What is a common benzodiazepine regimen for status epilepticus in the ED?

• A. Midazolam 8 mg IV as first-line.
• B. Diazepam 0.5 mg/kg IV as first-line.
• C. Lorazepam 0.1 mg/kg IV (max 4 mg) as first-line; alternatives include diazepam 0.15–0.2 mg/kg IV.
• D. Chloral hydrate 50 mg/kg IV.

Answer: (C)

Benzodiazepines are the first-line, rapid-acting treatment to halt ongoing seizures in status epilepticus. The preferred regimen in the ED is intravenous lorazepam given at 0.1 mg/kg, up to a maximum of 4 mg, as the initial dose. This choice is based on its reliable anticonvulsant effect that lasts longer in the CNS compared with some other benzodiazepines, giving better seizure control with one dose and reducing the need for rapid re-dosing. If seizures persist, a second lorazepam dose can be considered, or diazepam can be used as an alternative at 0.15–0.2 mg/kg IV. Diazepam can be effective but tends to have a shorter duration due to redistribution, which may necessitate earlier escalation to additional anticonvulsants. Chloral hydrate is not appropriate for acute seizure control. Midazolam is an option when IV access is difficult, but its shorter duration makes it less favored as the sole first-line in many ED protocols.