What is the most appropriate initial medication for a patient in status epilepticus with hyperthermia and possible hyponatremia?

Immediate Administration of Lorazepam IV

Lorazepam 4 mg IV at 2 mg/min is the most appropriate first medication to administer for this patient in status epilepticus. 1, 2, 3

Rationale for Lorazepam as First-Line Treatment

Benzodiazepines represent Level A (strongest) evidence as first-line treatment for generalized convulsive status epilepticus, with lorazepam demonstrating 65% efficacy in terminating seizures—superior to phenytoin alone (44%) in head-to-head comparison. 1, 2 The American College of Emergency Physicians designates this as the highest quality evidence supporting lorazepam as initial therapy. 2

Equipment to maintain a patent airway, bag-valve-mask ventilation, oxygen, and suction must be immediately available before administering lorazepam, as respiratory depression can occur. 2, 3

Why Not the Other Options

• Phenytoin (Option D) is a second-line agent reserved for benzodiazepine-refractory seizures and should never be given as initial therapy for active seizures. 1 It has only 44% efficacy when used alone compared to 65% for lorazepam. 2

• Ceftriaxone (Option A) addresses potential CNS infection but does not terminate active seizure activity. While searching for reversible causes like infection is crucial, it must occur simultaneously with—not instead of—immediate seizure termination with benzodiazepines. 1, 2

• Hypertonic saline (Option B) addresses the suspected hyponatremia from water intoxication, but correcting electrolyte abnormalities does not provide immediate seizure termination. The priority is stopping the seizure first with lorazepam, then addressing underlying causes. 1

Critical Simultaneous Actions

While administering lorazepam, immediately:

• Check fingerstick glucose and correct hypoglycemia if present with 50 mL of 50% dextrose IV. 1, 2
• Search for reversible causes including hyponatremia (highly suspected given history), hypoxia, drug toxicity (ecstasy), CNS infection (given hyperthermia), and other metabolic derangements. 1, 3
• Initiate continuous monitoring with pulse oximetry, cardiac monitoring, and vital signs. 2

Dosing Protocol

Administer lorazepam 4 mg IV slowly at 2 mg/min. 1, 2, 3 If seizures continue after a 10-15 minute observation period, give an additional 4 mg IV dose (total 8 mg maximum). 1, 3 Patients receiving less than 4 mg experience significantly increased progression to refractory status epilepticus (87% vs 62%), supporting guideline-recommended dosing. 4

If Seizures Persist After Benzodiazepines

Immediately escalate to second-line agents if seizures continue after two doses of lorazepam (total 8 mg): 1, 2

• Valproate 20-30 mg/kg IV over 5-20 minutes (88% efficacy, 0% hypotension risk) 1
• Levetiracetam 30 mg/kg IV over 5 minutes (68-73% efficacy, minimal cardiovascular effects) 1
• Fosphenytoin 20 mg PE/kg IV at maximum 50 mg/min (84% efficacy, but 12% hypotension risk requiring cardiac monitoring) 1

Common Pitfalls to Avoid

• Never use neuromuscular blockers alone (like rocuronium)—they only mask motor manifestations while allowing continued electrical seizure activity and brain injury. 1
• Do not underdose lorazepam—the full 4 mg dose is critical for patients over 40 kg to prevent progression to refractory status epilepticus. 4
• Do not delay benzodiazepines to correct hyponatremia or treat infection first—these interventions must occur simultaneously with immediate seizure termination. 1, 3