Neurocritical Care

Monitoring

Continuous EEG monitoring is necessary for status epilepticus and RSE.

adequate concentrations and mitigate the risk of toxicity. Because of altered protein binding, obtaining

a free level of highly bound medications is preferred.

Antiepileptic

Drug

Dosing

Common

Adverse Effects

Considerations

Lorazepam

0.1 mg/kg IV (slow IV push)

(maximum 4 mg/dose); up to 8

mg total

Sedation, hypotension

IV formulation contains propylene

glycol

Midazolam

(intermittent)

0.2 mg/kg IM (maximum 10

mg/dose)

Sedation, hypotension

Short duration with IV bolus

Diazepam

0.15 mg/kg IV (slow IV push);

typically up to 10 mg total

0.2 mg/kg rectally (20 mg

maximum)

Sedation, hypotension

IV formulation contains propylene

glycol; rectal administration may be

considered

Fosphenytoin

20 mg PE/kg IV (not to exceed

150 mg PE/min);

may also give IM

Hypotension,

arrhythmia,

hepatotoxicity

Several drug-drug interactions

Phenytoin

20 mg/kg IV (not to exceed 50

mg/min)

Hypotension,

arrhythmia,

phlebitis, purple

glove syndrome,

hepatotoxicity

Several drug-drug interactions,

IV formulation contains propylene

glycol and ethanol. Addition of

parenteral phenytoin to dextrose

and dextrose-containing solutions

should be avoided because of lack of

solubility and resultant precipitation

Valproic acid

40 mg/kg IV (not to exceed 6

mg/kg/min)

Hyperammonemia,

thrombocytopenia,

hepatotoxicity

Many drug-drug interactions, avoid

in patients with a TBI

Levetiracetam

60 mg/kg IV (maximum 4.5 g)

Sedation/paradoxical

excitation, irritability

Renally eliminated, limited drug-

drug interactions

Lacosamide

400 mg IV (typically over

15–30 min)

Dizziness,

bradyarrhythmia, P-R

interval prolongation

Limited drug-drug interactions

Topiramate

PO/enteral loading dose of

300–800 mg, followed by a

daily dose of 400–1000 mg in

2–3 doses

Metabolic acidosis,

nephrolithiasis

No IV formulation available

Phenobarbital

20 mg/kg (not to exceed 100

mg/min)

Sedation,

hypotension,

respiratory depression

IV formulation contains propylene

glycol