UNCONTROLLED WHEN PRINTED
Introduction
  • A water-soluble benzodiazepine that has anxiolytic, sedative and anticonvulsive characteristics. This is due to its bonding with receptors in the CNS; its action to increase the inhibitory effect of the g-aminobutyric acid (GABA) neurotransmitter on the GABA receptors and subsequent membrane threshold.
  • Midazolam is lipid-soluble in physiological pH and it reaches the CNS quickly.

Pharmacology Review

Indications
  • Prolonged seizure activity - generalised seizure lasting ≥ 5 minutes OR recurrent / status seizure activity as per CPG
  • Focal seizure activity which is prolonged (≥ 5 minutes) and is associated with a GCS ≤ 12 as per CPG
  • Second-line IV agent for maintenance of sedation after Droperidol administration for Disturbed and/or abnormal behaviour
Critical Care Paramedic only
  • For the purpose of providing and maintaining procedural sedation
Contraindications
  • Hypersensitivity
Precautions / Notes
  • Early monitoring as soon as practicable is required when administering midazolam; including SpO2, respiratory rate, pulse and blood pressure
  • SpO2 and etCO2 monitoring must be applied whenever level of consciousness drops (~RASS <0)
  • Paediatrics - have a low threshold to consult with ASMA when repeat or maintenance doses are required for sedation
  • Use of Midazolam after Ketamine sedation requires ASMA consult
  • Psychostimulants, in toxic levels can produce severe agitation and psychotic behaviour.
Management
Seizures

Adult < 70 years:

  • IM
    • 5mg, repeat once after 10 min if needed and no IV access.
  • IV/IO
    • 2.5 - 5mg, repeat dose 2.5mg every 5 min as needed to 15mg max.

Adult ≥ 70 years or frail:

  • IM
    • 2.5mg, repeat once after 10 min if required and no IV access.
  • IV/IO
    • 2.5mg, repeat dose 1mg every 5 min as needed to 15mg max.

Paediatric:

  • IM
    • 0.2mg/kg max single bolus 5mg, repeat once after 10 min if needed and no IV access.
  • IV/IO
    • 0.1mg/kg to a max single bolus dose of 2.5mg, repeat as needed every 5 min to a 10mg max.

The use of Midazolam in both adults and paediatric patients for other seizure types outside of CPG requires ASMA authority.

Maintenance of Sedation (IV Only)

Adult < 70 years of age:

  • IV
    • 1 - 2mg, titrated to effect every 5-10 mins as required to a total max dose 5mg

Adult ≥ 70 years or frail:

  • IV
    • 0.5 - 1mg, titrated to effect every 5-10 mins as required to a total max dose 5mg

Paediatric (6-15 years of age):

  • IV
    • 0.5mg - 1mg, titrated to effect every 5-10 mins as required to a total max dose 5mg
Special Considerations
  • Respiratory depression
  • Hypotension
  • Anterograde and retrograde amnesia
  • Myasthenia Gravis

References
References
Presentation
15mg in 3mls (5mg/ml)
Midazolam
label-midazolam
MUST BE LABELLED

DILUTION

IM

  • Do NOT dilute in general

IV / IO

  • Dilute 15mg / 3ml with 12ml NaCl in 20ml syringe (equivalent to 1mg/ml)
  • Part dilution into a 10 ml syringe is no longer advocated
MUST BE LABELLED
Colour assist:

Discarding unused medication must be witnessed and countersigned by attendant and credible witness.

Document Control


Directorate
Clinical Services

Responsible Manager
Head of Clinical Services

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