patients have DRE, which increases risks (including SUDEP). Early referral to an epilepsy center is essential.
Surgical Options Resection, lesionectomy, lobar/multilobar resections, or hemispherectomy in catastrophic cases; corpus callosotomy may reduce drop attacks.
Neuromodulation Techniques VNS: Vagus nerve stimulation (VNS) has demonstrated that approximately 49% of patients achieve a ≥50% reduction in seizure frequency within 1–2 years (see VNS outcomes).

RNS: Responsive neurostimulation (RNS) offers a median seizure reduction of around 60% over several years (see RNS outcomes).

DBS: Deep brain stimulation (DBS) targeting the anterior nucleus of the thalamus has shown a median seizure reduction of about 56% in controlled trials (see DBS outcomes).
Dietary & Other Therapies Ketogenic diet (or variants), immunotherapies, etc.
References ILAE/AAN recommendations; ACNS guidelines; UpToDate; Epilepsy Foundation.