ANTIEPILEPTIC MEDICATIONS AND SEIZURES

Seizures are common after severe brain trauma. Administer seizure prophylaxis to avoid the hemodynamic changes and increased cerebral metabolic activity caused by seizures. Seizure medications help prevent early post-traumatic seizures, but do not prevent all seizures. Up to 25% of patients with severe TBI will have seizures even with prophylactic treatment. Fifty percent of seizures may be non-convulsive in nature. Patients with subdural hematoma, neurosurgical procedure, or penetrating brain injury are at the highest risk of seizures. Post-traumatic seizures have been shown to increase morbidity and mortality after trauma.44-47

- If severe TBI is suspected, seizure prophylaxis should be administered during the initial evaluation and within 30 minutes of arrival.
  - Preferred agent: Levetiracetam (Keppra) 1500mg IV loading dose, followed by 1000mg IV BID
  - Second line agent: Lacosamide (Vimpat) 400mg IV loading dose, followed by 200mg IV q12hours.
  - Continue seizure prophylaxis for 7 days after a moderate or severe TBI.25,48-52 (Appendix A)
  - Seizure medications should be continued past post-injury day seven if the patient had evidence of seizure activity.
  - Rapid assessment and treatment of seizures is important to prevent secondary neurologic insult. Use a rapid response EEG device (if available) to diagnose seizures accurately and quickly.54-58
- Active Seizures

Lorazepam 1-2mg IV or Midazolam 5-10mg IV. Lorazepam is preferred. If no IV access, Midazolam IM is as effective as Lorazepam IV