A 32-year-old has been fitting for 35 minutes despite 2 doses of IV lorazepam and a phenytoin load. How do you proceed?

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This patient is now in **refractory status epilepticus** — failure to respond to a benzodiazepine and a second-line agent at 35 minutes. NICE NG217 and the ILAE staircase guide management.

**ABCDE and reversible causes (in parallel).** Airway support, high-flow oxygen, capillary glucose (give 10% dextrose if low and IV **Pabrinex** if any alcohol or malnutrition risk), check **Na, Ca, Mg, glucose**, ABG, FBC, U&E, LFTs, CRP, anti-epileptic drug levels, beta-hCG, toxicology screen, blood cultures. Cover with **IV ceftriaxone + aciclovir** empirically if any meningoencephalitic features.

**Therapy already given:** two doses of lorazepam (correct first-line) and phenytoin (correct second-line). ESETT trial confirmed **levetiracetam, valproate and fosphenytoin are equivalent** as second-line agents.

**Third-line — anaesthetic induction.** Refractory status requires **immediate ITU involvement, RSI, and a continuous anaesthetic infusion** — typically **propofol or midazolam**, with thiopentone as alternative. I would phone ITU and anaesthetics now, transfer to ITU, intubate, and start a **continuous EEG**.

**EEG-guided control.** Target seizure cessation and **electrographic burst suppression** for **24 hours**, then attempt slow wean of the anaesthetic agent with continuous EEG. Maintain background AEDs (levetiracetam ± phenytoin) at therapeutic levels.

**Investigate cause.** Once stabilised: **CT head, MRI brain, lumbar puncture** (CSF cell count, protein, glucose, viral PCR, autoimmune encephalitis antibodies — NMDAR, LGI1, CASPR2, GAD), HIV, paraneoplastic panel.

**Super-refractory (>24 h).** Add **ketamine infusion**, consider **ketogenic diet**, **immunotherapy** (IV methylprednisolone + IVIG / plasma exchange) if autoimmune cause suspected, and discuss with the **tertiary neurology / neuro-ITU centre**.

**Communication.** Honest conversation with family about cause uncertainty, prognosis, and ITU course. Safeguard pregnancy if positive (managed jointly with obstetrics). Document carefully, debrief team, and reflect — refractory SE is a learning case for M&M.

Refractory status epilepticus

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