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Status Epilepticus — RACP Adult Medicine MCQ

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ModerateNeurologyStatus EpilepticusRACP Adult Medicine

A 45-year-old woman presents to ED with status epilepticus. She has a known seizure disorder and has been non-adherent with her medications. IV midazolam has been given without effect. She continues to have generalised tonic-clonic seizures for 20 minutes. What is the most appropriate next step?

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Correct answer: A — IV phenytoin (or fosphenytoin)

For established status epilepticus (seizures >5 minutes despite first-line benzodiazepine), second-line agents include IV phenytoin/fosphenytoin (20 mg/kg), IV levetiracetam (60 mg/kg, max 4.5 g), or IV sodium valproate (40 mg/kg). Phenytoin remains a standard choice. If seizures persist after two second-line agents, the patient has refractory SE requiring anaesthetic agents (propofol or thiopentone) in ICU.

Reference: eTG Neurology – 2024 – Status Epilepticus; NICE 2024 SE Guidelines