Critical Care, Improving Outcomes, Mythbusting

No benefit for Keppra in Status Epilepticus?

This was a prehospital, randomized, double blind, placebo controlled trial of adults with convulsions lasting >5minutes comparing 2.5g (!) of levetiracetam (Keppra) or placebo in combination 1mg of clonazepam. If convulsions lasted another 5 minutes, another 1mg of clonazepam was given. The primary outcome was cessation of convulsions within 15 minutes of initial drug injection. The trial was stopped early due to no evidence of a treatment difference after an interim analysis showed no difference (68 patients in intent-to-treat analysis per arm). Convulsions were stopped at 15 minutes in 57/68 (84%) patients receiving clonazepam vs 50/68 (74%) of patients receiving levetiracetam.

This study was funded by UCB, who manufactures Keppra.

As someone who embraces aggressive treatment of status epilepticus (escalating benzos + early dilantin / keppra followed by early intubation if needed) – particularly with Keppra since it can be given relatively quickly – this makes me go back to the literature rethink my treatment algorithm.

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Mythbusting

Ativan v. Versed

Quick, the patient in room 2 started seizing. They do not have IV access. What do you ask for?

If you say Ativan, keep reading.

2mg IM Midazolam (Versed) did not need rescue therapy when administered by EMS 73.4 % of the time compared to 63.4 % for 2mg of IV Ativan for pre-hospital seizures. The primary reason I have heard from attendings to lean towards Ativan rather than Versed has been that Versed would be more likely to have a recurrence of seizures given that it is short acting.  The reality is that there is a 11.4% vs 10.6% recurrence and the need for an advanced airway is 14.1 % vs 14.4 % (for Versed and Ativan, respectively). The caveat being that if they have an IV, time to cessation of convulsions for Ativan is 1.6 minutes vs 3.3 minutes for IM Versed (I’d imagine IV Versed would be less than 3.3 minutes, but alas, that was not studied). Adverse event rates were similar in the two groups.

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Importantly, intubation and recurrence are the same.  However, less rescue therapy is required in the Versed group, so, in theory, I could see this saving a few hospitalizations just based on the fact that a provider is uncomfortable discharging someone that required two or more meds / rounds of meds for stabilization. 

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Intramuscular versus intravenous therapy for prehospital status epilepticus. PMID: 22335736

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