Diazepam Administration Routes: IV Preferred, IM Not Recommended
Diazepam can be given intravenously (IV) but intramuscular (IM) administration is NOT recommended due to erratic absorption and risk of tissue necrosis. 1, 2
Route-Specific Recommendations
Intravenous (IV) Route - PREFERRED
- IV is the strongly preferred route for diazepam administration 3, 4
- Inject slowly, taking at least one minute for each 5 mg (1 mL) given 3, 4
- Avoid small veins (such as dorsum of hand or wrist) 3, 4
- Take extreme care to avoid intra-arterial administration or extravasation 3, 4
- For status epilepticus specifically, the IV route is "by far preferred" 3, 4
Intramuscular (IM) Route - NOT RECOMMENDED
- IM diazepam should NOT be used due to erratic absorption and risk of tissue necrosis 1, 2
- The American Academy of Pediatrics explicitly states "IM route is not recommended because of tissue necrosis" 1
- If IM injection must be used (only when IV is impossible), inject deeply into the muscle 3, 4
- FDA labeling acknowledges IM as technically possible but notes IV is "by far preferred" even in emergencies 3, 4
Clinical Context: Status Epilepticus
When treating status epilepticus and IV access is unavailable:
- Use IM midazolam (0.2 mg/kg, max 6 mg) instead of IM diazepam 1, 2
- Midazolam is rapidly absorbed from IM sites (93-100% efficacy) unlike diazepam 5
- Rectal diazepam (0.5 mg/kg up to 20 mg) is preferred over IM diazepam when IV unavailable 1
- IM midazolam achieves seizure cessation faster than IV lorazepam in prehospital settings (73.4% vs 63.4% success) 6
Key Safety Considerations
Critical pitfall: The major risk with IM diazepam is tissue necrosis at the injection site, making this route unsuitable for routine use 1, 2. Additionally, absorption from IM sites is slower and more erratic compared to other benzodiazepines like midazolam 7, 5.
For sedation procedures (endoscopy, anxiety disorders, muscle spasm):