Managing the generalised tonic-clonic seizure and preventing progress to status epilepticus: a stepwise approach

Seizures are a commonly encountered medical problem. Seizure protocols have been shown to be effective by avoiding inappropriate over- and undertreatment, but are not presently utilised in many centres in Australia. We outline a stepwise approach to effective seizure management based on timely investigation and escalating treatment with an appropriate choice of medications. Because large-scale clinical trials are lacking, we base our approach on the underlying seizure pathophysiology and the pharmacological properties of the available drugs. Early management consists of finding and correcting possible reversible causes and ensuring patient safety. With ongoing seizure length, spontaneous resolution becomes unlikely, necessitating administration of anti-epileptic drugs. Benzodiazepines are the agents of first choice, with a preference of short-acting drugs. With ongoing seizures, other agents (i.e. valproate, levetiracetam, phenobarbitone, phenytoin) are utilised. Refractory status epilepticus requires aggressive treatment in an intensive care setting. Novel approaches and agents, including ketamine, topiramate, lacosamide, pregabalin and intravenous immunoglobulins, are discussed. We provide our own recently developed hospital protocol as a guide. This protocol relies on a time-based four-step escalating approach to seizure management, ranging from supportive management of the initial simple seizure to the use of multiple agents for established status epilepticus.