From the FDA Drug Label
The treatment of status, however, requires far more than the administration of an anticonvulsant agent. It involves observation and management of all parameters critical to maintaining vital function and the capacity to provide support of those functions as required. Ventilatory support must be readily available. The use of benzodiazepines, like lorazepam injection, is ordinarily only one step of a complex and sustained intervention which may require additional interventions (e.g., concomitant intravenous administration of phenytoin). 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 In adults, a loading dose of 10 to 15 mg/kg should be administered slowly intravenously, at a rate not exceeding 50 mg per minute
The immediate management for an active seizure patient involves:
- Administration of an anticonvulsant agent such as lorazepam injection, with a usual recommended dose of 4 mg given slowly (2 mg/min) for patients 18 years and older 1
- Concomitant administration of other medications such as phenytoin, with a loading dose of 10 to 15 mg/kg administered slowly intravenously, at a rate not exceeding 50 mg per minute 2
- Observation and management of vital functions, including ventilatory support and monitoring of electrocardiogram and blood pressure
- Support of vital functions as required, including artificial ventilation equipment and maintenance of an unobstructed airway Key considerations include:
- Monitoring of serum levels to ensure therapeutic levels are maintained
- Adjustment of dosage as needed to prevent excessive serum levels or subtherapeutic ranges
- Continuous monitoring of the patient's condition, including electrocardiogram, blood pressure, and respiratory function.
From the Research
The immediate management for an active seizure patient focuses on ensuring safety and stopping the seizure, with benzodiazepines as the first-line treatment, specifically intravenous lorazepam (4 mg IV), diazepam (10 mg IV), or midazolam (10 mg IM or intranasal) if IV access is unavailable, as supported by the most recent study 3.
Initial Management
To manage an active seizure patient, the following steps should be taken:
- Protect the patient from injury by clearing the area of hazardous objects, loosening tight clothing, and placing them in a side-lying position to prevent aspiration.
- Do not restrain the patient or place anything in their mouth.
- Monitor vital signs and maintain airway patency.
Medication Administration
If the seizure continues beyond 5 minutes (status epilepticus), administer benzodiazepines as first-line treatment. Options include:
- Intravenous lorazepam (4 mg IV)
- Diazepam (10 mg IV)
- Midazolam (10 mg IM or intranasal) if IV access is unavailable, with a study showing midazolam autoinjector delivering IM drug compared to IV lorazepam had a 73.4% response rate in stopping seizures 4.
Second-Line Treatment
If seizures persist after initial benzodiazepine treatment, second-line agents such as:
- Fosphenytoin (20 mg PE/kg IV)
- Valproate (40 mg/kg IV)
- Levetiracetam (60 mg/kg IV, max 4500 mg) should be administered.
Ongoing Care
Throughout treatment, continuously monitor respiratory status, as benzodiazepines can cause respiratory depression. Simultaneously, address potential underlying causes such as: