Levetiracetam is available in intravenous formulation and can be given at 100-300 mg/min. Loading doses have not been established, but usually range from 1.5 to 2 g in adults, with a daily maintenance dose of 2 g per day. No adjustment is needed for patients with hepatic dysfunction. The drug is renally excreted, but can still be used safely in patients with renal insufficiency, including end-stage renal disease, by adjusting the dosing schedule.

At this point, levetiracetam can be considered an adjunct to current status epilepticus management. It may have a role as a third-line alternative (after benzodiazepines and phenytoin/fosphenytoin) to help obviate the need for stronger sedative drugs and avoid causing respiratory depression and hypotension.

If these measures have failed to control seizure activity, continuous infusions of pentobarbital, midazolam, or propofol should be used. There is little evidence to guide the use of these medications. It is the authors’ opinion that the dosing of the continuous infusions should be titrated up to the maximum tolerable dose (even with some mild hypotension) until the possibility of subclinical nonconvulsive status epilepticus has been evaluated by EEG. The major side effects are hypotension and respiratory depression, so the patient should be intubated and measures taken to support cardiovascular status (fluids and occasionally vasoactive medications).

Midazolam can be bolused at 0.2-0.3 mg/kg, then infused at 0.05-2 mg/kg/hr. Of the continuous infusions, midazolam was associated with the least amount of hypotension but higher rates of breakthrough seizures.¹⁸

Propofol is bolused at 2-5 mg/kg, then infused at 20-100 mcg/kg/min. It appears to be equally efficacious as midazolam, with fewer breakthrough seizures but more hypotension.

Propofol use is limited by infusion syndrome consisting of hypotension, metabolic acidosis, and hyperlipidemia seen with prolonged infusions.²²

Pentobarbital is bolused at 5-15 mg/kg, then infused at 0.5-10 mg/kg/hr. Compared with midazolam and propofol, it has the highest rates of seizure control and the fewest breakthrough seizures, but almost double the rate of significant hypotension.

Summary

Seizures are a common complaint seen in the emergency department. There are many important steps that the physician can take to optimize care for these “routine” patients. In addition, the emergency physician must always be aware of possible complicating factors including pregnancy, toxidromes, and status epilepticus. Levetiracetam is a new medication that is showing potential as another option for treatment in even the most severe patients and should be considered as an addition to the standard therapy.