Midazolam

Question 1

What is the presentation?

Answer 1

15mg in 3mls (5mg/ml)

Question 2

What is it and how does it work?

Answer 2

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.

Question 3

What are the indications?

Answer 3

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
Disturbed and/or abnormal behaviour that poses a threat to others or themselves as per CPG
Critical Care Paramedic only

Question 4

What are the contraindications?

Answer 4

Hypersensitivity

Question 5

What are the precautions?

Answer 5

Early monitoring where practicable is required when administering midazolam; ideally this would include SpO2, respiratory rate, pulse and blood pressure
Psychostimulants, in toxic levels can produce severe agitation and psychotic behaviour.

Question 6

What are the doses for non-TBI seizures and sedation in an adult?

Answer 6

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.

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

Question 7

What are the doses for non-TBI seizures and sedation in a child?

Answer 7

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.

Question 8

What is the dose for drug-induced psychosis?

Answer 8

IM: 10 mg (half doses for the paediatric, small, or frail patient).

Question 9

What are the special considerations/side effects?

Answer 9

Respiratory depression
Hypotension
Anterograde and retrograde amnesia
Myasthenia Gravis
Discarding unused medication must be witnessed and countersigned by attendant and credible witness.

Question 10

How do you dilate this drug for IV/IO administration?

Answer 10

Draw up 15mg/3ml with 12ml normal saline to produce 15mg/15ml = 1mg/ml