What is the best treatment for seizures in an elderly patient with no intravenous (IV) access, considering the use of lorazepam (Ativan)?

Lorazepam for Seizures in Elderly Patients Without IV Access

For elderly patients experiencing seizures without IV access, intramuscular (IM) lorazepam at a dose of 0.05-0.10 mg/kg (maximum 4 mg) is recommended as an effective alternative treatment. 1

Route of Administration Options

When IV access is unavailable in an elderly patient experiencing seizures, the following options exist in order of preference:

1. Rectal diazepam - First-line when IV access is unavailable 1
2. Intramuscular lorazepam - Alternative when rectal administration is not possible due to medical or social reasons 1
3. Sublingual lorazepam - May be considered for prolonged or repetitive seizures 2

Important Considerations for IM Lorazepam

• Dosage: 0.05-0.10 mg/kg (maximum 4 mg per dose) 1
• Timing: May repeat dose every 10-15 minutes if needed for continued seizures 1
• Caution: Increased risk of respiratory depression, especially when combined with other sedative agents 1
• Monitoring: Oxygen saturation should be continuously monitored 1
• Preparation: Equipment to maintain patent airway should be immediately available 3

Evidence-Based Approach

The WHO guidelines specifically recommend that when IV access is not available, rectal diazepam should be administered first. However, if rectal use is not possible due to medical or social reasons, IM lorazepam may be considered 1.

While the FDA label notes that IM lorazepam is not preferred in status epilepticus because therapeutic levels may not be reached as quickly as with IV administration, it acknowledges that the IM route may prove useful when an intravenous port is not available 3.

Special Considerations for Elderly Patients

• Lower initial doses may be appropriate for elderly patients due to:

  • Altered pharmacokinetics
  • Increased sensitivity to benzodiazepines
  • Higher risk of respiratory depression
  • Potential for paradoxical excitation

• Start with 0.05 mg/kg (lower end of dosing range) and titrate as needed 1

• Monitor closely for:

  • Respiratory depression
  • Hypotension
  • Excessive sedation
  • Paradoxical agitation

Alternative Routes to Consider

Recent research has shown that sublingual lorazepam solution may be effective for interrupting prolonged and repetitive seizures. In a study of patients using sublingual lorazepam (median dose 1 mg, range 0.5 to 2 mg), 70% of those with prolonged seizures reported seizure activity ceased within 5 minutes of treatment 2.

Treatment Algorithm

1. Assess airway and breathing

   • Ensure patent airway
   • Provide supplemental oxygen if needed
   • Position patient to prevent aspiration

2. Administer antiseizure medication

   • First choice: Rectal diazepam if available
   • Alternative: IM lorazepam 0.05-0.10 mg/kg (maximum 4 mg)

3. Monitor response

   • If seizures continue after 10-15 minutes, may repeat dose once
   • Monitor vital signs and oxygen saturation continuously

4. Prepare for escalation of care

   • If seizures persist after second dose, prepare for transfer to higher level of care
   • Consider alternative agents if available (IM midazolam, IM phenobarbital)

Common Pitfalls to Avoid

1. Underdosing - Studies show lorazepam is commonly underdosed in status epilepticus, which increases the risk of progression to refractory status epilepticus 4

2. Delayed administration - Time to treatment is crucial, and clinical response to benzodiazepines diminishes with prolonged seizure activity 5

3. Inadequate monitoring - Respiratory depression can occur, especially in elderly patients, requiring close monitoring and preparation for respiratory support 1

4. Failure to prepare for adverse effects - Have flumazenil available to reverse life-threatening respiratory depression, but note that it will also reverse anticonvulsant effects 1

By following this approach, healthcare providers can effectively manage seizures in elderly patients when IV access is unavailable, while minimizing risks associated with treatment.