Levetiracetam in toxic seizures

Figures & data

Figure 1. Included and excluded patients in primary and secondary screening.

Table 1. Demographic characteristics of patients treated for toxic seizures.

Demographic characteristics of patients treated for toxic seizures
	Male	Female	Total
Sex: N (%)	23 (68)	11 (32)	34 (100)
Age: Median (IQR)	39 (23–45)	39 (32–55)	39 (24–48)
No. of substances of exposure: Median (IQR)	1 (1–2)	3 (1–4.5)	1.5 (1–3)
Prior seizure history: N (% within sex)	10 (43)	5 (45)	15 (44)
History of prior LEV use: N (%)	5 (22)	3 (27)	8 (24)

Table 2. Substances identified by history, urine, and/or blood.

Substance	Count	Substance	Count	Substance	Count	Substance	Count
Cocaine	6	Quetiapine	2	Ibuprofen	1	Lamotrigine	1
Amitriptyline	5	Trazodone	2	Tiotropium	1	Levetiracetam	1
Ethanol	5	Venlafaxine	2	Levothyroxine	1	Metoclopramide	1
Methamphetamine	4	Oxycodone	2	Tramadol	1	Zolpidem	1
Gabapentin	4	Metoprolol	2	Baclofen	1	Methocarbamol	1
Methadone	3	Cannabis	1	Oxybutynin	1	Diazepam	1
Carbamazepine	3	Ethylene glycol	1	Energy drink	1	Difluoroethane	1
Heroin	3	Propylene glycol	1	Nortriptyline	1	Fluoxetine	1
Bupropion	3	MDMA	1	Boric Acid	1	Hydromorphone	1
Acetaminophen	3	Alprazolam	1	Ciprofloxacin	1	Bath Salts	1
Synthetic cannabinoid	3	Phenytoin	1	Diphenhydramine	1	Buspirone	1
Mirtazapine	3	Clonazepam	1

Table 3. Demographic characteristics of patients treated for toxic seizures.

Adverse events with long term sequelae:	Other in-hospital adverse events:
Cerebrovascular accident and acute kidney injury	Rhabdomyolysis
Brain injury with persistent neurologic sequelae	Acute kidney injury requiring hemodialysis
Death from sepsis and aspiration pneumonia	Acute kidney injury (2)
Persistent vegetative state	Aspiration pneumonia
Acute kidney injury and non-ST segment elevation myocardial infarction	Continued suicidal ideation
Heart failure with reduced ejection fraction	Tibia & fibula fracture
	Change in affect

Table 4. Complete list of patients.

Type of seizure	Sex	Age (Years)	Toxic substances	Number of seizures after LEV	Patient outcome	Length of stay (Days)	Summary of events
GCSE	F	22	Methamphetamine	0	Recovered	3.7	Prehospital seizure, intubated, EEG showing persistent seizure, received lorazepam (LOR) and levetiracetam (LEV). Documentation reports seizure “improved after keppra and ativan.”
GCSE	F	32	Ethylene glycol, propylene glycol	3	Cerebrovascular accident, acute kidney injury	15.8	Prehospital seizure, intubated, received midazolam (MID) & LEV. Patient unresponsive on ground three days into admission, thought to be unwitnessed seizure. Complained of “aura,” which ceased after LEV dosage increase.
GCSE	F	18	Acetaminophen, boric acid, ciprofloxacin	3	Takotsubo cardiomyopathy, persistent myoclonus	18.8	Altered, intubated, received propofol, 15 min seizure in ED after propofol infusion decreased, given LOR. Second seizure 2 h later, lasting two minutes after propofol stopped. Received LEV 2 h later. Patient had myoclonus the following day, confirmed on EEG, but documented as seizures, given LOR
GCSE	F	55	Methamphetamine, synthetic cannabinoid, synthetic cathinone, cocaine	0	Recovered, tibia & fibula fracture	20.3	Prehospital seizure, persistent altered mental status with initial response to naloxone. EEG confirmed persistent seizure for greater than 24 h. Received LEV, EEG showed possible seizure termination two days later.
GCSE	F	88	Venlafaxine, buspirone, gabapentin, mirtazapine, trazodone, levothyroxine, metoprolol	0	Death, sepsis, aspiration pneumonia	9.3	Prehospital seizure of 30 min, received LOR, MID, MID infusion, intubated, LEV 8 h later.
GCSE	M	36	Amitriptyline	0	Recovered, rhabdomyolysis	2.7	Prehospital seizure, received MID and LOR. Obtunded and agitated in ED, given LEV after seizure control.
GCSE	M	23	Heroin	0	Persistent vegetative state	96.1	Prehospital seizure, second seizure at outside facility, received LOR, MID, LEV, intubated, and transferred.
GCSE	M	16	Synthetic cannabinoid	0	Stabilized and transferred to an outside facility	0.2	Prehospital seizure, three seizures en route, given MID. Two seizures upon arrival, received fosphenytoin and LEV. Transferred to an outside hospital due to insurance issues.
GCSE	M	23	Difluoroethane	2	Acute kidney injury	12.8	Persistent seizure in ED, given LOR, MID, LEV, phenytoin, intubated.
GCSE	M	50	Cocaine	1	Recovered	16.5	Two prehospital seizures, received MID en route, started LEV thirty-four minutes later. LEV stopped the following day. Patient had a second seizure three days later, given LOR, LEV, phenytoin.
GCSE	M	16	Methadone, MDMA	0	Anoxic brain injury with neurologic sequelae	55.6	Prehospital seizure, received fosphenytoin & placed on LOR infusion. LOR stopped because of respiratory failure. LEV started 5 days later. Patient noted to be “posturing” 16 days later, EEG reported non-epileptiform activity.
GCSE	M	55	Alprazolam, heroin	0	Recovered	1.5	Prehospital seizure, received naloxone, LOR, MID, intubated. Persistent seizure-like motions, with reported EEG of “potentially epileptogenic cerebral dysfunction.” Received LEV 0-4 hours after termination.
GCSE	M	41	Heroin, methamphetamine	0	Recovered	2.1	Prehospital seizure of 20 min, received naloxone, MID. Second, 24 min seizure five hours later in hospital, received MID, LOR, olanzapine. Received LEV two hours after second seizure.
GCSE	M	28	Clonazepam, methadone	1	Recovered	1.6	Prehospital seizure, followed by 25 min seizure in outside hospital, received LOR, diazepam, went into respiratory failure, intubated, received LEV, with immediate seizure termination. Had another seizure the next day, given fosphenytoin.
GCSE	M	22	Amitriptyline, diazepam	3	Recovered	10.6	Patient presented altered, intubated. Seized after receiving LOR, propofol; received LEV 1+ hours later. Patient had three more seizures 4 h later, received LOR, and LEV dosage increased.
GCSE	M	44	Nortriptyline, bupropion, gabapentin	0	Persistent suicidal ideation	7.8	*Seizure in ED, placed on MID infusion. Second seizure later in the day, MID infusion increased and given LEV.
GCSE	M	64	Methadone, oxycodone, quetiapine, metoprolol, ibuprofen, tiotropium	0	Recovered	2.5	Prehospital seizure, received MID and LOR, LEV started 1+ day after admission for seizure prophylaxis.
TCS	F	39	Cocaine, etoh	0	Recovered	0.4	Unwitnessed prehospital seizure, missed morning LEV dose, restarted on LEV 5 h after presentation.
TCS	F	32	Methamphetamine	0	Recovered	0.4	Missed two doses of LEV, prehospital seizure, received LEV 4 h after admission.
TCS	F	45	Carbamazepine	0	Recovered	1.1	Prehospital seizure. LEV restarted 8 h after presentation.
TCS	F	32	Quetiapine, trazodone, venlafaxine, mirtazapine	0	Acute kidney injury with need for hemodialysis	16.2	Prehospital seizure, received MID, intubated. Had 2-3 seizures same day, received LEV 3-4 h after seizure control.
TCS	F	57	Baclofen, bupropion, mirtazapine, hydromorphone, gabapentin	0	Recovered	3.1	Prehospital seizure, received LEV 5 h after admission.
TCS	F	54	Diphenhydramine, lamotrigine, levetiracetam, gabapentin, metoclopramide, oxycodone, zolpidem, acetaminophen, methocarbamol, marijuana	1	Change in affect	3.7	History of epilepsy on LEV, presented with three prehospital seizures. Had one seizure in hospital the day after admission, received LEV 30 min later. Had another seizure 1 h later. LEV initially withheld due to concerns of toxicity.
TCS	M	44	Carbamazepine	0	Recovered	2.6	Seized in ED, administered LOR with no further seizure activity. History of LEV and carbamazepine use, restarted on LEV.
TCS	M	46	Phenytoin	0	Recovered	24.0	Several witnessed seizures pre-hospital in the past week, received LEV on hospital day 2.
TCS	M	18	Synthetic cannabinoid	0	Acute kidney injury	5.7	Prehospital seizure, received LEV 11 h after presentation.
TCS	M	39	Cocaine	0	Recovered	6.1	Two prehospital seizures, received “benzodiazepine” from EMS, unknown agents given at outside facility, seized en route. Received LEV 0–9 h after arrival.
TCS	M	22	Tramadol	0	Recovered	0.6	Prehospital seizure with subarachnoid hemorrhage injury, received LEV 5 h later.
TCS	M	34	Energy drink	0	Recovered	1.5	Prehospital seizure, with second seizure in ED, received LOR, ondansetron, promethazine, LEV.
TCS	M	67	Cocaine	0	Acute kidney injury, NSTEMI	1.4	Unwitnessed prehospital seizure. Received LEV 22 h after admission.
TCS	M	32	Cocaine	0	Recovered	0.6	“Rather quick” seizure while in ED, received LOR and LEV.
TCS	M	49	Oxybutynin, amitriptyline	0	Departed against medical advice	11.2	Prehospital seizure, received MID, LOR, intubated admitted to MICU. Two seizures 37 and 40 h after admission, received LOR, documented LEV administration not confirmed by nursing. Patient went into ventricular tachycardia, became pulseless, 30 min code. LEV charted to have been given 4 hours after onset of code.
TCS	M	40	Amitriptyline, bupropion, acetaminophen	0	Recovered	9.6	Altered mental status on arrival, three witnessed seizures three hours of admission. Received LEV 44 min after final seizure.
TCS	M	39	Carbamazepine, amitriptyline, fluoxetine	0	Recovered	2.4	Unwitnessed prehospital seizure, received LEV 11 h after presentation.