A Modern Artillery to put off the Electric Storm of the Brain– A case report of aborting seizure with brivaracetam 2-minute intravenous bolus in a patient with a compromised airway.
Maycky Tang1, Prathyankara Premkumar2
1University of Missouri - University Hospital, 2Rockbridge High School
Objective:

A case report of successful seizure treatment using bolus administration of intravenous brivaracetam over 2 minutes in a patient with compromised airway.

Background:

As time is brain, it is paramount to rapidly treat seizures and status epilepticus to avoid permanent neuronal injuries. Benzodiazepines are the recommended first-line antiepileptic medications, but with initial and repetitive dosing, airway compromise can occur even before seizure resolution. Alternative fast-acting antiepileptics that can minimize this effect could lead to better outcomes and decreased ICU stays.

Design/Methods:
N/A
Results:

Our patient is a 47-year-old male with a history of developmental delay and chronic ventriculomegaly was successfully extubated after external ventricular drain weaning. While his mentation improved, he had ongoing difficulties clearing secretions requiring a heated high-flow nasal cannula and repeated nebulizer treatments. The following day, the patient acutely had a seizure, manifesting as obtundation, whole body rigidity, and left lateral forced gaze deviation. Given ongoing respiration issues, lorazepam was held, and he was given a 2-minute bolus of intravenous brivaracetam 100mg instead.  Post administration, patient's mentation improved with the resolution of the gaze deviation. Continuous video electroencephalogram did not show any electrographic seizures.  Patient was continued on brivaracetam 100 mg twice daily. 

Conclusions:
Brivaracetam with high lipophilicity of 1.04 and T-max of less than 5 minutes can be given intravenously as a rapid 2-minute bolus. While there are no high-quality studies substantiating the efficacy of brivaracetam as a first-line medication, its pharmacokinetic/pharmacodynamic properties could make it a reasonable alternative to benzodiazepines as the first-line anti seizures medication, especially in pre-existing tenuous airways to avoid further compromise and reduce ICU and hospital length of stay. The benefits of its fast onset of action and efficacy may mitigate the major barriers of ready accessibility and cost.
10.1212/WNL.0000000000203033