Immediate Lorazepam Administration for Active Seizures
Administer lorazepam immediately once a seizure has lasted 5 minutes or longer—do not wait beyond this point. 1, 2
Critical Timing Threshold
The operational definition of status epilepticus has been reduced from 20 minutes to 5 minutes specifically for treatment purposes, meaning you should initiate benzodiazepine therapy at the 5-minute mark of continuous seizure activity. 1
While status epilepticus is technically defined as unremitting seizure activity lasting 20 minutes or more, waiting this long significantly increases the risk of permanent neurological damage and treatment failure. 1, 3
Immediate Administration Protocol
Give lorazepam 4 mg IV slowly (2 mg/min) for adults as soon as the 5-minute threshold is reached. 2, 4
For pediatric patients, administer 0.1 mg/kg IV (maximum 4 mg per dose). 5, 4
Equipment to maintain a patent airway, bag-valve-mask ventilation, oxygen, and suction must be immediately available before administering lorazepam. 2, 4
If Seizure Continues After First Dose
If seizures continue or recur after a 10-15 minute observation period, give a second 4 mg dose (total 8 mg). 2, 4
If seizures persist after two doses of lorazepam, immediately proceed to second-line agents (IV valproate 30 mg/kg, IV levetiracetam 30 mg/kg, or IV fosphenytoin 20 mg PE/kg)—do not give additional lorazepam beyond 8 mg total. 1, 2
Critical Pitfall to Avoid
Do NOT administer lorazepam if the seizure has already stopped on its own—a single self-limiting seizure does not require acute benzodiazepine treatment. 2
The evidence shows that response rates to second-line agents drop dramatically (7.0%) and third-line agents are even worse (2.3%), emphasizing the critical importance of early, adequate dosing with lorazepam at the 5-minute mark. 3
Underdosing lorazepam (giving less than 4 mg in adults >40 kg) significantly increases progression to refractory status epilepticus (87% vs 62%). 6