A 10-year-old is admitted in refractory convulsive status epilepticus (CSE) — seizures persisting despite IV lorazepam 0.1 mg/kg twice and IV fosphenytoin 20 mg PE/kg. He continues seizing at 45 minutes. The most appropriate next step is:
- A RSI with midazolam/ketamine and intubation for burst-suppression therapy ✓
- B Levetiracetam 60 mg/kg IV over 15 minutes
- C Phenobarbitone 20 mg/kg IV
- D Sodium valproate 40 mg/kg IV over 1 hour
Correct answer: A. RSI with midazolam/ketamine and intubation for burst-suppression therapy
Explanation
Refractory CSE is defined as seizures persisting beyond 30-60 minutes despite two adequate anti-epileptic drug (AED) regimens. At this stage (third-line therapy), anesthetic agents — midazolam infusion, propofol, thiopental, or ketamine — with airway protection via RSI are indicated, targeting EEG burst-suppression. Levetiracetam and phenobarbitone are second-line options used earlier (before this point); a second-line drug had already been given. Valproate is another second-line agent. Once true refractory status is established, anesthetic coma is the standard of care.
Reference: Ghai Essential Pediatrics, 10th ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.