Epileptic seizures are among the leading causes of visits to emergency services, with nearly one million annual visits in the United States¹. These patients may present with isolated seizures, seizure clusters, or status epilepticus². Among these, status epilepticus is associated with the highest morbidity and mortality and is recognized as a neurological emergency. However, seizure clusters and isolated seizures can also lead to complications requiring immediate interventions^{2, 3}. To address this, the term "urgent epileptic seizure" has been adopted to encompass these three clinical scenarios and facilitate their quick identification for timely treatment⁴.

Current evidence highlights time to treatment and adequate medication dosing as critical determinants of patient outcomes, underscoring the importance of prompt therapeutic action⁵. Nevertheless, delayed treatment times and subtherapeutic dosing remain common⁶. Therefore, classifying patients under the term "urgent epileptic seizure" may help trigger a sense of emergency to medical staff and achieve faster treatment times.

While some centers in high-income countries have implemented effective protocols and order sets for managing urgent seizures^{7, 8, 9}, these initiatives face significant barriers in lower- and middle-income countries. Challenges include the absence of prehospital care infrastructure, a lack of electronic medical records, limited availability of intravenous antiseizure medications, and variability in hospital treatment practices^{10, 11, 12}. As a result, there may be an increased risk of complications including prolonged seizures, increased hospital stays, and an increased likelihood of patients developing functional limitations or progressing to more refractory states of status epilepticus.

Recognizing these challenges and following the success of other groups in implementing protocols with highly favorable outcomes⁴, Dr. Camilo Espinosa and his team at Hospital de Kennedy in Bogota, Colombia, developed a comprehensive approach to improving outcomes in patients with urgent epileptic seizures. Their multidisciplinary strategy integrates neurology, emergency medicine, intensive care, nursing, and prehospital care to ensure rapid and coordinated treatment. Drawing inspiration from the “time is brain” concept in stroke management, the team implemented a "seizure code” protocol, emphasizing the critical importance of early intervention in seizure management^{13, 14}. The seizure code strategy aligns with evidence showing that the therapeutic window for epileptic seizures is even shorter than that for acute stroke. These seizure code protocols have proven highly beneficial, particularly in lower-income populations, where simple and cost-effective interventions have yielded very favorable results.

A recent publication by Dr. Espinosa’s team demonstrated the efficacy of the seizure code strategy¹⁴. The implementation of this protocol led to markedly improved outcomes, including:  

• A reduction in the time to administer benzodiazepines from 100 minutes to 20 minutes (p = 0.063)
• A decrease in the time to administer antiseizure medications from 155 minutes to 39 minutes (p = 0.071)
• Decreased rates of prolonged hospital stays from 48% to 36% (p = 0.047)
• Decreased in-hospital seizure recurrence for patients with seizure clusters from 27% to 4.9% (p < 0.001)
• A decrease in mortality from 5.3% to 0.4% (p = 0.007)

This seizure code strategy has also served as the foundation for collaborative efforts across several Latin American countries. Over time, groups in Argentina, Chile, and Mexico have begun implementing seizure code protocols, tailoring them to their specific demographic and economic context. In July, an academic meeting in Mexico City brought together physicians from across the region to share their experiences and strategies. This event, which was supported by pharmaceutical partnerships, facilitated discussions on optimizing this protocol while generating new research ideas. One main objective is to establish the first Latin American consensus on managing urgent seizures, with a focus on improving prehospital care quality, a critical area of need in the region.

While significant challenges remain, the seizure code strategy highlights the potential of collaborative, evidence-based approaches to improving outcomes for patients with urgent seizures. By prioritizing rapid treatment and coordinated care, this initiative offers a scalable model for improving functional outcomes and reducing the burden of seizures in resources-limited settings. Additionally, the implementation of a seizure code could also be applied in higher-income countries; despite well-organized educational interventions conducted at sites of recent clinical trials, consistent guideline-recommended dosing of anti-seizure medications remains a work in progress¹⁵. This serves as one of many potential examples of bidirectional strategies and therapeutic interventions that can be mutually adapted and shared between higher- and lower-income countries.

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