Should I administer lorazepam (Ativan) to a patient who just had a seizure?

Should You Administer Lorazepam Now After a Seizure?

Yes, administer lorazepam IV immediately if the seizure is ongoing or not self-limiting, but do NOT give it if the seizure has already stopped on its own. 1, 2

Immediate Decision Algorithm

If Seizure is ACTIVE (ongoing):

• Administer lorazepam 4 mg IV slowly (2 mg/min) for adults 2
• Pediatric dose: 0.1 mg/kg IV (maximum 4 mg per dose) 1
• If seizure continues after 10-15 minutes, give a second dose of 4 mg IV 2
• Maximum total: 8 mg before moving to second-line agents 3

If Seizure has STOPPED (self-limiting):

• Do NOT administer lorazepam 1
• A single self-limiting seizure does not require acute benzodiazepine treatment 1
• Monitor closely for recurrence during routine vital sign checks 1
• Do NOT start long-term anticonvulsants for a single immediate post-event seizure 1

Critical Pre-Administration Requirements

Before giving lorazepam, ensure these are immediately available: 2

• Equipment to maintain patent airway
• Bag-valve-mask ventilation capability
• Oxygen and suction
• Cardiac monitoring and pulse oximetry 3

The FDA label explicitly states: "EQUIPMENT NECESSARY TO MAINTAIN A PATENT AIRWAY SHOULD BE IMMEDIATELY AVAILABLE PRIOR TO INTRAVENOUS ADMINISTRATION OF LORAZEPAM" 2

Why Lorazepam is First-Line

• Highest efficacy: 65% success rate vs 44% for phenytoin alone (Class I evidence) 3
• Superior to diazepam: 76% vs 51% seizure control with single dose 4
• Longer duration of action than diazepam (no recurrence within 15-20 minutes) 1, 5
• Lower respiratory depression risk: 3% vs 15% with diazepam 4

Administration Technique

Rate of administration is critical: 2

• Give slowly at 2 mg/min to avoid pain at IV site 1
• Faster administration increases respiratory depression risk 1
• Monitor oxygen saturation and respiratory effort continuously 1

What Happens After Lorazepam

If Seizure Stops:

• Continue monitoring for recurrence 1
• No additional lorazepam needed 2
• Consider maintenance anticonvulsant only if recurrent seizures occur 1

If Seizure Continues After 2 Doses (8 mg total):

Immediately proceed to second-line agents: 3

• Levetiracetam 30 mg/kg IV at 5 mg/kg/min, OR 6, 7
• Fosphenytoin 18-20 mg/kg IV over 20 minutes 7

Common Pitfalls to Avoid

Underdosing is dangerous: 8

• Patients receiving <4 mg had 87% progression to refractory status epilepticus vs 62% with full 4 mg dose 8
• Always give the full 4 mg dose in adults >40 kg unless contraindicated 8

Don't confuse acute treatment with prophylaxis: 1

• Prophylactic anticonvulsants after stroke are NOT recommended and may harm neurological recovery 1
• Only treat active or recurrent seizures 1

Don't delay for IV access: 1

• IM lorazepam 0.2 mg/kg (max 6 mg) can be given if IV unavailable 1
• Rectal lorazepam 0.5 mg/kg (max 20 mg) is 100% effective when IV access impossible 4

Special Population Adjustments

Elderly patients (>50 years): 3, 2

• Consider lower initial doses due to increased sensitivity 3
• Standard 4 mg dose should ordinarily not be exceeded 2

Neonates: 9

• 0.05 mg/kg IV, may repeat up to total 0.15 mg/kg 9
• Effective for phenobarbital-refractory neonatal seizures 9