A 7-year-old boy presents with fever, altered consciousness, and generalized tonic-clonic seizures lasting 35 minutes despite two doses of IV lorazepam (0.1 mg/kg each) given 10 minutes apart. His blood glucose is 82 mg/dL. Which is the MOST appropriate next pharmacological intervention?

• A IV fosphenytoin 20 mg PE/kg over 10 minutes ✓
• B IV phenobarbitone 20 mg/kg over 30 minutes
• C IV levetiracetam 60 mg/kg over 15 minutes
• D IV valproate 40 mg/kg over 5 minutes

Explanation

This child has benzodiazepine-refractory status epilepticus (SE); two adequate benzodiazepine doses failing to terminate SE at 30+ minutes defines refractory SE requiring a second-line antiseizure medication. Fosphenytoin (20 mg PE/kg IV) is the traditional first-choice second-line agent and is preferred in this age group because it is faster to administer and better tolerated than phenytoin. IV levetiracetam (60 mg/kg) is increasingly used and is an acceptable alternative, but fosphenytoin remains the first-line second-line agent per established PALS/Neurocritical Care Society guidelines. Phenobarbitone is a third-line agent used if fosphenytoin fails. IV valproate is contraindicated in children under 2 years with possible mitochondrial disease but can be used as second-line when fosphenytoin is contraindicated.

Reference: Ghai Essential Pediatrics, 10th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.