A 26-year-old man is brought in with generalised tonic-clonic seizures continuing for 12 minutes without regaining consciousness between them. Intravenous access is obtained. What is the correct first-line drug and management step?

• A Intravenous phenytoin loading dose immediately
• B Intramuscular midazolam only if intravenous access fails
• C Intravenous lorazepam 0.1 mg/kg as the initial therapy ✓
• D Intravenous valproate 40 mg/kg as the initial therapy

Explanation

Convulsive status epilepticus is treated with an intravenous benzodiazepine first, classically lorazepam 0.1 mg/kg per dose, repeatable once. Benzodiazepines abort the seizure fastest and precede second-line agents such as phenytoin, valproate, or levetiracetam. Phenytoin as first line delays control because infusion takes time. IM midazolam is the alternative when IV access cannot be secured, not the preferred route when access exists.

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

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