A 34-year-old man presents with generalized tonic-clonic seizures that began 40 minutes ago. He received two adequate doses of midazolam buccally by paramedics but seizures continue. Airway and glucose have been addressed. What is the next step in management?
- A Intravenous levetiracetam or sodium valproate infusion ✓
- B Intravenous phenobarbitone bolus immediately
- C Repeat a third dose of buccal midazolam
- D Immediate rapid sequence intubation with thiopentone
Correct answer: A. Intravenous levetiracetam or sodium valproate infusion
Explanation
Seizures persisting after two adequately dosed benzodiazepine doses define established (benzodiazepine-refractory) status epilepticus. The next step is a second-line intravenous antiseizure medication such as levetiracetam, sodium valproate, or fosphenytoin, as shown by the ESETT trial comparing these agents. Repeating benzodiazepines adds little benefit, barbiturate coma and general anesthesia with intubation are third-line measures reserved for failure of second-line therapy.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.