HWN Suggests

Becoming Well-Versed with Benzos

Classic teaching is that the benzodiazepine (lorazepam) is given in combination with the antipsychotic (haloperidol) in order to more quickly calm/sedate the patient while the antipsychotic starts to take effect. But, if we actually look at the pharmacology of these meds, lorazepam and haloperidol both (20-25 min) have relatively slow onsets of action when administered IM.

So, do we have any medications we can give that will work faster and help us with this agitated patient? In fact, we do! The fastest acting IM benzodiazepine is midazolam (Versed) with an onset of action between 5-15 minutes. Knowing this information, why do we keep administering lorazepam? One potential reason is…

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Articles of Interest

Midazolam is more likely to cause hypotension than etomidate in emergency department rapid sequence intubation

Midazolam, even in low dose, was more likely than etomidate to cause significant hypotension when used as an induction agent for rapid sequence intubation. Etomidate is a better alternative.

Midazolam use in the emergency department

Midazolam is the first water-soluble benzodiazepine. As with other benzodiazepines it has amnestic, sedative, hypnotic, anxiolytic, and anticonvulsant properties. Midazolam is about two to four times more potent than diazepam.

Advancing Airway Management: Special Consideration for Non-Paralytic RSI Using Etomidate Only

Midazolam is generally a poor drug choice for airway management because of its long onset of action and need for high doses (0.3mg/kg–0.4mg/kg). Generally, etomidate is the preferred single agent used for non-paralytic RSI.

Etomidate or Midazolam for Rapid Sequence Induction in Patients with Suspected Sepsis?

In this study, use of a single bolus of etomidate for induction in patients with sepsis was not associated with any deleterious outcomes. Etomidate is an ideal induction agent because of its predictable dosing, rapid onset, short duration of action, and excellent hemodynamic stability. This report adds to a growing body of well-designed studies that refute the assertion that etomidate should not be used in patients with sepsis.

Induction agents for rapid sequence intubation in adults for emergency medicine and critical care

The routine induction dose of midazolam for RSI is 0.2 mg/kg. In this dose, midazolam causes moderate hypotension, with an average drop in mean arterial blood pressure in healthy patients of 10 to 25 percent. This tendency to induce hypotension limits midazolam's usefulness in the setting of hypovolemia or shock.

Rapid Sequence Intubation Pharmacology

Midazolam is a benzodiazepine dosed at 0.2-0.3 mg/kg IV; the onset of action is 60-90 seconds, and the duration of action is approximately 15-30 minutes.1 Midazolam has direct negative effects on systemic vascular resistance and the myocardium. In a prospective study comparing midazolam versus etomidate, Choi and colleagues observed a 10% reduction in mean systolic blood pressure in patients receiving midazolam.21 The poor side effect profile and slow onset of action make midazolam an unfavorable induction agent.

Underdosing of Midazolam for RSI in the ED Is Common

Midazolam is so frequently used for sedation in the ED that it is not surprising that emergency physicians would choose the more familiar lower doses when administering this agent for induction. EPs should become familiar with the higher recommended doses for induction (0.1-0.3 mg/kg) in order to best use midazolam for this purpose.

Underdosing of midazolam in emergency endotracheal intubation

Underdosing of midazolam during ED RSI is frequent, and appears to be related to incorrect dosage selection, rather than to a deliberate intention to reduce the dose used.

Versed a good alternative to Ativan for seizure first responders

Intravenous benzodiazepine, most commonly lorazepam (Ativan), is the preferred first-line treatment for prolonged epileptic seizures in the emergency department, but IV medication can be difficult for first responders to administer. An alternative is for paramedics to give intramuscular midazolam (Versed) , a treatment commonly used due to its speed and relative simplicity of administration.

Resources

Midazolam

Act via benzodiazepine receptor in CNS, linked and facilitate action of the GABA receptor.

Parenteral Benzodiazepines

Midazolam has a rapid onset, short time to peak effect, and a short duration of effect.