A 7-year-old boy is brought to the physician because of spells of unresponsiveness and upward rolling of the eyes for 2 months. The episodes start abruptly and last a few seconds. During that time he does not hear anyone’s voice or make any purposeful movements. When the episodes end, he continues what he was doing before the spell. He does not lose his posture or fall to the ground. Episodes occur multiple times during the day. Physical examination shows no abnormal findings. An EEG following hyperventilation shows 3 Hz spike-and-slow-wave discharges. Which of the following is the most appropriate pharmacotherapy at this time?

No pharmacotherapy at this time

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 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 8-year old boy is brought to the emergency department because he has been lethargic and has had several episodes of nausea and vomiting for the past day. He has also had increased thirst over the past two months. He has lost 5.4 kg (11.9 lbs) during this time. He is otherwise healthy and has no history of serious illness. His temperature is 37.5 °C (99.5 °F), blood pressure is 95/68 mm Hg, pulse is 110/min, and respirations are 30/min. He is somnolent and slightly confused. His mucous membranes are dry. Laboratory studies show: Hemoglobin 16.2 g/dL Leukocyte count 9,500/mm3 Platelet count 380,000/mm3 Serum Na+ 130 mEq/L K+ 5.5 mEq/L Cl- 99 mEq/L HCO3- 16 mEq/L Creatinine 1.2 mg/dL Glucose 570 mg/dL Ketones positive Blood gases, arterial pH 7.25 pCO2 21 mm Hg Which of the following is the most appropriate next step in management?

Intravenous hydration with 0.9% normal saline and insulin

Intravenous hydration with 0.45% normal saline and insulin

Intravenous hydration with 5% dextrose solution and 0.45% normal saline

Intravenous hydration with 0.9% normal saline and potassium chloride

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 16-year-old boy is brought to the physician for a follow-up examination. He has a 6-year history of type 1 diabetes mellitus and his only medication is insulin. Seven months ago, he was treated for an episode of diabetic ketoacidosis. He has previously been compliant with his diet and insulin regimen. He wants to join the high school soccer team. Vital signs are within normal limits. His hemoglobin A1C is 6.3%. Which of the following is the most appropriate recommendation at this time?

Lower insulin dosage on days of exercise

Limit activity to 20 minutes per day

Advise against physical activity

Switch from insulin to metformin

Increase insulin dosage on days of exercise

Status epilepticus management for USMLE Step 1: High-Yield Pediatrics Lessons

SE Definition & Initial Care - The First 5 Minutes

Status Epilepticus (SE) Definition: Seizure lasting >5 minutes, OR ≥2 seizures in a row without regaining full consciousness between them.
Initial Management (Time: 0-5 min): Focus on ABCDEs.
- Airway: Maintain patent airway; lateral position, suction as needed.
- Breathing: Provide high-flow O₂; monitor respiratory effort.
- Circulation: Secure IV/IO access; attach cardiac monitor.
- Disability: Check blood glucose; assess GCS.
- Exposure: Check temperature, look for injuries.

⭐ High-Yield: Always check capillary blood glucose immediately. Hypoglycemia is a critical, reversible cause of seizures and must be corrected promptly with IV Dextrose.

Pediatric Status Epilepticus Management Algorithm

First-Line Therapy - Benzo Blitz

Goal: Terminate seizure within 5 minutes.
Benzodiazepines are the cornerstone. Choice depends on IV access.

⭐ Exam Fact: Intranasal (IN) Midazolam is as effective as IV Diazepam for pre-hospital seizure termination and is often preferred over rectal diazepam for its social acceptability and rapid onset.

Second-Line Therapy - Beyond Benzos

Administer if seizures persist >10 minutes after initial benzodiazepine doses.

Choose ONE of the following (no evidence for superiority of one over another):
- Fosphenytoin: 20 mg PE/kg (Max: 1500 mg PE). Water-soluble prodrug.
- Phenytoin: 20 mg/kg (Max: 1500 mg). ⚠️ Slower infusion; risk of Purple Glove Syndrome.
- Levetiracetam: 40-60 mg/kg (Max: 4500 mg). Favorable side-effect profile.
- Valproate: 20-40 mg/kg (Max: 3000 mg). ⚠️ Avoid in <2 yrs & suspected metabolic disease.
- Phenobarbital: 20 mg/kg (Max: 1500 mg). ⚠️ High risk of respiratory depression.

⭐ Fosphenytoin vs. Phenytoin: Fosphenytoin is preferred due to its lower risk of local tissue injury (e.g., Purple Glove Syndrome) and can be infused faster.

Purple Glove Syndrome from Phenytoin Infusion

Refractory SE - The ICU Phase

Defined as seizures unresponsive to 1st (BZD) & 2nd line (AED) agents. Requires ICU admission & continuous EEG monitoring.
Goal: Achieve clinical & electrographic seizure control (e.g., burst-suppression on EEG).
Initiate continuous IV anesthetic infusion. Common agents:
- Midazolam: Load 0.2 mg/kg, then 1-10 mcg/kg/min infusion.
- Propofol: Load 1-2 mg/kg, then 20-80 mcg/kg/min infusion. ⚠️ Risk of PRIS.
- Thiopentone: Load 3-5 mg/kg, then 1-5 mg/kg/hr infusion. Causes significant hypotension.

⭐ Propofol Infusion Syndrome (PRIS): Characterized by metabolic acidosis, rhabdomyolysis, arrhythmia, and renal failure. Avoid prolonged high-dose use, especially in young children.

High-Yield Points - ⚡ Biggest Takeaways

Status epilepticus is a medical emergency; always secure ABCs first.

IV Lorazepam is the drug of choice. If no IV access, consider IM Midazolam, buccal Midazolam, or rectal Diazepam.

Always check capillary blood glucose immediately to rule out hypoglycemia.

Second-line agents include IV Phenytoin/Fosphenytoin, Valproate, or Levetiracetam.

Refractory status epilepticus (RSE) requires ICU care and continuous infusion of agents like Midazolam.

The goal is rapid seizure termination to prevent permanent neuronal damage.

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