What is the recommended dose of Ativan (lorazepam) for the management of status epilepticus?

Lorazepam Dosing for Status Epilepticus

For adults with status epilepticus, administer lorazepam 4 mg IV slowly (2 mg/min), and if seizures continue after 10-15 minutes, give an additional 4 mg dose. 1

Adult Dosing Protocol

• Initial dose: 4 mg IV administered at 2 mg/min for patients 18 years and older 1
• Repeat dose: Additional 4 mg IV if seizures continue or recur after a 10-15 minute observation period 1
• This dosing achieves approximately 0.1 mg/kg for average-weight adults and demonstrates superior efficacy compared to phenytoin (64.9% vs 43.6% success rate, P=0.002) 2

Pediatric Dosing Protocol

The dosing differs significantly based on seizure type:

For Convulsive Status Epilepticus (Pediatric):

• Initial dose: 0.1 mg/kg IV (maximum 2 mg per dose) 3
• Repeat after at least 1 minute if needed, up to maximum of 2 doses 3
• Transfer patient to PICU immediately 3

For Non-Convulsive Status Epilepticus (Pediatric):

• Lower dose: 0.05 mg/kg IV (maximum 1 mg per dose) 3
• Can repeat every 5 minutes up to maximum of 4 doses 3

General Pediatric Guidance:

• The American Academy of Pediatrics recommends 0.05-0.10 mg/kg IV/IM (maximum 4 mg per dose), repeatable every 10-15 minutes 3

Critical Safety Considerations

Equipment for airway management must be immediately available before administering lorazepam - this is non-negotiable. 1

• Respiratory depression risk increases significantly when combined with other sedative agents 3
• Monitor oxygen saturation continuously and be prepared to provide ventilatory support 3, 1
• Lorazepam causes significantly less hypotension than phenytoin while maintaining equal or superior efficacy 2
• The intramuscular route is NOT preferred for status epilepticus due to delayed therapeutic levels, though it may be used when IV access is unavailable 1

Comparative Efficacy Evidence

Lorazepam demonstrates clear superiority over alternative first-line agents:

• Lorazepam vs. diazepam: Lorazepam reduces risk of seizure non-cessation (RR 0.64,95% CI 0.45-0.90) and need for additional drugs/anesthesia (RR 0.63,95% CI 0.45-0.88) 4
• Lorazepam vs. phenytoin: Lorazepam is significantly more effective (64.9% vs 43.6% success, P=0.002) 2
• Lorazepam vs. placebo: Dramatic reduction in seizure non-cessation (RR 0.52,95% CI 0.38-0.71) 4

Refractory Status Epilepticus

If seizures persist after initial lorazepam dosing:

• High-dose continuous infusion: 0.3 to 9 mg/hour titrated to EEG cessation of seizures 5
• This approach avoids hypotension seen with pentobarbital and may be preferred for refractory cases 5
• Second-line agents include phenytoin (20 mg/kg), valproate (20-30 mg/kg), levetiracetam (30 mg/kg), or phenobarbital (20 mg/kg) 6

Common Pitfalls to Avoid

• Do not administer too slowly - the 2 mg/min rate is critical for rapid seizure control 1
• Do not delay repeat dosing - waiting beyond 10-15 minutes for the second dose allows seizures to cause progressive neuronal damage 1
• Do not use IM route as first choice - therapeutic levels are delayed compared to IV administration 1
• Do not forget to simultaneously search for underlying causes including hypoglycemia, hyponatremia, hypoxia, CNS infection, or toxicity 6, 1