What is a recommended medication for immediate anxiety relief in the Emergency Department (ED)?

Immediate Anxiety Relief in the Emergency Department

For rapid anxiety relief in the ED, lorazepam 2-4 mg IV/IM is the recommended first-line medication, providing effective anxiolysis within 15 minutes with a well-established safety profile. 1, 2, 3

Primary Pharmacologic Approach

Lorazepam as First-Line Agent

• Administer lorazepam 2-4 mg IV or IM for immediate anxiety relief in cooperative patients 1, 2
• IV administration provides onset within minutes, while IM administration achieves peak effect at 30-60 minutes 3
• For IV dosing, titrate slowly over at least 2 minutes and allow an additional 2 or more minutes to fully evaluate the sedative effect 3
• Lorazepam demonstrated marked reduction in overt anxiety and agitation with fewer side effects compared to haloperidol in ED studies 1

Dosing Considerations by Patient Population

• Healthy adults under 60 years: Start with 2 mg IV, titrate in 1 mg increments if needed, maximum 4 mg total dose 3
• Patients over 60 years or debilitated: Start with 1-1.5 mg IV over at least 2 minutes, with slower titration due to increased risk of respiratory depression 3
• Renal impairment: Terminal half-life increases by 55% in renal dysfunction; consider dose reduction 3

Alternative Rapid-Acting Options

Midazolam for Severe Agitation

• When more rapid sedation is required, midazolam 2.5-5 mg IV demonstrates superior sedation at 15 minutes compared to lorazepam 2, 4
• Titrate slowly over at least 2 minutes with additional 2-minute intervals between doses 4
• Patients over 60 years should receive no more than 1.5 mg over 2 minutes initially due to higher risk of hypoventilation and apnea 4

Combination Therapy for Cooperative Patients

• For agitated but cooperative patients who can take oral medications, combine oral lorazepam 2 mg with oral risperidone 2 mg 2
• This combination produces similar improvement to haloperidol plus lorazepam with better tolerability 1

Critical Safety Considerations

Respiratory Monitoring Requirements

• Immediate availability of resuscitative drugs and airway management equipment is mandatory 4
• Monitor for respiratory depression, especially in elderly patients and those with COPD or sleep apnea 3, 5
• Benzodiazepines cause dose-dependent CNS depression with unpredictable duration, particularly problematic in elderly patients 6

Avoid Concurrent CNS Depressants

• Patients receiving concomitant opioids or other CNS depressants require 30-50% less benzodiazepine dosing 4, 3
• Combining benzodiazepines with opioids can cause severe respiratory depression, coma, and death 5

Paradoxical Reactions

• Benzodiazepines have a 10% rate of paradoxical agitation, particularly in younger children and elderly patients 6
• If paradoxical excitement occurs, discontinue benzodiazepine and consider alternative agents 1

When to Consider Antipsychotics Instead

Undifferentiated Agitated Delirium

• If the etiology of anxiety involves psychosis or agitated delirium, consider droperidol 5 mg IM/IV or haloperidol 5 mg IM as monotherapy 2
• Droperidol works faster than haloperidol and may be preferred when rapid sedation is required 2
• For patients with known psychiatric illness requiring antipsychotics, use an antipsychotic as monotherapy rather than benzodiazepines 2

Alcohol Withdrawal Consideration

• Benzodiazepines are particularly advantageous when anxiety might involve alcohol withdrawal or seizure risk 2
• In these cases, lorazepam remains the preferred agent due to its anticonvulsant properties 2

Common Pitfalls to Avoid

• Do not underdose lorazepam: The recommended dose is 0.1 mg/kg up to 4 mg; doses less than 4 mg are associated with treatment failure 7
• Do not combine oral lorazepam premedication with subsequent IV benzodiazepine sedation: This may paradoxically increase the need for additional sedatives 8
• Do not use benzodiazepines for routine long-term anxiety management: They are indicated for acute relief only, not chronic treatment beyond 4 weeks due to rebound anxiety and withdrawal risk 9
• Avoid rapid IV administration: Always administer over at least 2 minutes to prevent respiratory compromise 4, 3