A 15-year-old boy is brought to the emergency department one hour after sustaining an injury during football practice. He collided head-on into another player while wearing a mouthguard and helmet. Immediately after the collision he was confused but able to use appropriate words. He opened his eyes spontaneously and followed commands. There was no loss of consciousness. He also had a headache with dizziness and nausea. He is no longer confused upon arrival. He feels well. Vital signs are within normal limits. He is fully alert and oriented. His speech is organized and he is able to perform tasks demonstrating full attention, memory, and balance. Neurological examination shows no abnormalities. There is mild tenderness to palpation over the crown of his head but no signs of skin break or fracture. Which of the following is the most appropriate next step?

Observe for 6 hours in the ED and refrain from contact sports for one week

Discharge without activity restrictions

Discharge and refrain from all physical activity for one week

Administer prophylactic levetiracetam and observe for 24 hours

Administer prophylactic phenytoin and observe for 24 hours

A 15-month-old girl is brought to the emergency department shortly after a 2-minute episode of rhythmic eye blinking and uncontrolled shaking of all limbs. She was unresponsive during the episode. For the past few days, the girl has had a fever and mild nasal congestion. Her immunizations are up-to-date. Her temperature is 39.2°C (102.6°F), pulse is 110/min, respirations are 28/min, and blood pressure is 88/45 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 100%. She is sleepy but opens her eyes when her name is called. Examination shows moist mucous membranes. Neurologic examination shows no abnormalities. The neck is supple with normal range of motion. An oral dose of acetaminophen is administered. On re-evaluation, the girl is alert and playing with toys in the examination room. Which of the following is the most appropriate next step in management?

Observe the patient for 24 hours

A previously healthy 5-year-old boy is brought to the emergency department because of a 1-day history of high fever. His temperature prior to arrival was 40.0°C (104°F). There is no family history of serious illness. Development has been appropriate for his age. He is administered rectal acetaminophen. While in the waiting room, he becomes unresponsive and starts jerking his arms and legs back and forth. A fingerstick blood glucose concentration is 86 mg/dL. After 5 minutes, he continues having jerky movements and is unresponsive to verbal and painful stimuli. Which of the following is the most appropriate next step in management?

Intravenous administration of lorazepam

Intravenous administration of phenobarbital

Intravenous administration of valproate

Intravenous administration of fosphenytoin

An 18-month-old girl is brought to the emergency department because of stiffening and jerking movements that began in her right arm and then spread to involve her whole body, followed by unresponsiveness that occurred 1 hour ago. Her symptoms lasted < 10 minutes. She has had coryza for 24 hours without any fever. She had an episode of a febrile generalized tonic-clonic seizure 6 months ago. Her past medical history has otherwise been unremarkable. Her vaccination history is up to date. Her uncle has epilepsy. Her temperature is 38.9°C (102.0°F). Other than nasal congestion, physical examination shows no abnormal findings. Which of the following factors most strongly indicates the occurrence of subsequent epilepsy?

Seizure within 1 hour of fever onset

Recurrence of seizure within 24 hours

History of prior febrile seizure

An orthopaedic surgeon at a local community hospital has noticed that turnover times in the operating room have been unnecessarily long. She believes that the long wait times may be due to inefficient communication between the surgical nursing staff, the staff in the pre-operative area, and the staff in the post-operative receiving area. She believes a secure communication mobile phone app would help to streamline communication between providers and improve efficiency in turnover times. Which of the following methods is most appropriate to evaluate the impact of this intervention in the clinical setting?

Failure modes and effects analysis

Status epilepticus for USMLE Step 1: High-Yield Management Lessons

Status Epilepticus - Defining the Emergency

Operational Definition: Seizure lasting >5 minutes, OR ≥2 seizures without baseline recovery.
Traditional Definition: Seizure lasting >30 minutes, implying risk of permanent neuronal damage.

⭐ The 5-minute threshold is key; most seizures resolve spontaneously before this. After 5 min, they are less likely to self-terminate, necessitating emergent intervention.

EEG showing status epilepticus with continuous spiking

SE Algorithm - Meds on the Clock

Follow a time-sensitive protocol for seizure cessation. First-line therapy uses benzodiazepines, followed by antiepileptic drugs if seizures persist. Refractory status epilepticus (RSE) requires continuous EEG monitoring and anesthetic agents.

⭐ Always administer thiamine before glucose in patients with suspected alcohol use disorder or malnutrition to prevent precipitating Wernicke's encephalopathy.

Status Epilepticus Management Algorithm

Refractory SE - The Deep End

Defined as seizures persisting after 1st-line (benzodiazepines) and 2nd-line (e.g., fosphenytoin, levetiracetam) agents. Requires ICU admission & continuous EEG monitoring.

EEG: Burst suppression pattern in status epilepticus

⭐ Propofol Infusion Syndrome (PRIS): A lethal risk with prolonged, high-dose infusions. Characterized by severe metabolic acidosis, rhabdomyolysis, hyperlipidemia, and cardiovascular collapse.

Post-Seizure Care - The Aftermath

Immediate Stabilization:
- Position: Lateral decubitus (recovery position) to prevent aspiration.
- Monitor: Vitals, pulse oximetry, and neurological checks.
- Airway: Ensure patent airway; provide supplemental O₂.
Diagnostic Workup:
- Labs: Fingerstick glucose, CMP, ABG, CK for rhabdomyolysis, toxicology screen.
- Imaging: Head CT/MRI to rule out structural lesions.
- EEG: Continuous monitoring if mental status does not return to baseline.
Common Complications:
- Todd's Paralysis: Focal neurological deficit post-seizure.
- Hyperthermia, aspiration pneumonia, neurogenic pulmonary edema.

⭐ Post-ictal lactic acidosis is a common, transient finding that typically self-resolves within 60-90 minutes; bicarbonate is rarely indicated.

High‑Yield Points - ⚡ Biggest Takeaways

Status epilepticus is a neurologic emergency: a seizure lasting > 5 minutes or ≥2 seizures without recovery.

Initial management is ABCDEs; always check fingerstick glucose and give thiamine/dextrose if indicated.

First-line therapy is an IV benzodiazepine (e.g., lorazepam, diazepam).

Second-line agents include IV fosphenytoin, valproic acid, or levetiracetam.

For refractory cases, consider continuous infusion of midazolam, propofol, or pentobarbital with EEG monitoring.

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