IV Keppra in the Emergency Department for Prevention of Early Recurrent Seizures
IV Keppra in the Emergency Department for Prevention of Early Recurrent Seizures
This study is looking at three seizure medicines. Patients with seizures are usually treated
 with phenytoin (Dilantin) or Fosphenytoin. These medicines can be given intravenously (IV)or
 by mouth. Another seizure medicine, levetiracetam (Keppra) can now be given this way also.
 This study will compare IV phenytoin (Dilantin) and IV fosphenytoin to levetiracetam (Keppra)
 in patients who have had a recent seizure. Only patients with a history of seizures can be
 involved. The patient must present to the emergency department within 4 hours of a seizure.
 The purpose of this study is to compare these three drugs, phenytoin (Dilantin),
 fosphenytoin, and levetiracetam (Keppra). The investigators are looking to see if these drugs
 can prevent another seizure in the next 24 hours. We are also looking for any possible side
 effects.
More than one in every one hundred patients presenting to the emergency department for care
 do so for seizures. More than half of these patients will require medications, often
 intravenously (IV), while in the emergency department. For many years the standard treatment
 has been phenytoin. However, there are many known contraindications to the use of this drug.
 These include known hypersensitivity, cardiac arrhythmias, cardiac disease, impaired liver or
 kidney function, diabetes mellitus, older age, thyroid disease, pregnancy, and alcohol use. A
 recent review of patients with seizure disorder at Emory Crawford Long and Emory University
 hospitals suggested that a significant percentage of those who were taking phenytoin actually
 had one or more of these contraindications. Additionally, the IV form of phenytoin has known,
 severe adverse effects including cardiovascular collapse, life threatening cardiac
 arrhythmias, and severe hypotension. There is another form of Phenytoin, called Fosphenytoin,
 that while safer in some respects still has similar concerns associated with its
 administration.

 Levetiracetam (Keppra) has been available as an oral drug in the United States since 2000 and
 has a well established safety record when used as an add-on drug for patients with partial
 onset seizures. A double-blinded randomized study has shown that levetiracetam is also
 effective for primary generalized seizures as well.

 The IV form of levetiracetam has recently been approved by the FDA for use. The only known
 contraindications other than known hypersensitivity include impaired renal function,
 psychiatric disorder, older age, and pregnancy. IV levetiracetam is not known to cause any of
 the acute, catastrophic events seen occasionally with phenytoin.

 The investigators would therefore like to compare IV phenytoin and fosphenytoin to IV
 levetiracetam in preventing early recurrent seizures. Patients with known seizure disorders
 would be randomly assigned to one of two groups and therefore receive either IV fosphenytoin
 or IV levetiracetam. After an observation period, seizure free patients would be discharged
 and 24 hour phone follow up conducted to assess for the effectiveness of these anti-seizure
 medications as well as for any adverse reactions.
Inclusion Criteria:

 -  age 18 or older

 -  patient presenting to Grady Memorial Hospital's Emergency Department after having a
 tonic-clonic seizure (primary or secondarily generalized) within the last 4 hours

 Cause of seizure for inclusion: reason for seizure is often undetermined at time of
 presentation to the Emergency Department. The most likely expected causes of a seizure are
 noncompliance to existing antiepileptic drug regimen, refractory epilepsy with breakthrough
 seizure, metabolic aberration, alcohol withdrawal, or unknown.

 Exclusion Criteria:

 -  non-English speaking

 -  first time seizure

 -  seizures other than tonic-clonic seizure (primary or secondarily generalized)

 -  more than 3 seizures in 24 hours or status epilepticus, pregnant patients by history
 or by urine pregnancy testing, serious neurologic insult resulting in seizure but
 where seizure is not the primary reason for admission (e.g. traumatic brain injury
 with seizure or hemorrhagic stoke would be excluded)

 -  contraindication to IV levetiracetam

 -  received IV phenytoin within 24 hours

 -  known allergy to phenytoin

 -  previously enrolled in the study