A 6-year-old presents with refractory convulsions lasting 45 minutes despite two doses of intravenous lorazepam (0.1 mg/kg each) and fosphenytoin 20 mg PE/kg. This is now classified as refractory status epilepticus. Which agent is appropriate as THIRD-LINE therapy?

• A Intravenous phenobarbitone 20 mg/kg
• B Intravenous midazolam infusion ✓
• C Intravenous ketamine 1.5 mg/kg bolus
• D Rectal diazepam 0.5 mg/kg

Explanation

Refractory status epilepticus (RSE) — seizures persisting after two adequate doses of benzodiazepine plus one second-line anti-seizure medication — requires third-line anesthetic agents. Continuous midazolam infusion (0.05–2 mg/kg/hr) is the preferred third-line agent for RSE in children due to its rapid titratability and favorable pharmacokinetic profile. Phenobarbitone is a second-line drug used before the RSE stage. Ketamine and propofol are alternatives in super-RSE. Rectal diazepam is first-line only out-of-hospital.

Reference: Ghai Essential Pediatrics, 10th ed.

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