A 24-year-old man presents in convulsive status epilepticus with ongoing tonic-clonic movements; there is no intravenous access yet. According to current guidelines, the appropriate immediate first-line treatment is:

• A Intravenous propofol infusion
• B Intravenous phenytoin loading dose
• C Rectal thiopentone
• D Intramuscular midazolam ✓

Explanation

Initial therapy of established status epilepticus is a benzodiazepine; when IV access is unavailable, intramuscular midazolam is recommended and was shown at least as effective as IV lorazepam in prehospital trials. Phenytoin, valproate or levetiracetam are second-line agents given after the benzodiazepine fails to stop seizures, and propofol infusion belongs to refractory status management in intensive care.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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