A 19-year-old man is brought to the ED by paramedics for a generalized tonic–clonic seizure. He was given rectal diazepam gel en route with no effect. His glucose level in the ambulance was 105 mg/dL. He has now been seizing for 10 minutes and an IV has been placed. What is the treatment of choice?
Intravenous lorazepam is the first-line treatment of choice in status epilepticus or impending status epilepticus, the latter being defined as seizure(s) for more than 5 minutes without recovery of consciousness. Lorazepam is effective, can be rapidly administered, and has a short onset of action. Doses of 2–4 mg can be given and repeated. The fact that the patient failed diazepam in the field does not change lorazepam’s first-line status. Glucose is not indicated in normoglycemia. Fosphenytoin, a water-soluble prodrug of phenytoin that can be rapidly administered, is a second-line agent and would be useful to abort a seizure that breaks through benzodiazepines or to prevent further seizures after control is established with benzodiazepines. Phenobarbital is a third-line agent in status epilepticus. Rectal diazepam and buccal midazolam are useful when there is no IV access.