ECT is administered to a 60-year-old woman with treatment-resistant depression. She develops prolonged seizure activity (>120 seconds). Which drug should be given immediately, and what is the maximum cumulative dose before switching to a barbiturate?
- A Diazepam IV 10 mg; switch after 30 mg total
- B IV lorazepam 2–4 mg (or IV midazolam 2–5 mg); if seizure persists after 4 mg lorazepam, give IV propofol or thiopentone ✓
- C IV haloperidol 5 mg to terminate the seizure
- D Succinylcholine 1 mg/kg repeat dose
Explanation
A prolonged ECT-induced seizure (>120–180 seconds EEG seizure or >60 seconds motor activity) is a medical emergency. First-line treatment is IV benzodiazepine: lorazepam 2–4 mg IV or midazolam 2–5 mg IV, which enhances GABA-A-mediated inhibition to terminate the seizure. If the benzodiazepine fails, IV propofol (1–2 mg/kg) or thiopentone/sodium thiopental is given as a barbiturate induction agent to produce burst suppression and abort the seizure. Succinylcholine paralyses muscles but does not stop the cerebral seizure — it is used prior to ECT to prevent musculoskeletal injury. Antipsychotics do not terminate seizures and may lower the seizure threshold further.
Reference: Kaplan & Sadock's Synopsis of Psychiatry, 11th ed.
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Written and medically reviewed by the StethoPrep medical team.