What is the role of benzodiazepines in emergency department (ED) sedation?

Answer

The benzodiazepines act by stimulating specific benzodiazepine receptors in the CNS. Stimulation of this receptor potentiates the inhibitory effects of gamma-aminobutyric acid (GABA) on GABA-A receptors. This results in chloride influx, hyperpolarization, and decreased ability of the neuron to reach an action potential, producing sedation and anxiolysis. In addition, this class of drugs produces amnesia and has anticonvulsant actions. They have no analgesic properties.

Their most significant adverse effect is respiratory depression and subsequent hypoxemia. Therefore, exercise caution when administering this medication to patients with underlying chronic obstructive pulmonary disease (COPD).^{[4, 1]}Cardiovascular depression, resulting in hypotension with reflex tachycardia, is another adverse effect, but it is not significant at typical doses unless hypovolemia is present or unless it is coadministered with centrally acting analgesics. Be cautious when giving a hepatically metabolized benzodiazepine (eg, midazolam) to a patient with cirrhosis.^[4]

Benzodiazepines differ by the methods they can be given, time of onset, action duration, mechanism of metabolism, and presence of active metabolites. As mentioned earlier, their mechanism of action is seen clinically as anxiolysis, amnesia, and sedation; if a particular procedure is painful, these drugs must be given with analgesic agents. In nonintubated patients, the desired effect is found by titration until the desired effect is achieved. Caution must be used in children; they may have a paradoxical disinhibition and increased agitation at low doses.^[1]For more information, see Pediatrics, Sedation.

Benzodiazepines include midazolam, lorazepam, and diazepam.

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