November 24, 2023

This week in Pharmacy Phriday, we look at a medication on our “next drug up” list, Valium. Valium was once “THE” benzodiazepine in our EMS drug boxes but now remains in our UH protocol only as a backup to the preferred benzo, Versed, and the second-string benzo, Ativan. Like the other benzos, Valium is indicated for status epilepticus (also an AEMT intervention in these cases), combative but non-violent psychiatric patients, sedation for airway control or painful procedures, and to counteract the effects of cocaine in acute coronary syndromes.

Some of the drawbacks of Valium that have caused its prevalence to slip are now concerns when using the medication. These include its long half-life (almost 20-50 hours), which prolongs unwanted side effects, the inability to administer the medication via the IN or IM route, and that it is incompatible with many other medications (if used, the provider should be sure to flush the IV line following administration). 

When used in accordance with UH protocols, Valium is administered to the adult patient via the IV or IO route for the indications listed above. When using the IV route, be aware that Valium can cause local venous irritation. The provider should inject the medication slowly, preferably through a large line. 

The adult dosage for Valium is 2.5-5mg. In cases of seizures or when desiring the amnestic effect, the higher dosing is normally recommended. Also, consider underlying conditions such as age, previous use of alcohol or depressants, etc., when determining an appropriate dose. The dosage can be repeated, typically at about five minutes, if the desired effect is not obtained. The maximum dose under UH protocols is 10 mg. 

For the pediatric patient, the standard dosage is 0.1mg/kg slow IV/IO. The dosage is doubled for status epilepticus at 0.2mg/kg. As with all pediatric medication dosages that are calculated, be careful not to exceed the adult dose, which is 5 mg in the case of Valium.

The rectal administration route is available for the pediatric patient without vascular access at a dosing rate of 0.5mg/kg for all indications to a maximum dose of 10 mg. Remember that the rectum typically promotes rapid drug absorption except in cases of gross fecal matter, diarrhea, or rectal bleeding.  

Although available commercially as Diastat, the pre-hospital provider will usually need to administer the liquid form of Valium using a syringe and catheter (no needle!!) or a small, lubricated ET tube with the BVM adapter removed. The procedure requires placing the patient on their side (some sources advocate the left side if possible), flexing the upper leg to expose the anus, placing the catheter or tube inside of the rectum, and injecting the medication. To permit retention and absorption of the medication, the provider should hold the patient’s buttocks together after withdrawing the catheter or tube. 

Valium, like other Benzos, can cause respiratory depression, hypotension, and altered mental status. It is vital that your patient is closely monitored, including capnography. Other than hypersensitivity to the medication, head injury, and the presence of alcohol or other CNS depressants, these side effects are useful to remember as contraindications and precautions to Valium’s use.

Have a great weekend and a safe week!

Sincerely,



The UH EMS-I Team

University Hospitals