Status epilepticus: SAQ

This boy is in established convulsive status epilepticus. The seizure has lasted twenty minutes, which places him between the ILAE t1 of five minutes and the t2 of thirty minutes, and he has already received one benzodiazepine dose without effect. His glucose is normal, so the cause is not hypoglycaemia, and his fever raises an infectious trigger. The priority is to give a second-line agent now, because a third benzodiazepine dose adds respiratory depression without adding efficacy, as the GABA-A receptors have begun to internalise. ^[1]

Question 1 (10 marks)

Outline the stepwise management of this boy from the moment of arrival, including the drugs and doses you would give and the time frame for each step. ^[2]

I would apply the APLS stepwise pathway. On arrival I would call for senior and anaesthetic help, start the clock, place the child in the lateral position, give high-flow oxygen, and apply cardiac and oxygen monitoring. I would confirm the bedside glucose is normal, which it is at 4.2 millimoles per litre, and I would weigh the child at 16 kilograms to anchor every dose. ^[2]

For the first-line benzodiazepine, the team has already given one dose of intravenous lorazepam eight minutes ago. I would give a second dose of lorazepam at 0.1 mg per kg, which is 1.6 mg intravenously, to a maximum of 4 mg, and I would give it now because he is still seizing and only one dose has been given. No more than two benzodiazepine doses are given in total, because the GABA-A receptors internalise and the efficacy falls steeply with time, so a third dose adds respiratory depression without adding seizure control. ^[2]

Because the seizure has lasted twenty minutes and persists despite the first benzodiazepine, I would proceed directly to a second-line agent. My preferred agent is levetiracetam at 40 mg per kg intravenously, which is 640 mg, to a maximum of 4.5 g, infused over five minutes. The alternative is fosphenytoin at 20 mg phenytoin-equivalent per kg, which is 320 mg phenytoin-equivalent, to a maximum of 1500 mg phenytoin-equivalent, infused over ten minutes with cardiac monitoring. ^[3]

If the seizure persists beyond thirty minutes despite adequate first and second-line therapy, the boy has refractory status epilepticus, and I would escalate to rapid sequence intubation to protect the airway and ventilate, and I would start a continuous midazolam, propofol, or thiopentone infusion titrated to burst suppression. Continuous EEG monitoring would be mandatory from this point, because the boy would be paralysed and the brain could still be seizing. ^[2]