Seizure Management

Seizure Management

April 15, 2024

Seizure management can be tricky in the undifferentiated patient. Join EMRA*Cast's Will Smith, MD, as he discusses the latest in first-, second-, even fifth-line medications with Col. Roderick Fontenette, MD, FACEP.


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Will Smith, MD

Emergency physician in Northern California
Graduate, Nuvance Health/Vassar Brothers Medical Center Residency
@WTSmithMD | wtsmithmd
EMRA*Cast Episodes


Roderick Fontenette, MD, CPE, MHCM, FACEP

Associate Professor, Military Associate Program Director
Department of Emergency Medicine | University of California, Davis
Lieutenant Colonel, USAF


Seizures are part of the bread and butter in emergency medicine. Most of the time when these patients arrive in the ED, the seizing has stopped and there isn’t much else for us to do. But in the cases where they seizures don’t stop or when the patient has multiple seizures, do you know what meds to give and how much? How about second line? Third? Perhaps, even fourth line? In this episode Dr. Rod Fontenette goes over the latest in seizure management when first line benzos don't work, the appropriate dosing of those meds, and what to do in certain patient populations.


  • Benzos are first AND second line; make sure you dose correctly
    • Lorazepam should be 1mg/kg up to 4 mg
  • 3rd/4th/5th line meds include phenytoin, valproic acid, and levetiracetam
    • Remember 20/40/60 mg/kg respectively to help with dosing
  • If a patient has been seizing for a long time or has had seizures that are hard to control and they stop seizing, but are taking a very long time to come back to baseline, consider non-convulsive status
    • This can only be seen on an EEG, so you may need to transfer
  • Patients without hyponatremia can be treated with 3% hypertonic saline
    • 100 mLs bolus to stop the seizures, then SLOWLY bring it up over the next 24 hrs
  • Seizing pregnant patient should get up to 4 g magnesium and make sure to order the OB consult at the same time
    • Many times the baby will need to be delivered

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