A patient brought to the emergency department with generalized tonic-clonic seizures for the past 20 minutes has failed an adequate dose of an intravenous benzodiazepine. According to standard management protocols, the next drug administered should be:

• A Intravenous phenobarbital
• B Oral topiramate loading
• C Intravenous midazolam infusion
• D Intravenous fosphenytoin ✓

Explanation

Status epilepticus management proceeds from a benzodiazepine (lorazepam or midazolam) to a second-line parenteral antiepileptic such as fosphenytoin, phenytoin, valproate or levetiracetam. Fosphenytoin is preferred over phenytoin because it causes less infusion-site reactions and cardiac arrhythmia, being a water-soluble prodrug converted by phosphatases. Phenobarbital is reserved as third-line after failure of two agents, so it is not the immediate next step.

Reference: Katzung Basic and Clinical Pharmacology, 15th ed.

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Written and medically reviewed by the StethoPrep medical team.