Can benzodiazepines (e.g. lorazepam, diazepam) be given to a patient with organophosphate poisoning who is experiencing agitation?

Benzodiazepines for Agitation in Organophosphate Poisoning

Yes, benzodiazepines should absolutely be administered to treat agitation in patients with organophosphate poisoning—this is a Class 1 recommendation from the American Heart Association with strong guideline support. 1

Primary Indication and Mechanism

• Benzodiazepines (diazepam or midazolam) are specifically recommended by the American Heart Association for both seizures AND agitation in organophosphate poisoning. 1, 2
• Agitation in organophosphate poisoning represents central nervous system toxicity from excessive acetylcholine accumulation, and benzodiazepines directly address this pathophysiology. 1
• The agitation may also facilitate mechanical ventilation when early intubation is required for life-threatening poisoning. 1

Treatment Algorithm for Agitated Organophosphate Poisoning Patient

Immediate concurrent therapies (all given together, not sequentially):

1. Atropine: 1-2 mg IV for adults (0.02 mg/kg for children), doubled every 5 minutes until bronchorrhea, bronchospasm, and bradycardia resolve 1, 2, 3
2. Benzodiazepines: Diazepam (first-line) or midazolam for agitation and seizure control 1, 2
3. Pralidoxime: 1-2 g IV loading dose, followed by 400-600 mg/hour continuous infusion for adults 1, 2
4. Early intubation: Consider for life-threatening poisoning, avoiding succinylcholine and mivacurium 1, 2

Evidence Quality and Strength

• The recommendation for benzodiazepines comes from the most recent American Heart Association guidelines (2025-2026) with consistent support across multiple guideline documents. 1, 2
• This represents the highest quality evidence available, with guideline-level recommendations specifically addressing agitation as an indication. 1
• Older research evidence from 1991,2004, and 2007 consistently supports benzodiazepines as part of the treatment triad (atropine, pralidoxime, benzodiazepines). 4, 5, 6

Critical Clinical Pitfalls to Avoid

• Never withhold benzodiazepines due to concerns about respiratory depression—the risk of undertreating organophosphate poisoning far exceeds medication risks, and mechanical ventilation should be available. 1
• Do not use benzodiazepines as monotherapy—they must always be given concurrently with atropine and pralidoxime, as benzodiazepines alone do not address the muscarinic or nicotinic effects of organophosphate poisoning. 1, 2
• Agitation may worsen with inadequate atropinization—ensure aggressive atropine dosing (potentially 10-20 mg in first 2-3 hours, sometimes up to 50 mg in 24 hours) while administering benzodiazepines. 3

Monitoring and Duration

• Maintain close observation for at least 48-72 hours, as delayed complications can occur with continued organophosphate absorption from the gastrointestinal tract. 2
• Continue all three therapies (atropine, pralidoxime, benzodiazepines) until clinical improvement is sustained, which may require approximately 72 hours of treatment. 7