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Intranasal Midazolam protocol for treating acute seizures:

Indications: For treatment of persistent seizure activity

Procedure:

  1. Assess ABC’s – Airway, Breathing, Circulation
  2. For pulseless patients, proceed to ACLS guidelines
  3. Apply 100% oxygen NRB mask to seizing patient
  4. Use age based table to determine proper volume of midazolam for atomization (see table below)
  5. To calculate it manually, use the below formula
    • Assess weight: children weight in kg = 10 + 2(Age in years)
    • Calculate appropriate dose of midazolam using the following formula:
      • Children: Total kg wt X 0.2 mg = total mg dose of midazolam, maximum of 10 mg
      • Adults over 50 kg: 10 mg (2 ml) of midazolam
      • Total volume in milliliters of midazolam (5mg/ml concentration) = (Total mg dose divided by 5mg/ml) + 0.12 ml for dead space of device.
  6. Load syringe with appropriate milliliter volume of midazolam (use only 5mg/ml concentration) and attach MAD nasal atomizer
  7. Place atomizer within the nostril
  8. Briskly compress syringe to administer 1/2 of the volume as atomized spray.
  9. Remove and repeat in other nostril, so all the medication is administered
  10. Continue ventilating patient as needed
If seizures persist 5 minutes after treating, consider repeating ½ dose of midazolam either intranasally, intramuscularly or intravenously. Secure airway if necessary.

Midazolam Dosing chart

Patient age

(years)

Weight

(kg)

IN Midazolam volume in ml*

5mg/ml concentration

 Volume        Dose (mg)

Neonate

  3  kg

0.3 ml             0.6 mg

<1  yr

  6  kg

0.4 ml             1.2 mg

1  yr

10  kg

0.5ml              2.0 mg

2  yr

14  kg

0.7 ml             2.8 mg

3  yr

16  kg

0.8 ml             3.2 mg

4  yr

18  kg

0.9 ml             3.6 mg

5  yr

20  kg

1.0 ml             4.0 mg

6  yr

22  kg

1.0 ml             4.4 mg

7  yr

24  kg

1.1 ml             4.8 mg

8  yr

26  kg

1.2 ml             5.2 mg

9  yr

28  kg

1.3 ml             5.6 mg

10  yr

30  kg

1.4 ml             6.0 mg

11  yr

32  kg

1.4 ml             6.4 mg

12  yr

34  kg

1.5 ml             6.8 mg

Small teenager

40  kg

1.8 ml             8.0 mg

Adult or full-grown teenager

> 50 kg

2.0 ml            10.0 mg

* This volume is based on the calculated dose PLUS 0.10 ml dead space in the device (the amount of medication that will remain within the syringe and atomizer tip and therefore will not be delivered to the child). The total volume is then rounded off to the next highest 0.1 ml. Slightly higher doses may be appropriate at the lower range of volume (in smaller children) due to measurement difficulties and possible under dosing which may not stop the seizure. 

In some children a higher dose (0.3 mg/kg) may be more appropriate

 Home Therapy directions for Intranasal midazolam during an acute seizure (Click Here)

Download a basic photographic display of how to draw up and administer intranasal midazolam for seizures or sedation (click here for MS word document 0.53 MB)