II. Indications
-
Procedural Sedation and Analgesia (PSAA)
- Other agents are preferred in most cases (unpredictable)
-
Rapid Sequence Intubation (induction agent)
- Other induction agents are preferred due to the large and unpredictable Midazolam doses required for induction
- Rarely given at adequate doses (a typical adult dose for RSI is an astounding 8-10 mg)
- Consider where IV Access unavailable or other intubation agents contraindicated
- Could be considered in Status Epilepticus (although Thiopental might be preferred)
- Other induction agents are preferred due to the large and unpredictable Midazolam doses required for induction
III. Class
- Parenteral short acting Benzodiazepine
IV. Mechanism
- Sedative, Anxiolytic, and amnestic effects
- Antagonist: Flumazenil
V. Dosing: Procedural Sedation
- Indications for Midazolam
- Other sedation agents are preferred in most cases
- Intranasal Versed in children may allow for imaging, Intravenous Access, Laceration Repair
- Intravenous
- Age 6 months to 5 years
- Initial: 0.05 to 0.1 mg/kg IV
- Titrate: Up to 1 mg increments IV every 3 min to max of 0.6 mg/kg
- Age 6 to 12 years
- Initial: 0.025 to 0.05 mg/kg IV
- Titrate: Up to 1 mg increments IV every 3 min to max of 0.4 mg/kg
- Adults (and over age 12 years)
- Initial: 0.02 mg/kg IV
- Titrate: 1 mg increments IV every 3 min (typically up to 5 mg)
- Age 6 months to 5 years
- Intramuscular
- Child: 0.1 to 0.15 mg/kg (up to 10 mg)
- Adult: 0.07 mg/kg (up to 10 mg)
- Other Dosing
- Oral: 0.5 mg/kg/dose
- Nasal: 0.2 to 0.5 mg/kg intranasal (1/2 in each nostril) using 5 mg/ml up to 10 mg
- Rectal 0.25 to 0.5 mg/kg/dose per Rectum
- Commonly used in combination with Fentanyl
- When combined with Opioids (e.g. Fentanyl), use lower Midazolam dose
- Risk of Deep Sedation with cardiopulmonary depression
VI. Safety
- Contraindicated in pregnancy (Category D)
- Wait at least 4 hours for Breast Feeding
- Unpredictable at increased doses (risk of respiratory and cardiovascular depression)
- Reversal: Flumazenil 0.01 mg/kg up to 2 mg over 15 seconds
- Do not use if on longterm Benzodiazepines
VII. Pharmacokinetics
-
General
- Duration: 1-4 hours
- Half life: 2.5 hours
- Oral
- Onset: 20 to 30 minutes
- Peak: 40 minutes
- Intramuscular
- Onset: 5 to 7 minutes (up to 10-20 minutes)
- Peak: 10 to 15 minutes
- Duration: 60-120 minutes
- Intravenous
- Onset: 2-3 minutes
- Peak: 5 to 10 minutes
- Duration: 45-60 minutes
VIII. Precautions
- Monitor closely with respiratory depression
- Have Ambubag and Oxygen available when administered
- Unpredictable at increased doses (risk of respiratory and cardiovascular depression)
- Best delivered in incremental doses (e.g. 1 mg increments)
- Risk of Hypotension
- Use with caution if risks for respiratory depression
- Elderly, debilitated patients or children
- Concurrent Narcotic use
- Existing CNS depression
- Chronic lung disease
- Neuromuscular disorder
- Apnea history
- Risk of Agitation
- Elderly
- Liver disease
IX. References
- Miner (2012) APLS Lecture, HCMC, Minneapolis
- Hamilton (2012) Tarascon Pharmacopeia, Jones and Bartlett, Burlington
- Rispoli (2002) Tarascon Pocket Orthopedics, Loma Linda, p. 115
- University Minnesota Childrens - Pediatric Emergency Drug Card
- Becker (2012) Anesth Prog 59:28-42 [PubMed]
- Brown (2005) Am Fam Physician 71:85-90 [PubMed]
- Singh in Blaivas (2012) Emergency Medicine - an International Perspective, p. 199-208
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