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Midazolam 2017 Class: ♦ Benzodiazapine, anticonvulsant Actions: ♦ Provides sedation without loss of consciousness ♦ Provides relief of anxiety ♦ Provides antegrade amnesia ♦ Benzodiazapines as a whole elevate seizure thresholds Indications: ♦ Sedation, anxiolysis, and amnesia prior to cardioversion or pacing in conscious patients ♦ Sedation to facilitate advanced airway compliance ♦ Situations where chemical restraint is needed to care for the patient or protect responders or bystanders – adult only ♦ Patients actively seizing or experiencing ongoing seizure activity ♦ Excited Delirium Syndrome ♦ Suspected nerve agent poisoning Dosage/Administration: Adult: • Treatment of seizure activity: o If no IV/IO, 10 mg IM, repeat at 5 mg every 5 min until termination of seizure activity IV/IO/IM/IN, to a max of 20 mg o If IV/IO is established, 5 mg IV/IO, repeat at 5 mg IV/IO every 5 min to max of 20 mg • Sedation prior to cardioversion, chemical restraint, and when needed to facilitate compliance with positive pressure ventilation, to facilitate CPAP application in an anxious patient*: o 2.5 - 5 mg IV/IO/IM/IN, repeat PRN in 5 minute intervals to a max total dose of 10 mg. * Use cautiously with elderly, debilitated, or chronically ill patients • For use with Excited Delirium Syndrome: o 5 - 10 mg IV/IO/IM/IN, repeat PRN in 5 minute intervals to a max total dose of 20 mg. Note: dosage must be individualized and titrated to desired effect. Individualized response may vary with age, physical status, and concomitant medications but may also vary independent of these factors. Pediatric: • Treatment of seizure activity: o If no IV/IO, 5 mg IM for any patient 13-40 kg (29-88 lbs - Yellow-Green on Peds card), repeat at 2.5 mg IM/IN every 5 min until termination of seizure activity to a max total dose of 10 mg Johnson County Emergency Medical Services Protocols Page 94 Midazolam 2017 • Once IV/IO is established, wait 5 minutes from initial administration, then administer 2.5 mg PRN x2 IV/IO to a max total dose of 10 mg. o If IV/IO is established, administer 2.5 mg IV/IO for seizure activity. Repeat at 2.5 mg every 5 min to a max total dose of 10 mg or termination of seizure activity. o If patient weight is less than 13 kg (<29 lbs), Administer the following to a max total dose of 10 mg or until termination of seizure activity: 0.1 mg/kg IV/IO/IM, repeat PRN in 5 minutes 0.2 mg/kg Intranasal, repeat PRN in 5 minutes Sedation prior to cardioversion, chemical restraint, and when needed to facilitate compliance with positive pressure ventilation: o 0.1 mg/kg IV/IO/IM, repeat PRN in 5 minute intervals to a max total dose of 10 mg. o 0.2 mg/kg Intranasal, repeat PRN in 5 minute intervals to a max total dose of 10 mg. Side Effects: ♦ Drowsiness, fatigue, dizziness, confusion, nausea, vomiting ♦ Respiratory depression and hypoventilation, with possible apnea ♦ Hypotension (rare) ♦ Reactions such as agitation, involuntary movements (including tonic/clonic movements and muscle tremors), hyperactivity, and combativeness have been reported Contraindications: ♦ Hypersensitivity to benzodiazepines ♦ Narrow angle glaucoma (relative contraindication) ♦ Shock Johnson County Emergency Medical Services Protocols Page 95 Midazolam 2017 Precautions: ♦ Pulse oximetry and cardiac monitoring must be in place as well as continuous monitoring of respiratory status ♦ Use with caution in renal impaired patients, due to altered pharmacokinetics ♦ Use with caution in CHF patients due to delayed onset of action and long half-life ♦ Geriatric patients and/or COPD patients are more susceptible to the respiratory depression associated with midazolam administration ♦ Concomitant use of barbiturates or other CNS depressants may increase the risk of hypoventilation and may contribute to profound and/or prolonged drug effect Protocol Reference: ♦ IPAP ♦ Dysrhythmias ♦ Excited Delirium Syndrome ♦ Patient Restraint ♦ Post Resuscitation ♦ Respiratory Distress ♦ Seizures ♦ Appendix G: DuoDote Kit Johnson County Emergency Medical Services Page 96