From the Guidelines
Seizure Management
During a seizure, it is crucial to administer a benzodiazepine to help control the seizure activity. The most appropriate medication to give during a seizure is lorazepam 2-4 mg intravenously or diazepam 5-10 mg rectally if intravenous access is not available 1. If the seizure persists, consider giving a second dose of the same medication. It is essential to maintain the person's airway, breathing, and circulation, and to seek immediate medical attention, especially if the seizure lasts more than 5 minutes, or if the person has multiple seizures without returning to normal, as indicated by the 2024 American Heart Association and American Red Cross guidelines for first aid 1. Some key points to consider when managing a seizure include:
- Activating emergency medical services for first-time seizures, seizures lasting more than 5 minutes, or seizures with injuries or breathing difficulty 1
- Administering the person's prescribed rescue medication according to their individualized plan, if they have a known seizure disorder
- Considering the use of rectal diazepam or intramuscular phenobarbital if intravenous access is not available 1
- Providing information and advice on avoiding high-risk activities and first aid relevant to the person and their family members 1
From the FDA Drug Label
For the treatment of status epilepticus, the usual recommended dose of lorazepam injection is 4 mg given slowly (2 mg/min) for patients 18 years and older. If seizures cease, no additional lorazepam injection is required. If seizures continue or recur after a 10- to 15-minute observation period, an additional 4 mg intravenous dose may be slowly administered
- Lorazepam is given during a seizure, specifically for the treatment of status epilepticus.
- The recommended dose is 4 mg given slowly (2 mg/min) for patients 18 years and older.
- If seizures continue or recur, an additional 4 mg intravenous dose may be given after a 10- to 15-minute observation period 2
From the Research
Administration Routes for Seizure Treatment
- Intramuscular (IM) route: can be used for antiepileptic drugs (AEDs) such as midazolam, lorazepam, and diazepam when intravenous route is not possible 3
- Rectal route: can be used for AEDs such as diazepam, but not for phenytoin and valproate due to poor absorption or solubility 3
- Intranasal route: midazolam nasal spray (Nayzilam) is FDA-approved for treating intermittent, stereotypic episodes of frequent seizure activity, and diazepam nasal spray (Valtoco) is also available for treating acute repetitive seizures 4, 5
Effective Medications for Seizure Treatment
- Midazolam: can be administered intramuscularly, intranasally, or rectally, and has been shown to be effective in terminating seizures 3, 6, 7, 4
- Diazepam: can be administered rectally or intranasally, and has been shown to be effective in reducing seizure frequency and time to recurrent seizures 3, 5
- Lorazepam: can be administered intramuscularly or intravenously, but has a slower onset of action compared to midazolam 3, 6
Advantages of Different Administration Routes
- Intranasal route: offers a large absorptive surface area, bypasses first-pass metabolism, and is needle-free and painless 4, 5
- Intramuscular route: is easier and less invasive than rectal administration, and can provide rapid absorption of midazolam 7
- Rectal route: can be used when other routes are not possible, but may have slower absorption and lower bioavailability compared to other routes 3