MCQ Quiz: Acute Management of Epilepsy

The acute management of epilepsy, particularly status epilepticus, is a neurological emergency where pharmacists play a critical role in ensuring rapid and appropriate treatment. The Patient Care VII: Brain and Behavior curriculum dedicates a specific unit to this topic, emphasizing the systematic approach to stabilizing the patient, selecting and dosing emergency medications, and transitioning to long-term care. This quiz will test your knowledge on the management of status epilepticus, the pharmacology of acute-use anti-seizure medications, and the crucial pharmacokinetic considerations that guide therapy in an urgent care setting.

1. Status epilepticus (SE) is a medical emergency. Operationally, it is defined as a continuous seizure lasting longer than:

• A. 30 seconds
• B. 1 minute
• C. 5 minutes
• D. 30 minutes

Answer: C. 5 minutes

2. What is the first-line class of medication for the emergent treatment of status epilepticus?

• A. Barbiturates
• B. Hydantoins
• C. Benzodiazepines
• D. Carboxylic acids

Answer: C. Benzodiazepines

3. A patient is brought to the emergency department in status epilepticus with no IV access established. Which of the following is an appropriate first-line treatment option?

• A. Intramuscular (IM) midazolam
• B. Intravenous (IV) phenytoin
• C. Oral levetiracetam
• D. Intravenous (IV) propofol

Answer: A. Intramuscular (IM) midazolam

4. The initial stabilization phase (0-5 minutes) in the management of SE involves:

• A. Immediately administering a second-line anti-seizure medication.
• B. Assessing and managing airway, breathing, and circulation (the ABCs).
• C. Obtaining a detailed family history.
• D. Starting a continuous EEG.

Answer: B. Assessing and managing airway, breathing, and circulation (the ABCs).

5. Which of the following is a recommended first-line benzodiazepine for the treatment of SE in a patient with IV access?

• A. IV Clonazepam
• B. IV Lorazepam
• C. IV Alprazolam
• D. IV Clobazam

Answer: B. IV Lorazepam

6. If a seizure continues after an adequate dose of a benzodiazepine, the patient is considered to have progressed to which stage?

• A. Early Status Epilepticus
• B. Established Status Epilepticus
• C. Refractory Status Epilepticus
• D. Super-refractory Status Epilepticus

Answer: B. Established Status Epilepticus

7. Which of the following is a recommended second-line therapy for established status epilepticus?

• A. A repeat dose of a benzodiazepine.
• B. An IV infusion of a non-benzodiazepine anti-seizure medication like fosphenytoin, valproic acid, or levetiracetam.
• C. An oral dose of carbamazepine.
• D. An inhaled anesthetic.

Answer: B. An IV infusion of a non-benzodiazepine anti-seizure medication like fosphenytoin, valproic acid, or levetiracetam.

8. Fosphenytoin is a prodrug of phenytoin. What is a primary advantage of using IV fosphenytoin over IV phenytoin in the acute setting?

• A. Fosphenytoin can be infused more rapidly with a lower risk of hypotension and cardiac arrhythmias.
• B. Fosphenytoin does not require a loading dose.
• C. Fosphenytoin has a much faster onset of action.
• D. Fosphenytoin is significantly less expensive.

Answer: A. Fosphenytoin can be infused more rapidly with a lower risk of hypotension and cardiac arrhythmias.

9. The “Acute Management of Epilepsy” is a core lecture within which module of the Patient Care VII course?

• A. Module 4: Mood Disorders
• B. Module 5: Anxiety and Sleep-Wake Disorders
• C. Module 6: Epilepsy.
• D. Module 7: Other Neuropsychiatric Disorders

Answer: C. Module 6: Epilepsy.

10. What is the purpose of administering a loading dose of a medication like phenytoin or valproic acid in the management of SE?

• A. To minimize the risk of side effects.
• B. To quickly achieve a therapeutic serum concentration.
• C. To test for an allergic reaction.
• D. To induce the drug’s metabolism.

Answer: B. To quickly achieve a therapeutic serum concentration.

11. The pharmacology of benzodiazepines makes them ideal first-line agents for SE because they:

• A. Have a slow onset of action but a long duration.
• B. Are potent GABA-A receptor modulators with a rapid onset of action.
• C. Do not cause respiratory depression.
• D. Work by blocking sodium channels.

Answer: B. Are potent GABA-A receptor modulators with a rapid onset of action.

12. “Purple glove syndrome” is a rare but serious infusion-site reaction associated with the intravenous administration of which medication?

• A. Levetiracetam
• B. Valproic acid
• C. Lorazepam
• D. Phenytoin

Answer: D. Phenytoin

13. A patient who continues to have seizures despite adequate trials of a benzodiazepine and a second-line ASM is considered to have:

• A. Provoked seizures.
• B. Absence epilepsy.
• C. Refractory status epilepticus.
• D. Benign rolandic epilepsy.

Answer: C. Refractory status epilepticus.

14. The management of refractory status epilepticus may involve a continuous infusion of which agents, requiring ICU admission and continuous EEG monitoring?

• A. Midazolam, pentobarbital, or propofol
• B. Fosphenytoin or levetiracetam
• C. Lorazepam or diazepam
• D. Valproic acid or lacosamide

Answer: A. Midazolam, pentobarbital, or propofol

15. What is the appropriate route of administration for diazepam rectal gel (Diastat)?

• A. Intravenous
• B. Intramuscular
• C. Oral
• D. Rectal

Answer: D. Rectal

16. The pharmacokinetics of fosphenytoin are measured in “phenytoin equivalents” (PE). A dose of 150 mg of fosphenytoin will deliver how much phenytoin?

• A. 100 mg of phenytoin
• B. 150 mg of phenytoin
• C. 225 mg of phenytoin
• D. 75 mg of phenytoin

Answer: B. 150 mg of phenytoin

17. The maximum recommended infusion rate for IV phenytoin in adults is:

• A. 25 mg/min
• B. 50 mg/min
• C. 100 mg/min
• D. 150 mg/min

Answer: B. 50 mg/min

18. A key management step after controlling an episode of status epilepticus is:

• A. Discontinuing all anti-seizure medications.
• B. Initiating or adjusting a long-term maintenance ASM regimen.
• C. Recommending a high-caffeine diet.
• D. Sending the patient home without follow-up.

Answer: B. Initiating or adjusting a long-term maintenance ASM regimen.

19. Which of the following is NOT a goal of acute seizure management?

• A. Terminate the seizure as quickly as possible.
• B. Prevent seizure recurrence.
• C. Minimize treatment-related adverse effects.
• D. Determine the patient’s long-term prognosis immediately.

Answer: D. Determine the patient’s long-term prognosis immediately.

20. A patient arriving in the ED with SE should have what checked immediately as part of the stabilization phase?

• A. A finger-stick blood glucose level.
• B. A lipid panel.
• C. A bone density scan.
• D. A detailed allergy history.

Answer: A. A finger-stick blood glucose level.

21. Intranasal midazolam is an emerging option for acute seizure management in the outpatient setting because it:

• A. Is more effective than IV lorazepam.
• B. Allows for rapid absorption and can be administered by caregivers without requiring IV access.
• C. Has no side effects.
• D. Is a non-benzodiazepine.

Answer: B. Allows for rapid absorption and can be administered by caregivers without requiring IV access.

22. IV valproic acid is a reasonable second-line option for established SE. What is a key adverse effect to monitor for?

• A. Gingival hyperplasia
• B. A severe rash
• C. Hepatotoxicity and hyperammonemia
• D. Kidney stones

Answer: C. Hepatotoxicity and hyperammonemia

23. The “Transcending Concept” lecture on the pharmacokinetics of specific ASMs is critical for acute management because it covers:

• A. The use of loading doses and therapeutic drug monitoring.
• B. The cost of medications.
• C. The color and shape of tablets.
• D. The legal classification of the drugs.

Answer: A. The use of loading doses and therapeutic drug monitoring.

24. The duration of action of a single IV bolus of diazepam is shorter than that of lorazepam due to:

• A. Slower metabolism.
• B. More rapid redistribution out of the CNS into peripheral tissues.
• C. Lower lipophilicity.
• D. Higher protein binding.

Answer: B. More rapid redistribution out of the CNS into peripheral tissues.

25. A pharmacist in the emergency department receives an order for an IV phenytoin loading dose. What is a crucial step before dispensing?

• A. Ensuring the patient has a cardiac monitor and a large-bore IV line.
• B. Confirming the dose is correct for the patient’s weight.
• C. Verifying the maximum infusion rate.
• D. All of the above.

Answer: D. All of the above.

26. The pharmacology of all first-line agents for SE involves enhancing the effects of which neurotransmitter?

• A. Glutamate
• B. Dopamine
• C. Serotonin
• D. GABA

Answer: D. GABA

27. After administering a loading dose of IV valproic acid, when should a trough level typically be drawn to guide maintenance therapy?

• A. Immediately after the infusion.
• B. 12 hours after the infusion.
• C. 24 hours after the infusion.
• D. A trough level is not necessary.

Answer: C. 24 hours after the infusion.

28. Propylene glycol is a diluent used in IV phenytoin and some IV lorazepam formulations. At high infusion rates, it can cause:

• A. A severe skin rash.
• B. Hypotension and cardiac arrhythmias.
• C. Agranulocytosis.
• D. Nephrotoxicity.

Answer: B. Hypotension and cardiac arrhythmias.

29. What is a primary advantage of levetiracetam as a second-line agent in the acute management of SE?

• A. It has a very narrow spectrum of activity.
• B. It has a favorable safety profile and minimal drug-drug interactions.
• C. It requires slow titration over several days.
• D. It is a potent enzyme inducer.

Answer: B. It has a favorable safety profile and minimal drug-drug interactions.

30. The “Implement” step of the PPCP in the acute management of epilepsy involves:

• A. Assessing the seizure type.
• B. Preparing and dispensing the emergency medication in a timely and accurate manner.
• C. Creating a long-term care plan.
• D. Following up with the patient a week later.

Answer: B. Preparing and dispensing the emergency medication in a timely and accurate manner.

31. Seizure “clusters” or “acute repetitive seizures” are managed in the outpatient setting with:

• A. A daily oral ASM.
• B. A rescue medication like rectal diazepam or intranasal midazolam.
• C. An antibiotic.
• D. A non-pharmacological approach only.

Answer: B. A rescue medication like rectal diazepam or intranasal midazolam.

32. The maximum infusion rate for IV fosphenytoin is:

• A. 25 mg PE/min
• B. 50 mg PE/min
• C. 100 mg PE/min
• D. 150 mg PE/min

Answer: D. 150 mg PE/min

33. What is a key advantage of IM midazolam over IM lorazepam for pre-hospital treatment of SE?

• A. IM midazolam has more reliable and rapid absorption.
• B. IM lorazepam has a faster onset of action.
• C. IM midazolam is not a controlled substance.
• D. IM lorazepam has fewer side effects.

Answer: A. IM midazolam has more reliable and rapid absorption.

34. The pharmacist’s role in the acute management of epilepsy includes all of the following EXCEPT:

• A. Dosing recommendations, including loading doses.
• B. IV compatibility and stability information.
• C. Monitoring for adverse drug events.
• D. Making the definitive diagnosis of the seizure type.

Answer: D. Making the definitive diagnosis of the seizure type.

35. After a patient is stabilized from SE, it is crucial to:

• A. Assume they will never have another seizure.
• B. Investigate and treat the underlying cause of the SE, if possible.
• C. Stop all medications to see if seizures recur.
• D. Discharge the patient immediately with no follow-up plan.

Answer: B. Investigate and treat the underlying cause of the SE, if possible.

36. A pharmacist is asked to prepare an IV infusion of phenytoin. It should be diluted in which of the following fluids?

• A. Dextrose 5% in water (D5W)
• B. Normal Saline (NS)
• C. Sterile water for injection
• D. Lactated Ringer’s solution

Answer: B. Normal Saline (NS)

37. The pathophysiology of prolonged seizures (SE) involves a decrease in the efficacy of GABAergic transmission and an increase in:

• A. Serotonergic transmission.
• B. Dopaminergic transmission.
• C. Glutamatergic transmission.
• D. Cholinergic transmission.

Answer: C. Glutamatergic transmission.

38. Which second-line agent for established SE is generally avoided in a patient with a known allergy to sulfa drugs?

• A. Valproic acid
• B. Levetiracetam
• C. Zonisamide (if considered)
• D. Phenytoin

Answer: C. Zonisamide (if considered)

39. A loading dose calculation for phenytoin must account for the drug’s:

• A. Half-life.
• B. Volume of distribution (Vd).
• C. Clearance.
• D. Oral bioavailability.

Answer: B. Volume of distribution (Vd).

40. A patient in refractory SE on a continuous midazolam infusion develops hypotension. This is a known pharmacodynamic effect of:

• A. High-dose benzodiazepines and other general anesthetics.
• B. The underlying seizure activity.
• C. An allergic reaction.
• D. A drug-food interaction.

Answer: A. High-dose benzodiazepines and other general anesthetics.

41. The primary goal of second-line therapy in established SE is to:

• A. Provide sedation only.
• B. Achieve long-term seizure control and prevent recurrence after the initial BZD.
• C. Reverse the effects of the benzodiazepine.
• D. Treat the patient’s anxiety.

Answer: B. Achieve long-term seizure control and prevent recurrence after the initial BZD.

42. A patient with non-convulsive status epilepticus may present with:

• A. Violent, jerking movements of all limbs.
• B. A prolonged state of confusion or altered mental status.
• C. A normal EEG.
• D. A high fever.

Answer: B. A prolonged state of confusion or altered mental status.

43. The management of acute seizures requires knowledge from which foundational course?

• A. Principles of Law & Ethics
• B. Principles of Drug Therapy Individualization (Pharmacokinetics).
• C. Population Health
• D. Drug Delivery Systems

Answer: B. Principles of Drug Therapy Individualization (Pharmacokinetics).

44. After a seizure is terminated, the “Follow-up” step of the PPCP would involve:

• A. Immediately starting a new medication.
• B. Monitoring for seizure recurrence, adverse drug effects, and assessing the need for changes to the maintenance regimen.
• C. Discharging the patient from the hospital.
• D. Assuming the treatment was successful with no further action needed.

Answer: B. Monitoring for seizure recurrence, adverse drug effects, and assessing the need for changes to the maintenance regimen.

45. Which of the following is a potential complication of untreated status epilepticus?

• A. Improved cognitive function
• B. Permanent neuronal damage and death
• C. A decrease in blood pressure
• D. A resolution of the underlying epilepsy

Answer: B. Permanent neuronal damage and death

46. The hospital pharmacist’s role in the acute management of SE is facilitated by:

• A. Working in isolation from the medical team.
• B. Having pre-printed protocols and order sets for SE management.
• C. Delaying the preparation of emergency medications.
• D. Only dispensing oral medications.

Answer: B. Having pre-printed protocols and order sets for SE management.

47. IV phenytoin should not be infused at a rate > 50 mg/min due to the risk of:

• A. Hepatotoxicity.
• B. Severe skin rash.
• C. Cardiovascular collapse and hypotension.
• D. Nephrotoxicity.

Answer: C. Cardiovascular collapse and hypotension.

48. Why is lorazepam often preferred over diazepam for IV treatment of SE in the hospital?

• A. It has a faster onset of action.
• B. It has a longer duration of action in the CNS due to less rapid redistribution.
• C. It causes less sedation.
• D. It is not a controlled substance.

Answer: B. It has a longer duration of action in the CNS due to less rapid redistribution.

49. The “Assess” step of the PPCP during an acute seizure event involves:

• A. Creating a long-term care plan.
• B. Rapidly evaluating the patient’s clinical status and the appropriateness of the current therapy.
• C. Educating the patient’s family.
• D. Documenting the event after it is over.

Answer: B. Rapidly evaluating the patient’s clinical status and the appropriateness of the current therapy.

50. The successful acute management of epilepsy requires:

• A. A slow, deliberate approach over several days.
• B. A rapid, systematic, and collaborative interprofessional team effort.
• C. The use of only one specific medication for all patients.
• D. The pharmacist to remain in the central pharmacy and not interact with the team.

Answer: B. A rapid, systematic, and collaborative interprofessional team effort.