Question 1 of 4

A 19-year-old man is brought to the ED by paramedics for a generalized tonic–clonic seizure. He was given rectal diazepam gel en route with no effect. His glucose level in the ambulance was 105 mg/dL. He has now been seizing for 10 minutes and an IV has been placed. What is the treatment of choice?

Intravenous dextrose

Intravenous fosphenytoin

Intravenous lorazepam

Intravenous phenobarbital

Rectal diazepam

Intravenous lorazepam is the first-line treatment of choice in status epilepticus or impending status epilepticus, the latter being defined as seizure(s) for more than 5 minutes without recovery of consciousness. Lorazepam is effective, can be rapidly administered, and has a short onset of action. Doses of 2–4 mg can be given and repeated. The fact that the patient failed diazepam in the field does not change lorazepam’s first-line status. Glucose is not indicated in normoglycemia. Fosphenytoin, a water-soluble prodrug of phenytoin that can be rapidly administered, is a second-line agent and would be useful to abort a seizure that breaks through benzodiazepines or to prevent further seizures after control is established with benzodiazepines. Phenobarbital is a third-line agent in status epilepticus. Rectal diazepam and buccal midazolam are useful when there is no IV access.