Paediatric convulsive status epilepticus — MRCEM SBA MCQ

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EasyPaediatric emergenciesPaediatric convulsive status epilepticusMRCEM SBA

A 4-year-old child is brought to the emergency department with a continuous generalised tonic–clonic seizure. Paramedics gave buccal midazolam 6 minutes after the seizure began. On arrival, intravenous access was obtained and lorazepam was given because the seizure had continued. Five minutes later, the child is still convulsing. Airway support, oxygen and monitoring are in place; capillary blood glucose is 5.1 mmol/L. There is no individualised seizure management plan. What is the most appropriate antiseizure treatment now?

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Correct answer: A — Give intravenous levetiracetam.

The child remains in convulsive status epilepticus despite two benzodiazepine doses: prehospital buccal midazolam and in-hospital intravenous lorazepam. The prehospital dose counts. NICE recommends an intravenous second-line antiseizure medicine after two benzodiazepine doses; levetiracetam is an appropriate choice and may be quicker to administer than the alternatives. Airway support and expert paediatric help should continue alongside treatment. ([nice.org.uk](https://www.nice.org.uk/guidance/ng217/chapter/7-Treating-status-epilepticus-repeated-or-cluster-seizures-and-prolonged-seizures)) B and C are tempting because benzodiazepines are first-line treatment, and intravenous access is now available. Either could be appropriate earlier in the sequence, but giving a third benzodiazepine delays second-line treatment here. D is a later-line option under expert guidance if second-line treatment fails, not the next step. E would address hypoglycaemia as a seizure precipitant, but the measured glucose is normal. The decision depends on recognising both the ongoing seizure and the number of effective treatment stages already attempted, rather than choosing a drug solely because intravenous access is present. ([nice.org.uk](https://www.nice.org.uk/guidance/ng217/chapter/7-Treating-status-epilepticus-repeated-or-cluster-seizures-and-prolonged-seizures))

Reference: Epilepsies in children, young people and adults (NG217), section 7: Treating status epilepticus (30 January 2025) — https://www.nice.org.uk/guidance/ng217/chapter/7-Treating-status-epilepticus-repeated-or-cluster-seizures-and-prolonged-seizures NG217: Rationale and impact, status epilepticus (30 January 2025) — https://www.nice.org.uk/guidance/ng217/chapter/Rationale-and-impact