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Refractory Status Epilepticus — FRCA Final MCQ

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HardIntensive Care MedicineRefractory Status EpilepticusFRCA Final

A 45-year-old woman has had continuous generalised tonic-clonic seizure activity for 40 minutes. Blood glucose is normal and there is no clinical context suggesting eclampsia. She has received lorazepam 4 mg intravenously twice, followed by adequate intravenous loading doses of phenytoin and levetiracetam, without seizure cessation. In the ICU, her oxygen saturation is 86% despite high-flow oxygen; she has copious airway secretions and absent airway reflexes. Continuous EEG monitoring is available. What is the most appropriate immediate next treatment?

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Correct answer: B — Induce general anaesthesia with thiopental or propofol and perform tracheal intubation

This is refractory convulsive status epilepticus with immediate failure of airway protection and oxygenation. General anaesthesia using an anticonvulsant induction agent such as thiopental or propofol, followed by tracheal intubation, ventilation and EEG-guided anaesthetic infusion, is therefore the immediate priority. NICE lists general anaesthesia and phenobarbital as third-line options after unsuccessful second-line treatments, but phenobarbital does not provide controlled airway protection and may worsen respiratory depression. Sodium valproate is another non-sedating second-line option, but giving it before securing this compromised airway would be unsafe. Further levetiracetam is inappropriate after an adequate loading dose has failed. Magnesium sulphate is indicated for eclamptic seizures, for which the stem provides no supporting context. EEG treatment should target electrographic seizure cessation; burst suppression is not invariably required.

Reference: NICE. Epilepsies in children, young people and adults (NG217), section 7.1, recommendations 7.1.9–7.1.11. Updated 2025. https://www.nice.org.uk/guidance/ng217/chapter/7-Treating-status-epilepticus-repeated-or-cluster-seizures-and-prolonged-seizures