Management of Inpatient Catatonia with Benzodiazepines

Initiation of Treatment

• Start with 2-4 mg IV midazolam and assess response within 30-60 minutes, as midazolam has more rapid onset than lorazepam but shorter duration requiring more frequent redosing 1

Administration of IV Diazepam

• Administer IV diazepam 0.1-0.3 mg/kg (maximum 10 mg per dose) over 2 minutes to avoid pain at the IV site 2
• Do NOT use IM diazepam as it has erratic absorption and is not recommended 3

Rectal Diazepam as Last Resort

• If IV access is not available and you cannot establish it, rectal diazepam 0.5 mg/kg up to 20 mg can be administered, though absorption may be erratic 2

Critical Monitoring Parameters

• Be prepared to support ventilation, especially if combining benzodiazepines with antipsychotics 2

Avoiding Common Pitfalls

• Do not use IM diazepam - this is a critical error as absorption is erratic and tissue necrosis can occur 2
• Avoid oral buspirone as an alternative - it takes 2-4 weeks to become effective and is inappropriate for acute catatonia requiring immediate relief 4