Immediate Administration of Lorazepam for Active Seizure
Administer intravenous lorazepam immediately—this is the first-line treatment for a patient actively seizing with generalized tonic-clonic activity. 1, 2, 3
Rationale for Lorazepam as First-Line Treatment
Lorazepam is the preferred benzodiazepine for terminating active seizures, with a demonstrated 59-65% efficacy in stopping status epilepticus and a longer duration of action compared to other benzodiazepines. 2, 4
The American College of Emergency Physicians designates benzodiazepines as Level A (strongest) first-line treatment for generalized convulsive seizures, with lorazepam specifically recommended due to superior efficacy over diazepam (59.1% vs 42.6% seizure termination). 1, 2, 4
This patient meets criteria for status epilepticus (actively seizing during examination), which is a life-threatening emergency requiring immediate benzodiazepine administration—not waiting for second-line agents. 2, 3
Correct Dosing Protocol
Administer lorazepam 4 mg IV at 2 mg/min for adults (or 0.1 mg/kg up to 4 mg maximum). 2, 3, 5
If seizures continue after 10-15 minutes, give a second 4 mg dose. 3
Underdosing lorazepam (less than 4 mg) significantly increases progression to refractory status epilepticus (87% vs 62%), making proper dosing critical. 5
Why Not the Other Options
Levetiracetam (Option B) and phenytoin (Option D) are second-line agents reserved for benzodiazepine-refractory seizures—they should never be given as initial therapy for active seizures. 1, 2
Carbamazepine (Option A) has no role in acute seizure termination and is not mentioned in any status epilepticus treatment guidelines. 1
Second-line agents (levetiracetam, fosphenytoin, valproate) are only administered if seizures persist despite adequate benzodiazepine dosing. 1, 2
Critical Simultaneous Actions
Check fingerstick glucose immediately while administering lorazepam, as hypoglycemia is a rapidly reversible cause (though this patient's glucose is 110 mg/dL, which is normal). 2, 3
Address the hypoxemia urgently with high-flow oxygen or bag-valve-mask ventilation—oxygen saturation of 85% requires immediate intervention. 2, 6
Have airway equipment immediately available before administering lorazepam, as respiratory depression can occur (though rates are low at 10.6%). 1, 3, 4
Position the patient on their side to prevent aspiration. 7
Treatment Algorithm After Lorazepam
If seizures continue after two doses of lorazepam (total 8 mg), escalate to second-line agents:
- Levetiracetam 30 mg/kg IV (68-73% efficacy, minimal cardiovascular effects). 1, 2
- Valproate 20-30 mg/kg IV (88% efficacy, 0% hypotension risk). 1, 2
- Fosphenytoin 20 mg PE/kg IV (84% efficacy, but 12% hypotension risk requiring cardiac monitoring). 1, 2
Common Pitfalls to Avoid
Never skip benzodiazepines and go directly to second-line agents—this violates all evidence-based guidelines and delays seizure termination. 2
Do not underdose lorazepam (giving 2 mg instead of 4 mg)—this dramatically increases refractory status epilepticus rates. 5
Do not delay lorazepam administration to obtain neuroimaging—CT scanning can be performed after seizure control is achieved. 2
Do not use neuromuscular blockers alone (like rocuronium)—they only mask motor manifestations while allowing continued electrical seizure activity and brain injury. 2
Answer: C. Lorazepam