Intranasal lorazepam instantly calms agitated and violent kid: Case Report

New York, NY: A case report published in the Annals of Emergency Medicine presents the case of a 7-year-old boy with severe agitation and violence showing signs of kicking, spitting, and struggling who was successfully managed after intranasal administration of lorazepam. After the administration, the child rapidly became cooperative.

The use of the intranasal route for the administration of calming medication to young emergency department (ED) patients with behavioural issues can be a real game-changer for these patients. This could save them from receiving an intramuscular medication (IM) that could be an additional source of agitation. IM route is associated with the risk of needlestick injuries to both hospital personnel and patients.

Joan S. Bregstein, Columbia University College of Physicians and Surgeons, New York City, and colleagues note that intranasal absorption is more rapid than intramuscular, with sedatives such as lorazepam reaching peak serum concentrations up to 6 times faster when administered intranasally.

The boy had a long-standing history of anxiety and oppositional defiant disorder. He was presented to the ED following violent and aggressive behaviour at home. His mood showed no improvement in the ED and he threatened the medical staff with death. Physical and chemical restraints were required.

Hospital personnel donned masks with eye shields, security guards provided physical restraint and stabilization of the patient’s head, and intranasal lorazepam (2 mg/mL) was administered into both nares using a mucosal atomization device.

Five minutes after the administration he was calm and cooperative. His peaceful behavior lasted for about 90 minutes at which point he started kicking and biting the security guards. He was then given IM haloperidol and diphenhydramine and subsequently slept through the night.

The following evening while awaiting inpatient admission, his anger erupted again and he attempted to escape from the ED. Physical and chemical restraints were required once more and intranasal lorazepam was repeated at a higher doze of 3 mg/kg. Again the patient was calm and cooperative within 5 minutes and soon fell asleep. When he awoke he was still calm and remained so for the whole 24 hours of his subsequent ED stay.

The investigators observe that sedatives such as lorazepam “can reach peak serum concentrations up to 6 times faster when administered intranasally compared with intramuscularly."

The intranasal route continued Dr. Bregstein, “has the potential for faster medication delivery and response, and the needle-less intranasal route is a safer alternative for ED providers administering the medication.”

She cautioned, “There’s still work to be done before intranasal lorazepam can be our go-to anxiolytic for this type of ED patient, but we are very encouraged that, at least in this one patient, IN lorazepam seems to have been very successful, safe and well-received."

To read the complete case study log on to https://doi.org/10.1016/j.annemergmed.2019.05.020