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A 4-year-old boy is brought to ED having a generalised tonic-clonic seizure that has lasted 8 minutes. He has IV access. Blood glucose is 5.2 mmol/L (normal). [1]
Questions
a) What is the diagnosis and what drug should be given immediately? (3 marks) [1]
Convulsive status epilepticus (seizure over 5 minutes). Immediate treatment: IV lorazepam 0.1 mg/kg (max 4 mg). Repeat once after 10 minutes if still seizing. Also: oxygen via face mask, ABC approach, recovery position to protect airway, continuous monitoring. [1]
b) If the seizure continues after two doses of lorazepam (at 20 minutes), what is the next step? (3 marks) [1]
Second-line AED (choose ONE):
- IV levetiracetam 40 mg/kg over 5 minutes (preferred — minimal interactions, rapid action)
- IV fosphenytoin/phenytoin 20 mg/kg over 20 minutes (cardiac monitoring — risk of arrhythmia)
- IV valproate 40 mg/kg over 10 minutes [1]
c) If the seizure continues beyond 30 minutes, what is the management? (2 marks) [1]
Refractory status epilepticus → RAPID SEQUENCE INTUBATION and transfer to PICU:
- IV propofol or thiopentone infusion (titrated to burst suppression on EEG)
- Continuous EEG monitoring
- Identify and treat the cause: hypoglycaemia, hypocalcaemia, hypomagnesaemia, CNS infection, structural lesion, drug withdrawal, metabolic disorder [1]
d) What investigations should be done during/after status epilepticus? (2 marks) [1]
Immediate: glucose (done), FBC, U&E, Ca, Mg, LFTs, VBG (lactate, acid-base), toxicology After control: EEG (rule out non-convulsive status), neuroimaging (CT acutely, MRI later), lumbar puncture (if CNS infection suspected), metabolic screen (ammonia, lactate, amino acids, organic acids) [1]
References1ShowHide
- [1]Fisher RS, Cross JH, French JA, Higurashi N, Hirsch E, Jansen FE, Lagae L, Moshé SL, Peltola J, Roulet Perez E, Scheffer IE, Zuberi SM. Operational classification of seizure types by the International League Against Epilepsy: Position Paper of the ILAE Commission for Classification and Terminology. Epilepsia, 2017.PMID 28276060