Antiepileptic Protocol in Neurotrauma

Primary Recommendation

The American College of Emergency Physicians recommends levetiracetam or phenytoin/fosphenytoin for early post-traumatic seizure prophylaxis, with levetiracetam preferred due to superior tolerability and fewer drug interactions 1

Antiepileptic prophylaxis should be initiated in patients with intracranial hemorrhage, as it is associated with a higher risk of seizures 2
The Brain Injury Foundation recommends antiepileptic prophylaxis in patients with depressed skull fracture, as it may reduce the risk of seizures 2
The American Academy of Neurology recommends antiepileptic prophylaxis in patients with loss of consciousness or amnesia >24 hours, as it may reduce the risk of seizures 2
The American Geriatrics Society recommends antiepileptic prophylaxis in patients >65 years with TBI, as it may reduce the risk of seizures 2

The American College of Emergency Physicians recommends levetiracetam as the first-line agent for seizure prophylaxis, with a dosing regimen of 1000-1500 mg IV loading dose, then 500-1500 mg twice daily 1
The American Academy of Neurology recommends phenytoin/fosphenytoin as an alternative to levetiracetam, with a dosing regimen of 18-20 mg/kg IV at maximum rate of 50 mg/min for phenytoin or 150 PE/min for fosphenytoin 3

The American College of Emergency Physicians recommends benzodiazepines, such as lorazepam, as the first-line treatment for active seizures in neurotrauma 5
The American Academy of Neurology recommends levetiracetam, fosphenytoin, or valproate as second-line treatments for refractory status epilepticus, with equal efficacy among the three agents 6

The American Academy of Neurology recommends continuous EEG monitoring in patients with depressed mental status disproportionate to brain injury severity to detect nonconvulsive seizures 2
The American College of Emergency Physicians recommends head CT as the preferred initial imaging modality to identify acute intracranial hemorrhage or mass effect requiring urgent intervention 2
The American Heart Association recommends serial neurological examinations in patients with TBI, as high-dose antiepileptics may confound clinical assessment and prognostication 7

The Brain Trauma Foundation recommends against the use of high-dose glucocorticoids after severe TBI, as it may worsen outcomes 8
The American Academy of Neurology recommends recognizing that myoclonic seizures may represent Lance-Adams syndrome, which is compatible with good outcomes, and overly aggressive treatment may not be warranted 7
The American Heart Association recommends against routine seizure prophylaxis in post-cardiac arrest patients with TBI, but active seizures should be treated 7
The American Academy of Neurology recommends considering higher loading doses of levetiracetam (1500 mg) for immediate neuroprotection in the acute setting 2