Status epilepticus: Case

This boy is in established convulsive status epilepticus bordering on refractory. The seizure has lasted twenty-five minutes, which places him just short of the ILAE t2 of thirty minutes, and he has already received two benzodiazepine doses without effect. His glucose is normal, so hypoglycaemia is excluded, and his fever and his first-presentation status raise a central nervous system infection as the likely trigger. The priority is to give a second-line agent at once and to prepare for refractory escalation. ^[1]

Clinical findings and assessment

The key findings are the continuous convulsion at twenty-five minutes, the failure of two adequate benzodiazepine doses, the fever of 39.0 degrees, and the normal glucose. The boy has crossed the t1 threshold of five minutes and is approaching the t2 threshold of thirty minutes, which places him in the established phase bordering on refractory. Because two benzodiazepine doses have failed, the next step is a second-line agent, not a third benzodiazepine, since the GABA-A receptors have internalised and further benzodiazepine doses add respiratory depression without adding efficacy. ^[2]

The differential of a first febrile presentation in status includes a central nervous system infection such as meningitis or encephalitis, a complex febrile seizure that has evolved into febrile status, and a first presentation of epilepsy provoked by fever. The absence of a prior seizure history and the high fever make an infectious cause the working diagnosis, which directs the investigation toward the blood culture, the lumbar puncture once stable, and the empirical antibiotics and aciclovir. ^[5]