Second-Line AED in SE — RACP Adult Medicine MCQ

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ModerateNeurologySecond-Line AED in SERACP Adult Medicine

A 40-year-old woman continues to seize after IV lorazepam 4 mg × 2 doses (total 8 mg). She has been seizing for 20 minutes. She has IV access and is being monitored. She is not on regular AEDs. What is the most appropriate next step?

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Correct answer: A — IV levetiracetam

Benzodiazepine-refractory SE → second-line AED. Options (all have similar efficacy per ESETT trial): IV levetiracetam (60 mg/kg, max 4500 mg over 15 min), IV fosphenytoin/phenytoin (20 mg PE/kg at 150 mg PE/min with cardiac monitoring), or IV valproate (40 mg/kg at 10 mg/kg/min). ESETT trial showed equivalent efficacy (~45% response) for all three second-line agents. If second-line fails → refractory SE requiring general anaesthesia (midazolam, propofol, or thiopentone infusion in ICU).

Reference: eTG Neurology – 2024 – SE; ESETT Trial; NES 2024