What are the next steps in managing a patient with a history of seizures, currently post-ictal and unable to take oral medications, who has been maintained on Depakote (valproate) ER and Vimpatt (lacosamide) and has received intravenous (IV) Keppra (levetiracetam) and Ativan (lorazepam) for breakthrough seizures?

Management of Post-Ictal Patient with Seizure History on Depakote and Vimpat

For this post-ictal patient with breakthrough seizures who is unable to take oral medications, immediate neurology consultation and intravenous administration of valproate (Depakote) is strongly recommended to restore the patient's home antiepileptic regimen while maintaining seizure control. 1

Immediate Management Steps:

• Request urgent neurology consultation to assist with management of this patient with refractory seizures 1
• Initiate IV valproate (Depakote) at 30 mg/kg IV (maximum rate 10 mg/kg/min) to restore the patient's home medication regimen in parenteral form 1
• Consider additional IV levetiracetam (Keppra) dosing if seizures recur, as the patient has already received 1g 1
• Continue PRN lorazepam (Ativan) for breakthrough seizures as currently ordered 2
• Implement close neurological monitoring for seizure activity and post-ictal state improvement 1

Rationale for IV Valproate:

• The patient is maintained on Depakote (valproate) and Vimpat (lacosamide) at home, suggesting these medications are effective for their seizure control 3
• IV valproate has demonstrated efficacy in 77-88% of status epilepticus cases 1, 3
• IV valproate has fewer cardiovascular side effects compared to phenytoin/fosphenytoin, with minimal risk of hypotension 1
• Valproate can be administered more rapidly than phenytoin (at rates up to 10 mg/kg/min) 1

Medication Considerations:

• The patient has already received IV Keppra (levetiracetam) 1g and Ativan (lorazepam) 4mg in the ER 1
• Lorazepam is appropriate as first-line therapy for acute seizures, with recommended dosing of 4mg IV (may repeat once after 10-15 minutes if seizures continue) 2
• For refractory status epilepticus after benzodiazepines, additional antiepileptic medication is strongly recommended (Level A recommendation) 1
• IV valproate, levetiracetam, or fosphenytoin are all acceptable options for seizures refractory to benzodiazepines (Level B recommendation) 1

Important Considerations:

• Avoid oral medications until the patient is fully alert and has intact swallowing function 4
• Maintain continuous cardiorespiratory monitoring during antiepileptic administration 2
• Ensure equipment for airway management is immediately available 2
• Investigate potential underlying causes of breakthrough seizures (medication non-compliance, infection, metabolic disturbances, etc.) 1
• The most recent evidence from the ESETT trial shows similar efficacy (approximately 45-47%) among levetiracetam, fosphenytoin, and valproate for benzodiazepine-resistant status epilepticus 1

Transition Plan:

• Once the patient is able to take oral medications, transition back to oral Depakote ER and Vimpat at home doses 4
• Ensure communication with the patient's outpatient neurologist regarding this breakthrough seizure episode 4
• Schedule follow-up appointment with neurology prior to discharge 4

Common Pitfalls to Avoid:

• Delaying administration of IV antiepileptic drugs in a patient with known epilepsy who has had multiple seizures 1
• Using phenytoin/fosphenytoin in a patient maintained on valproate and lacosamide (not matching home regimen) 1
• Failing to investigate potential causes of breakthrough seizures 1
• Inadequate dosing of antiepileptic medications 1
• Neglecting to maintain the patient's established antiepileptic regimen during hospitalization 4