Abstracts

Rationale: Acute repetitive seizures (ARS), multiple seizures within 24 h, often require Emergency Department (ED) management and hospitalization. The treatment of ARS in the ED is not as well-defined as for status epilepticus (SE) but includes benzodiazepine (BZD), longer-acting antiepileptic drug (AED), commonly phenytoin (PHT), or combination therapy. It has been suggested that levetiracetam (LEV), may be a safe and effective alternative to PHT in this setting. A better understanding of the current management of ARS in the ED with the advent of intravenous (IV) LEV, including response to therapy and the need for hospitalization, may provide insight into evolving treatment protocols for ARS. Methods: Patients who presented from 7/1/05-12/31/06 and 2/1/08-3/31/08 to a university-based ED with ARS were identified. Initial search criteria included all patients at least 18 years of age with ED diagnosis codes for seizure(s). ARS characteristics, ED treatment course, and outcome were extracted. Those with SE or seizures only due to alcohol withdrawal were excluded. Results: Over the 9-month study period, 827 adult patients had ED diagnosis codes for seizure(s). 53 (6.4%) met our criterion for ARS, having multiple seizures within 24-hours prior to ED arrival. A BZD, lorazepam or diazepam, was the most common initial treatment in 31 patients (58.5%), with 12 patients (22.6%) also receiving a concomitant longer-acting AED such as PHT, valproic acid or LEV. 8 patients received PHT alone and 2 received LEV without concomitant BZD therapy. Following initial treatment, 9 patients (17.0%) had seizure recurrence. 22.6% of patients who received a BZD as initial therapy had seizure recurrence while 15.4% of patients who received a longer-acting AED alone (PHT or other AED) had seizure recurrence. No patients had seizures following treatment with LEV. 22 patients (41.5%) were hospitalized following initial ED management. 59.4% of patients who had received BZD were hospitalized while only 22.2% of patients who had received only a longer-acting AED were hospitalized. 75% (3 of 4) of patients treated with LEV were discharged home compared to 51.7% (15 of 29) of those treated with PHT . Conclusions: After BZD, PHT was the most commonly used AED in the acute management of ARS, even following the introduction of IV LEV. Seizure recurrence in the ED was as likely with use of BZD as with use of only longer-acting AEDs. No patients treated with LEV in the ED, with or without BZD, had seizure recurrence, though numbers were small. Hospitalization was nearly 3 times more likely in patients who received a BZD than in those who had received only a longer-acting AED. Although not statistically significant, a larger proportion of patients treated with LEV in comparison to PHT were discharged home. Retrospective design limits the ability to attribute outcome effects to specific therapies over patient selection bias. Still, the more favorable outcome associated with use of longer-acting AEDs, including LEV, sparing BZD use, argues for more prospective randomized trials in the development of novel treatment protocols for ARS in the ED.