Seizure Management with Lorazepam

Introduction to Lorazepam Administration

Nothing should be given by mouth to a patient who has just had a seizure due to decreased responsiveness and aspiration risk in the immediate postictal period, as stated by the American Heart Association, in guidelines similar to those from the Circulation journal 1
The American Academy of Pediatrics recommends that oral lorazepam is NOT used for acute post-seizure management—intravenous or intramuscular routes are the standard of care for seizure emergencies, with a standard IV dose of 0.1 mg/kg (maximum 4 mg per dose) for status epilepticus, which may be repeated every 10-15 minutes if seizures persist 2

The American Academy of Pediatrics suggests an IM dose of 0.2 mg/kg (maximum 6 mg per dose) when IV access is unavailable, which can be repeated every 10-15 minutes 2
Respiratory support must be immediately available regardless of route, with monitoring of oxygen saturation continuously, due to increased risk of apnea, especially when combined with other sedatives, as recommended by the American Academy of Pediatrics 2

The American Heart Association recommends calling EMS immediately for first-time seizure, seizure lasting >5 minutes, multiple seizures without return to baseline between episodes, patient not returning to baseline within 5-10 minutes after seizure stops, or seizure with traumatic injury, difficulty breathing, or occurring in water, as stated in guidelines similar to those from the Circulation journal 1

The American Academy of Pediatrics suggests a dose of 0.05-0.10 mg/kg (maximum 4 mg per dose) for status epilepticus in pediatric patients, which may be repeated every 10-15 minutes if needed 3, 4
Monitor oxygen saturation and be prepared to provide respiratory support due to increased incidence of apnea when combined with other sedative agents 3
Flumazenil may be administered to reverse life-threatening respiratory depression, but it will also counteract anticonvulsant effects and may precipitate seizures 3

The American Academy of Pediatrics recommends continuing monitoring for seizure recurrence for at least 2 hours after initial lorazepam administration, as part of post-administration management in pediatric patients 5
The American Academy of Pediatrics advises against using flumazenil to reverse sedation in seizure patients, as it will precipitate seizure recurrence, and instead recommends preparing to administer long-acting anticonvulsant (phenytoin/fosphenytoin) if seizures persist 5

The American Academy of Pediatrics recommends an alternative dosing range of 0.05-0.10 mg/kg (maximum 4 mg) for pediatric status epilepticus 6
For convulsive status epilepticus, 0.1 mg/kg IV (maximum 2 mg) may be repeated after at least 1 minute (maximum 2 doses), as suggested by guidelines from the Nature Reviews Clinical Oncology 7
For non-convulsive status epilepticus, use 0.05 mg/kg (maximum 1 mg) IV, repeating every 5 minutes up to 4 doses, according to the Nature Reviews Clinical Oncology 7

Rectal administration (0.5 mg/kg up to 20 mg) has erratic absorption and is not recommended as first-line, as stated in the Pediatrics journal 8
There is an increased incidence of apnea when lorazepam is combined with other sedative agents, according to the Pediatrics journal 6

If seizures persist after lorazepam, immediately administer a long-acting anticonvulsant such as phenytoin (18 mg/kg IV over 20 minutes) or fosphenytoin (20 mg phenytoin equivalents/kg at ≤150 mg/min), as recommended by the BMJ 9
Lorazepam is rapidly redistributed and seizures often recur within 15-20 minutes, necessitating long-acting anticonvulsant coverage, as stated in the Pediatrics journal 8
If seizures continue after benzodiazepine and phenytoin/fosphenytoin, consider phenobarbital (15-20 mg/kg IV over 10 minutes), according to the BMJ and Nature Reviews Clinical Oncology 7, 9