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Lorazepam or diazepam for generalised convulsions in adults
  1. John Butler,
  2. Mark Lewis
  1. Department of Emergency Medicine, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK

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    Report by John Butler, Specialist Registrar Search checked by Mark Lewis, Specialist Registrar

    Clinical scenario

    A 45 year old woman epileptic presents after sustaining a grand mal convulsion at home. She starts fitting again on arrival in the emergency department; the fit does not stop spontaneously after five minutes. The paramedics have secured intravenous access before arrival but have not given any anticonvulsants. You wonder whether lorazepam is more effective than diazepam as a first choice drug to safely terminate this convulsion.

    Three part question

    In [an adult epileptic patient suffering a grand mal fit] is [intravenous lorazepam safer and more effective than intravenous diazepam] at [safely terminating the convulsions].

    Search strategy

    Medline 1966–09/00 using the OVID interface. [(exp epilepsy OR exp epilepsy, generalised OR exp epilepsy, tonic-clonic OR epilepsy.mp OR fits.mp OR exp convulsions OR convulsion$.mp OR exp seizures OR exp alcohol withdrawal seizures OR seizure$.mp) AND (exp lorazepam OR lorazepam$.mp)] LIMIT to human AND english.

    Search outcome

    Altogether 133 papers found of which 131 were irrelevant or of insufficient quality. The remaining two papers are shown in the table 1.

    Table 1

    Comments

    The incidence of status epilepticus is given as 15–30 per 100 000 per year. It carries a considerable mortality (approximately 10%). The best first line treatment remains controversial. The use of diazepam is limited by its rapid redistribution out of the CNS. The duration of action of diazepam is approximately 20–30 minutes. Pharmacokinetic studies of lorazepam have shown it has an elimination half life of 13 hours. Lorazepam has a much longer duration of anticonvulsant action than diazepam and has an equivalent onset of action. Studies in healthy volunteers suggest it has reduced cardiorespiratory side effects compared with other benzodiazepines. There may be an increased risk of thrombophlebitis when compared with intravenous diazemuls.

    Clinical bottom line

    Intravenous lorazepam is effective and safe in the treatment of status epilepticus. It should be the first line of treatment.

    Report by John Butler, Specialist Registrar Search checked by Mark Lewis, Specialist Registrar

    References

    View Abstract

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