First Seizures, Acute Repetitive Seizures, and Status Epilepticus

ABSTRACT OBJECTIVE This article provides current evidence on how and when to treat unprovoked first seizures in children and adults, guides intervention with appropriate doses and types of modern and effective therapies for acute repetitive (cluster) seizures, and reviews evidence for the diagnosis and management of established, refractory and super-refractory status epilepticus. LATEST DEVELOPMENTS Artificial intelligence shows promise as a clinical assistant in decision making after a first seizure. For nonanoxic convulsive refractory status epilepticus third-phase treatment, equipoise exists regarding whether it is better to add a second IV nonsedating antiseizure medication given via loading dose (eg, brivaracetam, lacosamide, levetiracetam, fosphenytoin or valproic acid) or to start an anesthetizing continuous IV infusion antiseizure medication such as ketamine, midazolam, propofol or pentobarbital. ESSENTIAL POINTS After a first seizure, the risk of a second seizure is about 36% at 2 years and 46% after 5 years. The risk is doubled in the presence of EEG epileptiform discharges, a brain imaging abnormality, a nocturnal first seizure, or prior brain trauma. For acute repetitive seizures, providers should give a proper dose of benzodiazepines based on the patient’s weight and needs. First-phase treatment for convulsive established status epilepticus is the immediate administration of full doses of benzodiazepines. Second-phase treatment for convulsive established status epilepticus is a full loading dose of IV fosphenytoin, levetiracetam, valproic acid, or if necessary, phenobarbital.