Benzodiazepines in the Field
Objective: Benzodiazepines can stop seizures and can calm severe agitation. They also reduce the drive to breathe. Protect the airway, use only the protocol indication, and do not combine them with opioids without a plan. Your protocol card sets the amount.
Why this matters
Midazolam, diazepam, and lorazepam appear in seizure, pacing, and agitation protocols. They increase the effect of gamma-aminobutyric acid (GABA), which slows the brain. They sedate. They also reduce the drive to breathe. Combined with alcohol, opioids, or a head injury, they are easy to overdo.
This lesson is the decision, not a dose card. Use them for the protocol indication only. Not for mild anxiety. Not for pain. Your protocol sets the drug, the route, and the milligrams. This site does not list doses.
- The indication is an ongoing seizure, severe agitation, or procedural sedation.
- The airway is ready: bag-valve mask, suction, oxygen saturation, and waveform capnography when you have it.
- The weight is in kilograms. Intranasal, intramuscular, and intravenous onset times are different.
- If opioids or alcohol are also present, I am naming the added risk to breathing.
Clinical sequence
- Name the indication. An ongoing seizure, severe agitation that is a safety or medical threat, or procedural sedation if your protocol includes it. Not mild anxiety. Not pain.
- Prepare the airway before a sedation-level dose. Have a bag-valve mask, suction, pulse oximetry, and waveform capnography when you have it, before the intramuscular, intranasal, or intravenous dose.
- Use kilograms and the route your protocol names. Intranasal, intramuscular, and intravenous onset times differ. Do not repeat the dose immediately because the patient is not asleep yet, unless the protocol says to.
- If opioids or alcohol are also present, say that risk out loud. Watch the airway more closely. Document the indication. Stay inside the protocol.
Common EMS Contexts
- Seizure: a benzodiazepine is first-line in most protocols when the seizure is not stopping. Intramuscular midazolam is an evidence-based route when there is no IV. Your protocol sets the drug, the route, and the dose. See the seizure lesson.
- Severe agitation that is a safety or medical threat, when you are authorized. Not for a loud argument.
- Awake pacing or cardioversion sedation in some systems.
Safety Habits
- Have a bag-valve mask, suction, pulse oximetry, and waveform capnography when available before a sedation-level dose.
- Do the weight-based math, and have a second person check it.
- Do not combine a benzodiazepine with an opioid or with alcohol without extra airway watch and a documented indication.
- This site does not list doses, routes, or maximums. The protocol card owns the amount.
- Flumazenil is not naloxone for benzodiazepines. It is not a routine field reversal. Seizures are a real risk, especially in a mixed overdose or in chronic use. Use it only if your protocol says so.
Common errors
- Using a benzodiazepine for pain because an opioid feels risky.
- Repeating intranasal sprays every few seconds in a closed ambulance with no bag-valve mask out.
- Calling the call finished after an intramuscular agitation dose and not watching ventilation.
Practice
One-minute check
Open your benzodiazepine protocol. For each line, say the indication, the preferred route, and the monitoring after the dose: (1) an ongoing seizure with no IV; (2) severe agitation that is a safety threat; (3) sedation for awake pacing, if your system includes it.
Sources & Further Study
Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.
- RAMPART (NEJM 2012) — Intramuscular midazolam compared with intravenous lorazepam for prehospital status epilepticus.
- ILAE 2015 status epilepticus definition — Defines status epilepticus for further study.
- NASEMSO National Model EMS Clinical Guidelines (2022) — Model EMS language for seizure and sedation.
- Benzodiazepines are for protocol indications such as status seizure and selected sedation. Watch ventilation. They are not a pain medicine. Your protocol sets the dose.
Education only. Apply learning within your protocols and medical direction. This is not clinical care guidance.
Check Your Understanding
Questions drawn only from this lesson. After you check, the key is highlighted. Education practice — not a certification exam.