Midazolam 

Midazolam (Versed)

Benzodiazepines

November 17, 2023

Welcome back to UH EMS-I’s Pharmacy Phriday series. Over the past few weeks, this series has focused on diabetic emergencies in recognition of National Diabetes Month. November is also Epilepsy Awareness Month, so over the next few weeks, we will focus on some of our pharmacological options for treatment in cases of seizures. This week’s Pharmacy Phriday will focus on Midazolam (Versed), one of the benzodiazepines used most by EMS.


Versed has become the preferred medication for multiple reasons. It is a short-acting medication with a relatively quick onset, has fewer storage restrictions compared to other benzos, and can be administered via many routes. In cases of seizures where IV access may be difficult, the ability to administer the critical medication via the IN or IM route is welcomed, and the efficacy of the medication via the IN route is very comparable to IV administration.


Epilepsy is one of the most common neurological disorders affecting people of all ages. There are roughly 470,000 children living with epilepsy in the United States alone. Some providers may recall seizure patients who were prescribed Diastat to be used by family or caretakers when their loved one would experience a seizure. A form of Midazolam, Nayzilam, packaged and used as a nasal spray (IN), is a newer seizure rescue medicine that appears to be another option for patients older than 12 years of age and is designed for use by parents or caregivers in the home or school setting. This product is seen as a more socially acceptable option to the rectal valium and may be encountered more and more in the pre-hospital setting.  


Versed is considered a sedative, anticonvulsant, and hypnotic that interacts within the complex chemical and electrical activity in the Central Nervous System (CNS). It increases the effect that GABA, a neurotransmitter, has within the CNS. GABA will block impulses between nerve cells in the brain. Thus, Versed assists the chemical GABA in slowing down or inhibiting the CNS system. Increased GABA equals increased sedation.


The sedative effect of Versed can also be advantageous for patients other than seizure patients. Protocols indicate its use in cases of agitation, alcohol withdrawal, behavioral emergencies, stimulant overdoses, or a cocaine or stimulant-induced STEMI. Versed can also be used prior to performing procedures such as pacing, cardioversion, advanced airway procedures, and new to the protocol in 2023, CPR-induced awareness. An additional benefit to the use of Versed in these cases is the medication’s tendency to cause amnesia.


Adverse reactions to Versed are related to the medication’s depressant or inhibiting effect on the CNS. These may include drowsiness, respiratory depression, or hypotension, just to name a few. These considerations also relate to the contraindications for the use of Versed. It is worth special note that the use of this medication should include close monitoring of the patient’s respiratory effort, including pulse ox and capnography. Also, be aware that the effects of the drug can be accentuated with the presence of alcohol or narcotics. Other cautions include its use for elderly, pregnant, and pediatric patients.


The standard dosing of Versed in our UH protocols for adults is 2.5mg as a slow IV push (over two minutes) or 5.0mg via the IN or IM route. The dosing may be repeated in 5 minutes to a maximum of 10mg. Pediatric patients are administered 0.1mg/kg for IV/IO administration or 0.2mg/kg for IN/IM administration. As for an adult patient, dosing may be repeated every 5 minutes as needed but only to a maximum dose of 5 mg for the pediatric patient. Versed can be administered by the Advanced EMT in cases of seizures and combative patients.

 

We wish everyone a very Happy Thanksgiving. Be sure to look for next week’s Pharmacy Phriday as we will look at an alternative to Versed, rarely used but still referenced in our protocols.


Till then, stay safe!




Sincerely,



The UH EMS-I Team

University Hospitals


November 29, 2024

Welcome back to UH EMS-I’s Pharmacy Phriday series. Over the past few weeks, this series has focused on diabetic emergencies in recognition of National Diabetes Month. November is also Epilepsy Awareness Month, where we raise awareness and support for people with epilepsy. As November comes to a close, we focus on one of the primary pharmacological options for treatment in cases of seizures: midazolam.  

 

Midazolam has become the preferred medication for multiple reasons. It is a short-acting medication with a relatively quick onset, has fewer storage restrictions compared to other benzodiazepines, and can be administered via many routes. In cases of seizures where IV access may be difficult, administering this critical medication via the IN or IM route is welcomed, and the efficacy via the IN route is comparable to IV administration. 

 

Epilepsy is one of the most common neurological disorders affecting people of all ages. More than 3.4 million people are currently living with epilepsy nationwide, with roughly 470,000 of them being children. According to the Epilepsy Foundation, nasal midazolam (brand name Nayzilam®), nasal diazepam (brand name Valtoco®), and rectal diazepam gel (brand name Diastat®) have been approved by the Food and Drug Administration (FDA) for out-of-hospital use for the treatment of acute repetitive seizures or clusters.1 It is not uncommon for EMS providers to arrive on the scene of a known epileptic who has been administered one of these products.


In cases where the EMS provider arrives and the patient is still actively seizing, midazolam is considered a standard of care. It is a sedative, anticonvulsant, and hypnotic that interacts with the complex chemical and electrical activity in the Central Nervous System (CNS). It increases the effect that gamma-aminobutyric acid (GABA), a neurotransmitter, has within the CNS. GABA blocks impulses between nerve cells in the brain, thus midazolam assists the chemical GABA in slowing down or inhibiting the CNS system. Increased GABA = increased sedation.  

 

The sedating effect of midazolam can also be advantageous for those other than seizure patients. Protocols indicate its use in cases of agitation, alcohol withdrawal, behavioral emergencies, stimulant overdoses, or cocaine- or stimulant-induced STEMI. Midazolam can also be used before performing procedures such as pacing, cardioversion, advanced airway procedures, and CPR-induced awareness. An additional benefit to the use of midazolam in these cases is the medication’s tendency to cause amnesia.  

 

Adverse reactions to midazolam are related to the medication’s depressant or inhibiting effect on the CNS and may include drowsiness, respiratory depression, or hypotension, to name a few. These considerations also relate to the contraindications for the use of midazolam. It is worth a special note that using this medication should include close monitoring of the patient’s respiratory effort including pulse ox and capnography. Be aware that the presence of alcohol or narcotics can accentuate the effects of the drug. Other cautions include its use for elderly, pregnant, and pediatric patients. 

 

The standard dosing of midazolam in our UH protocols for adults is 2.5 mg as a slow IV push (over two minutes) or 5.0 mg via the IN or IM route. The dosing may be repeated in 5 minutes to a maximum of 10 mg. Pediatric patients are administered 0.1 mg/kg for IV/IO administration or 0.2 mg/kg for IN/IM administration. As for adult patients, dosing may be repeated every 5 minutes as needed, but only to a maximum dose of 5 mg for the pediatric patient. Midazolam can be administered by the Advanced EMT in all listed uses except for cases of procedural sedation, airway management, or the combative pediatric patient.



Till the next time, stay safe!




Sincerely, 


The UH EMS-I Team 

University Hospitals 


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