A 7-year-old child is brought unconscious after a witnessed generalized tonic-clonic seizure lasting 35 minutes. Two doses of IV lorazepam have been given without effect. The next most appropriate pharmacological intervention according to PALS guidelines is:
- A IV phenobarbitone 20 mg/kg
- B IV valproate 40 mg/kg
- C IV fosphenytoin 20 mg/kg phenytoin equivalents ✓
- D IV midazolam 0.2 mg/kg
Correct answer: C. IV fosphenytoin 20 mg/kg phenytoin equivalents
Explanation
After two failed doses of benzodiazepine in established status epilepticus, the second-line agent per updated PALS/ILAE guidelines is IV fosphenytoin (20 mg PE/kg) or IV phenytoin. Phenobarbitone is an alternative second-line agent at 15–20 mg/kg; valproate at 40 mg/kg is also used in refractory cases but is third-line. Additional midazolam at this point is not appropriate as benzodiazepine resistance is established.
Reference: Ghai Essential Pediatrics, 10th ed.
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