Initial Treatment for Active Status Epilepticus
Administer intravenous lorazepam 4 mg at 2 mg/min immediately—this is the only appropriate first-line treatment for a patient actively seizing for 20 minutes. 1
Why Lorazepam is the Correct Answer (Option B)
Benzodiazepines are Level A (strongest evidence) first-line treatment for generalized convulsive status epilepticus, with lorazepam specifically demonstrating 65% efficacy in terminating status epilepticus. 1
This patient meets criteria for status epilepticus (seizure lasting ≥20 minutes), which is defined operationally as seizure activity lasting 5 minutes or more for treatment purposes, though the formal definition is 20 minutes. 1
Lorazepam has superior efficacy over diazepam (59.1% vs 42.6% seizure termination) and has a longer duration of action compared to other benzodiazepines, making it the preferred agent. 1
Why the Other Options Are Incorrect
Levetiracetam (Option A), phenytoin (Option C), and valproate (Option D) are all second-line agents that should never be given as initial therapy for active seizures—they are reserved exclusively for benzodiazepine-refractory seizures. 1
95% of neurologists recommend phenytoin/fosphenytoin only after benzodiazepines have failed, not as first-line treatment. 1
Starting with second-line agents delays definitive treatment and violates established treatment algorithms that mandate benzodiazepines first. 1, 2
Critical Immediate Actions Alongside Lorazepam
Check fingerstick glucose immediately and correct hypoglycemia while administering lorazepam, as this is a rapidly reversible cause of seizures. 1
Have airway equipment immediately available before administering lorazepam, as respiratory depression can occur with benzodiazepine administration. 1
Establish continuous vital sign monitoring, particularly respiratory status and blood pressure, and be prepared to provide respiratory support. 1
Simultaneously search for reversible causes including hypoglycemia, hyponatremia, hypoxia, drug toxicity, CNS infection, stroke, intracerebral hemorrhage, and withdrawal syndromes. 1
Treatment Algorithm After Initial Lorazepam
If seizures continue after adequate benzodiazepine dosing (can repeat lorazepam once), immediately escalate to one of these second-line agents: 1
Valproate 20-30 mg/kg IV over 5-20 minutes: 88% efficacy with 0% hypotension risk—potentially the best second-line choice given superior safety profile. 1
Levetiracetam 30 mg/kg IV over 5 minutes: 68-73% efficacy with minimal cardiovascular effects and no cardiac monitoring requirements. 1
Fosphenytoin 20 mg PE/kg IV at maximum rate of 50 mg/min: 84% efficacy but 12% hypotension risk requiring continuous ECG and blood pressure monitoring. 1
Phenobarbital 20 mg/kg IV over 10 minutes: 58.2% efficacy but higher risk of respiratory depression. 1
Common Pitfalls to Avoid
Never skip benzodiazepines and go directly to second-line agents—this violates all established guidelines and delays the most effective initial treatment. 1
Never use neuromuscular blockers alone (such as rocuronium)—they only mask motor manifestations while allowing continued electrical seizure activity and ongoing brain injury. 1
Do not delay anticonvulsant administration for neuroimaging—CT scanning can be performed after seizure control is achieved and the patient is stabilized. 1
Time is brain—prolonged seizures cause changes in synaptic receptors leading to a more proconvulsant state and increased risk of brain lesion and sequelae. 2
Refractory Status Epilepticus Protocol
If seizures persist despite benzodiazepines and one second-line agent, initiate continuous EEG monitoring and escalate to anesthetic agents: 1
Midazolam infusion: 0.15-0.20 mg/kg IV load, then 1 mg/kg/min continuous infusion (80% efficacy, 30% hypotension risk). 1
Propofol: 2 mg/kg bolus, then 3-7 mg/kg/hour infusion (73% efficacy, 42% hypotension risk, requires mechanical ventilation). 1
Pentobarbital: 13 mg/kg bolus, then 2-3 mg/kg/hour infusion (92% efficacy but 77% hypotension risk). 1