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Seizure Escalation Management in Community — SCE Palliative Medicine MCQ

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ModerateSyringe Driver & Drug CompatibilitySeizure Escalation Management in CommunitySCE Palliative Medicine

A 70‑year‑old man with advanced prostate cancer is receiving a CSCI delivering diamorphine 80 mg, midazolam 20 mg, and haloperidol 5 mg over 24 hours. He develops focal seizures. The community nurse administers midazolam 5 mg SC as anticipatory medication, but the seizures continue. What is the next appropriate action?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: C — Repeat SC midazolam and obtain urgent clinical review

Explanation lettering: C = shown as A · E = shown as B · D = shown as C · A = shown as D · B = shown as E

Option D aligns with UK community palliative care protocols: midazolam rescue should be repeated (5 mg SC or buccal after 10 minutes) if initial dose fails to terminate seizures, followed by urgent review to escalate maintenance CSCI dose (typically 20–30 mg/24 h) and consider alternative routes (buccal or rectal benzodiazepine) if seizures persist or oral route is unsuitable. Option A delays necessary seizure control; B is inappropriate—diamorphine within therapeutic range does not induce seizures so opioid reversal is not indicated; C is impractical in this setting—oral phenytoin cannot be given SC and requires swallowing and loading; E is incorrect—haloperidol has no anticonvulsant activity.

Reference: Scottish Palliative Care Guidelines: Acute Convulsive Seizures; GMMMG Palliative Care Pain & Symptom Control Guidelines, 2025: https://www.nice.org.uk/guidance/ng217/chapter/recommendations