Should I administer PRN (as needed) Ativan (lorazepam) intramuscularly to a patient who had a seizure that resolved 20 minutes ago to prevent another seizure?

Should You Administer PRN IM Ativan Now?

No, you should not administer intramuscular lorazepam (Ativan) at this time for a patient whose seizure resolved 20 minutes ago, as benzodiazepines are indicated for active seizures or status epilepticus, not for prophylaxis after seizure cessation. 1

Rationale for This Recommendation

When Benzodiazepines Are Indicated

• Benzodiazepines like lorazepam are first-line treatment for active seizures lasting ≥5 minutes or for status epilepticus (defined as unremitting seizure activity ≥20 minutes or intermittent seizures without regaining consciousness). 1, 2

• The 2024 AHA/Red Cross guidelines clearly state that seizures are usually self-limited and resolve spontaneously within 1-2 minutes, and emergency intervention is needed for seizures lasting >5 minutes. 1

• Your patient's seizure has already stopped for 20 minutes—the indication for acute benzodiazepine administration has passed. 1

Why IM Lorazepam Is Not Appropriate Now

• IM lorazepam is specifically indicated for active status epilepticus when IV access is not available—not for seizure prophylaxis after resolution. 3

• The FDA labeling explicitly states: "IM lorazepam is not preferred in the treatment of status epilepticus because therapeutic lorazepam levels may not be reached as quickly as with IV administration. However, when an intravenous port is not available, the IM route may prove useful." 3

• This guidance applies to ongoing seizures, not post-ictal prophylaxis. 3

What You Should Do Instead

Monitor and activate EMS if indicated:

• Stay with the patient and monitor for return to baseline mental status within 5-10 minutes after seizure cessation. 1

• Activate EMS if: 1

  • This was a first-time seizure
  • The patient does not return to baseline within 5-10 minutes
  • Another seizure occurs
  • The patient has difficulty breathing, traumatic injuries, or is pregnant
  • The seizure occurred in water or with choking

Consider second-line anticonvulsants only if seizure recurs:

• If the patient has a recurrent seizure, then benzodiazepines would be appropriate as first-line treatment. 2, 4

• If seizures become refractory (failing benzodiazepines), second-line agents include valproate (30 mg/kg IV), levetiracetam (30 mg/kg IV), fosphenytoin (20 mg PE/kg IV), or phenobarbital (20 mg/kg IV). 2, 4

Important Caveats About Prophylactic Anticonvulsants

• There is lack of evidence to support or refute loading with anticonvulsant medication after a single resolved seizure to prevent early recurrent seizures. 1

• The 2014 ACEP guidelines note that "seizure recurrence after antiepileptic medication loading in these studies was an infrequent event, so even these phenytoin studies are not powered to determine a difference in seizure prevention." 1

• If you are considering anticonvulsant loading for a patient with known epilepsy who is subtherapeutic, this is a different clinical scenario—but even then, there is no evidence supporting one route over another for preventing recurrence. 1

Safety Considerations

• Administering benzodiazepines unnecessarily carries risks of respiratory depression (0-18% incidence) and sedation in a post-ictal patient who may already have altered mental status. 5, 6

• The 2024 AHA/Red Cross guidelines explicitly state as a Class 3 Harm recommendation: "Nothing should be put in the mouth and no food, liquids, or oral medicines should be given to a person who is experiencing a seizure or who has decreased responsiveness after a seizure." 1

Clinical Algorithm

1. Seizure stopped >5 minutes ago → No acute benzodiazepine needed
2. Monitor for return to baseline (5-10 minutes expected) 1
3. If another seizure occurs → Administer benzodiazepine (IM lorazepam acceptable if no IV access) 2, 3
4. If seizure lasts >5 minutes → Treat as status epilepticus with benzodiazepines first-line 2, 4
5. If fails benzodiazepines → Second-line agents (valproate, levetiracetam, fosphenytoin, or phenobarbital) 2, 4