What is the recommended dose of Ativan (lorazepam) for a seizure lasting more than 5 minutes?

Recommended Lorazepam Dosing for Seizures Lasting >5 Minutes

For seizures lasting more than 5 minutes, the recommended dose of lorazepam is 4 mg given slowly (2 mg/min) intravenously for adults, or 0.1 mg/kg (maximum 4 mg) for children. 1

Adult Dosing Protocol

First-Line Treatment:

• Initial dose: 4 mg IV given slowly (2 mg/min)
• If seizures continue after 10-15 minutes observation period, administer an additional 4 mg IV dose 1

Important Administration Notes:

• Prior to IV use, lorazepam must be diluted with an equal amount of compatible diluent
• Inject slowly with repeated aspiration to ensure proper IV placement
• Ensure equipment to maintain a patent airway is immediately available 1

Pediatric Dosing Protocol:

• 0.05-0.1 mg/kg IV/IM (maximum: 4 mg per dose)
• May repeat dose every 10-15 minutes if needed for continued seizures 2

Clinical Considerations

When to Activate EMS:

Immediate emergency medical services activation is required for:

• Seizures lasting >5 minutes
• Multiple seizures without return to baseline mental status between episodes
• Seizures with traumatic injuries, difficulty breathing, or choking
• Seizures in infants <6 months of age
• Seizures in pregnant individuals
• Failure to return to baseline within 5-10 minutes after seizure cessation 2

Monitoring and Safety:

• Monitor vital signs continuously
• Maintain an unobstructed airway
• Have artificial ventilation equipment available
• Be prepared to provide respiratory support as lorazepam may cause respiratory depression 1

Common Pitfalls to Avoid:

1. Underdosing: A recent study showed that patients who received less than the recommended 4 mg dose had significantly higher rates of progression to refractory status epilepticus (87% vs 62%) 3

2. Inadequate monitoring: Respiratory depression is the most important risk with lorazepam for status epilepticus. Ensure airway patency and monitor respiration closely 1

3. Improper administration: Never administer intra-arterially or allow perivascular extravasation 1

4. Delayed treatment: Seizures lasting >5 minutes may not stop spontaneously and require prompt intervention 2

Alternative Routes When IV Access is Unavailable

• Intramuscular: While not preferred for status epilepticus, IM administration may be useful when IV access is unavailable 1

• Intranasal: Studies have shown intranasal lorazepam (0.1 mg/kg) is not inferior to IV administration for terminating acute convulsive seizures in children, with 83.1% efficacy within 10 minutes 4

• Sublingual: For home treatment of prolonged or repetitive seizures, sublingual lorazepam solution (median dose 1 mg, range 0.5-2 mg) showed 70% efficacy in stopping prolonged seizures within 5 minutes 5

Special Populations

• Elderly patients: No dosage adjustments needed, but patients over 50 years may experience more profound and prolonged sedation 1

• Hepatic disease: No dosage adjustments needed 1

• Renal disease: For acute administration, no adjustment needed, but caution with frequent dosing over short periods 1

Remember that seizures lasting >5 minutes represent a critical medical emergency (status epilepticus) and require prompt intervention to prevent neurological damage and mortality.