Identify etiology

• Cerebrovascular accident, subarachnoid hemorrhage, intracerebral hemorrhage, central nervous system tumor or infection, head trauma, autoimmune encephalopathy, and pre-eclampsia/eclampsia

• Low antiepileptic drug levels, drug overdose (e.g., cocaine, isoniazid, theophylline, phenothiazine), ethanol related, and drug withdrawal

• Cerebral hypoxia/anoxia, hypoglycemia, hyponatremia, hypernatremia, hypomagnesemia, hypocalcemia, and hypercalcemia (rare)

Management

• Airway/breathing/circulation (ABCs)

• Oxygen by nasal cannula or mask

   ○ Consider endotracheal intubation if respiratory assistance is needed

• Obtain appropriate laboratory tests

   ○ Complete blood count, serum chemistries, arterial blood gases, and antiepileptic blood levels

   ○ Urine and blood toxicological panel

• Manage complications

   ○ Hyperthermia, metabolic acidosis, arrhythmias, cerebral edema, and rhabdomyolysis

• Thiamine (unless patient is known to be euglycemic)

   ○ 100 mg IV administered before dextrose

• Dextrose 50 % (unless patient is known to be euglycemic)

   ○ 50 mL IV

• Lorazepam (preferred initial benzodiazepine)

   ○ 0.1 mg/kg IV (up to 4 mg per dose)

   ○ Do not exceed an infusion rate of 2 mg/min

   ○ May repeat in 5–10 min

   ○ May administer IM in patients without IV access (maximum 3 mL per IM injection)

   ○ Patients on chronic benzodiazepine pharmacotherapy may require higher doses

• Diazepam

   ○ 0.15 mg/kg IV (up to 10 mg per dose)

   ○ May repeat in 5 min

   ○ Do not exceed an infusion rate of 5 mg/min

   ○ Duration of effect is typically less than 20 min

   ○ May administer IM in patients without IV access (maximum 3 mL per IM injection)

• Phenytoin

   ○ 15–20 mg/kg IV