Convulsive status epilepticus in a child with Dravet syndrome — MRCEM SBA MCQ

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HardPaediatric emergenciesConvulsive status epilepticus in a child with Dravet syndromeMRCEM SBA

A 20-month-old boy weighing 12 kg has genetically confirmed Dravet syndrome and takes regular oral levetiracetam. He has had a continuous generalised convulsion for 19 minutes during a febrile illness. His mother gave 5 mg buccal midazolam 13 minutes ago, and paramedics gave a further 5 mg 8 minutes ago. No individualised rescue plan is available. In the emergency department he remains convulsing despite oxygen and airway support. Intravenous access is established, senior paediatric and anaesthetic help has been requested, blood glucose is 5.4 mmol/L and sodium is 138 mmol/L. What is the most appropriate antiseizure treatment now?

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Correct answer: D — Give intravenous levetiracetam 40 mg/kg over 5 minutes.

This is ongoing convulsive status epilepticus. Both appropriately spaced prehospital midazolam doses count towards the two-dose benzodiazepine limit; establishing intravenous access does not restart that sequence. Glucose and sodium do not suggest an immediately correctable metabolic cause. The next antiseizure step is an intravenous second-line medicine. Levetiracetam is the best choice here: the regional paediatric status epilepticus pathway specifies 40 mg/kg over 5 minutes and explicitly says to give the full loading dose even when a child takes maintenance levetiracetam. For 12 kg, that is 480 mg. Continue airway and physiological monitoring while arranging ongoing paediatric assessment. ([nice.org.uk](https://www.nice.org.uk/guidance/ng217/chapter/7-Treating-status-epilepticus-repeated-or-cluster-seizures-and-prolonged-seizures)) A is an attractive choice now that intravenous access is available, but it would be a third benzodiazepine dose. B is an accepted second-line option in some patients, but phenytoin is relatively contraindicated in Dravet syndrome; the regional pathway reserves its consideration for failure of other agents. C is also listed by NICE as a possible second-line drug, but this regional paediatric pathway advises against valproate in children under 2 years. E has a role later in the pathway or in particular patient groups, rather than being the preferred next drug for this child. ([nice.org.uk](https://www.nice.org.uk/guidance/ng217/chapter/7-Treating-status-epilepticus-repeated-or-cluster-seizures-and-prolonged-seizures))

Reference: NICE NG217: Treating status epilepticus, repeated or cluster seizures, and prolonged seizures (30 January 2025) — https://www.nice.org.uk/guidance/ng217/chapter/7-Treating-status-epilepticus-repeated-or-cluster-seizures-and-prolonged-seizures North-West & North Wales Paediatric Critical Care Operational Delivery Network: Generalised Convulsive Status Epilepticus in CYP under 16 years, version 3 (13 February 2026) — https://northwestchildrensodnhub.nhs.uk/wp-content/uploads/2026/03/Guideline-for-Management-of-Generalised-Convulsive-Status-Epilepticus-version-3-FINAL.pdf