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MIDAZOLam

high alert medication

Controlled and targeted substance

Short-acting benzodiazepine

ACP: Sedation of agitated patients

ACP: Control of seizures

ACP: Maintenance of anesthesia in intubated patients

  • Hypersensitivity to MIDAZOLam or other benzodiazepines
  • Acute narrow-angle glaucoma
  • Shock
  • Decreased level of consciousness
  • Hypotension

ACP: All indications

  • 2-5 mg IV/IO in increments to effect
  • 5-10 mg IM
  • May repeat as required in small increments
  • Maximum dose from all sources is 30 mg

Follow weight-based dosing

ACP: All indications

  • 0.2 mg/kg IN, OR
    • Maximum dose 10 mg
    • Intranasal drug administration is recommended over intramuscular because of a more consistent absorption
    • Administer half the dose in each nare
    • Consult PR11: Intranasal Medication Administration for additional information on the use of mucosal atomizer devices
  • 0.1 mg/kg IV/IO, OR
    • Maximum dose 5 mg
  • 0.2 mg/kg IM

Like other benzodiazepines, MIDAZOLam intensifies the activity of gamma aminobutyric acid, the major inhibitory neurotransmitter in the central nervous system.  This action is believed to result in hyperpolarization of neuronal cells, which then take longer to reach threshold and depolarize. 

  • Onset: 3-5 minutes (IM); 1-3 minutes (IV) 
  • Peak: 15 minutes (IM); 10 minutes (IV)
  • Duration: 30 minutes (IM); 20 minutes (IV)
  • Sedation, headache, blurred vision
  • Hypotension
  • Nausea and vomiting
  • Pain and tenderness if given IM
  • Respiratory depression

Benzodiazepine overdoses should be managed supportively, with oxygenation and ventilation supported as necessary, and fluids given to maintain an adequate blood pressure.  Reversal agents are available in-hospital. 

Use with caution when administering other central nervous system depressants or narcotic analgesics. 

  • Erythromycin, diltiazem, verapamil, ketoconazole, fluconazole, and itraconazole can significantly increase the bioavailability of MIDAZOLam and may produce prolonged sedation.  
  • Ritonavir and nelfinavir may cause deep and prolonged sedation that may progress to respiratory depression.
  • Rifampin, carbamazepine, and phenytoin may markedly reduce the effectiveness of MIDAZOLam. 

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