HWN Suggests

Therapeutics: Agitation in the ED

Benzodiazepines are often the agent of choice when sedating an undifferentiated patient without obvious delirium or psychiatric disease...

Lorazepam is available IV, IM, oral, as well as intranasal, which is commonly used in children. Typical dosing is 0.5-2 mg IM or IV. The suggested interval for re-dosing is 30 minutes. Lorazepam is longer-acting compared to midazolam. Lorazepam has an average time to adequate sedation of 32 minutes and patient’s average total sedation time is up to 217 minutes. Intranasal has been found to lead to more rapid absorption compared to IM, with sedating effects found at 5 minutes, vs. up to 15-30 minutes with IM. Intranasal dosing recommendations for children…

read full article

Featured

 Lorazepam, diazepam, midazolam: What’s the difference?

Benzodiazepines (BZDs) are used on a daily basis in the ED. We routinely reach for lorazepam, diazepam, midazolam and other BZDs to treat seizures, alcohol withdrawal and acute agitation, and hiommonly administer them for anxiolysis and procedural sedation. But how do the various BZDs differ? Are particular BZDs preferred in certain conditions? Let’s review the common BZDs and their indications.

 One Benzo Fits All? Lorazepam vs Diazepam for Paediatric Status Epilepticus

The authors conclude that treatment with lorazepam did not result in improved efficacy or safety compared with diazepam and as such their findings do not support preferential use of lorazepam for paediatric status epilepticus. Our consensus at the real-life St Emlyn’s journal club was that this study wasn’t going to change our practice. APLS protocols advice lorazepam for paediatric status epilepticus and we found no reason to deviate from that – however, should we find lorazepam in short supply then we felt reasonably confident that we would have no issues reaching for intravenous diazepam instead (in either case keeping a bag-valve-mask nearby).

Articles of Interest

A small randomized trial of physostigmine vs. lorazepam in patients with antimuscarinic delirium/agitation

Although this is a small study, it showed that physostigmine is better than lorazepam in treating antimuscarinic delirium and agitation.

Emergency Management of Status Epilepticus

Lorazepam IV: 4mg q4 minutes, may repeat once (*often underdosed in observational studies) Midazolam IM: 10 mg IM once (*often underdosed in observational studies)

Intranasal Lorazepam for Treatment of Severe Agitation in a Pediatric Behavioral Health Patient in the Emergency Department

The treatment of severe agitation, aggression, and violent behavior in behavioral health patients who present to the emergency department (ED) often requires the intramuscular administration of a sedative. However, administering an intramuscular sedative to an uncooperative patient is associated with the risk of needlestick injuries to both patients and health care providers, and times to onset of sedation range from 15 to 45 minutes.

Lorazepam and Propylene Glycol

Patients receiving continuous infusions of lorazepam are at risk for propylene glycol toxicity. Propylene glycol toxicity primarily causes a metabolic acidosis and acute tubular necrosis.

Lorazepam confirmed as first-line treatment for stopping prolonged seizures in children

The evidence supports lorazepam as the preferred intravenous drug; shouldn’t we prioritise trials on whether it should be the preferred non-intravenous one?

Lorazepam is better than diazepam for generalised convulsions in adults

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. Pharmcokinetic studies of lorazepam have shown it has an elimination half-life of 13 hours. Lorazepam has a much longer duration of anti-convulsant action than diazepam and has an equivalent onset of action. Studies in healthy voluteers suggest it has reduced cardio-respiratory side-effects compared to other benzodiazepines. There may be an increased risk of thrombophlebitis when compared to IV Diazemuls.

Lorazepam Versus Diazepam in the Management of Emergency Department Patients With Alcohol Withdrawal

In our sample of ED patients with acute alcohol withdrawal, patients receiving lorazepam had an admission rate similar to that of those receiving diazepam.

Lorazepam vs Midazolam for Acute Agitation

Midazolam’s quick onset, reliable IM absorption, and evidence that supports its use an effective pharmacologic agent for acute agitation could lead clinicians to argue that midazolam is more efficacious than lorazepam for acute agitation.

Lorazepam vs. Dimenhydrinate in Treating Vertigo

The authors conclude that dimenhydrinate treatment of patients with acute vertigo provides a greater decrease in the primary end point, vertigo with ambulation, as well as other secondary end points, than lorazepam. However, the differences in improvement are small. Sedation was greater after lorazepam treatment, which delayed discharge of otherwise symptomatically improved patients. Therefore, dimenhydrinate appears to be the preferred intravenous agent for relief of vertigo in the emergency department setting.l

The Status on Status: Management of Status Epilepticus

The RAMPART trial (2012), a randomized, noninferiority trial of 893 children and adults demonstrated that IM midazolam is not inferior to IV lorazepam. In cases where an IV line cannot be easily established, IM midazolam is the medication of choice. When access is available, IV lorazepam is preferred instead.

Tips for Managing Active Seizures in the Emergency Department

It is imperative the first dose of benzodiazepine is dosed properly (ie, lorazepam 0.1 mg/kg IV up to 4 mg or midazolam 0.2 mg/kg intramuscular [IM] up to 10 mg). IV lorazepam is the preferred benzodiazepine because it has been shown to be better than diazepam for time to cessation of seizures and requirement of a different drug or general anesthesia.

Treatment of Agitation With Lorazepam in Clinical Practice: A Systematic Review

Lorazepam is a benzodiazepine that is widely used for management of acute agitation. Despite its widespread use, there is remarkably little clinical evidence for the benefits of lorazepam in acute agitation.