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Refractory Status Epilepticus — RACP Adult Medicine MCQ

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HardNeurologyRefractory Status EpilepticusRACP Adult Medicine

A 55-year-old remains in electrographic status epilepticus after two adequate benzodiazepine doses and an appropriate full-dose second-line antiseizure medicine. He is intubated, haemodynamically stable and connected to continuous EEG. Which intervention should now be instituted?

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Reveal the answer and explanation

Correct answer: A — Commence a titratable continuous IV anaesthetic infusion in ICU with EEG-guided seizure suppression

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

A is correct. Failure of an adequate benzodiazepine sequence and a properly dosed second-line agent defines refractory status epilepticus; treatment escalates to ICU anaesthesia with a titratable agent such as midazolam, propofol or thiopentone and continuous EEG. B adds respiratory and haemodynamic toxicity without providing a controllable refractory-status strategy. C can be discussed as an adjunct, but ongoing status should not be left untreated for a day. D confuses disappearance of convulsions after paralysis or intubation with electrographic seizure control. E removes the only reliable monitor of treatment response. The anaesthetic target and duration are individualised with neurology and intensive-care input rather than automatically pursuing a prolonged flat EEG.

Reference: NSW Agency for Clinical Innovation: Seizures—adult emergency care: https://aci.health.nsw.gov.au/ecat/adult/seizures International League Against Epilepsy: Treatment of status epilepticus: https://www.ilae.org/guidelines/guidelines-and-reports