Sedation Prior to Intubation

Dosing Guidelines

• The American Academy of Pediatrics recommends administering diazepam as an IV/IO bolus at 0.2-0.4 mg/kg for rapid sequence intubation (RSI) 1
• The maximum recommended single dose is 20 mg, regardless of patient weight 1

Clinical Considerations

• Diazepam will lower intracranial pressure (ICP) and typically does not significantly lower blood pressure, making it a desirable agent for patients with head injury, multisystem trauma, or hypotension 1
• Onset of action is rapid with duration of approximately 10-15 minutes 1

Potential Adverse Effects

• May cause brief myoclonic activity (hiccups, cough, twitching) 1
• May exacerbate focal seizure disorders 1
• Causes transient adrenal suppression that is not clinically significant 1
• There is an increased risk of respiratory depression when combined with other sedative agents, particularly opioids 3
• Elderly patients, those with obesity, or patients with hepatic or renal impairment may require dose reduction (20% or more) due to reduced clearance 3

Monitoring and Safety Precautions

• Monitor oxygen saturation and respiratory effort during administration 4
• Be prepared to provide respiratory support if needed 4
• Have flumazenil available for reversal of benzodiazepine effects if severe respiratory depression occurs 5
• Flumazenil dosing for benzodiazepine reversal: 0.01-0.02 mg/kg IV (maximum: 0.2 mg); can repeat at 1-minute intervals to a maximum cumulative dose of 0.05 mg/kg or 1 mg, whichever is lower 5

Special Considerations

• Use with caution in benzodiazepine-dependent patients, as flumazenil may precipitate acute withdrawal if needed 3