Midazolam Use in the Emergency Department

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Midazolam Use in the Emergency Department

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Conscious sedation

• Minimally depressed level of consciousness
• Independently and continuously maintain an airway
  and adequate cardiorespiratory function.
• Respond to tactile stimulation and/or verbal
  command.
• Tolerate the unpleasant procedures.

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Conscious sedation (Procedural sedation) in the ED

• Alleviate anxiety
• Provide amnesia
• Pain not adequately addressed.

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Clinical indications for sedation in the ED

• Orthopedic reduction.
• Cardioversion.
• Wound debridement.
• Pediatric laceration repair.
• Lumbar puncture.
• Abscess incision and drainage.

• Chest tube insertion.
• Burn care.
• CT scans and other diagnostic procedures in
  children.
• Peritoneal lavage.
• Removal of vaginal or rectal foreign body.

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Drugs for conscious sedation

• Benzodiazepines Midazolam
• Opioids Fentanyl, Meperidine.
• Hypnotics agents Barbiturates, Propofol,
  Ketamine.

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Midazolam

• Rapid onset. (i.v. 1-3 min, i.m. 5 min)
• Shorter duration.
• No injection pain.
• Existence of antagonist- Flumazenil

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Pharmacology of midazolam

• Anxiolytic
• Muscle relaxant
• Anticonvulsant
• Sedative
• Hypnotic
• Amnesic

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Side effects of midazolam

• Respiratory depression
• Short-lived.
• Respond to verbal stimulation and oxygen
  alone.
• Injection rate-related. (slowly injection)
• Rare
• Hiccups.
• Cough.
• Nausea/Vomiting.

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Antagonist (Flumazenil, Anexate)

• Reverse hypnotic-sedative effect.
• Reverse respiratory depression? (dose)
• Overdose CNS symptoms occurred.
• Suggest Given by incremental dose (0.2 mg)
• Short duration of action.

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Other use of midazolam in the ED

• Anticonvulsant
• i.v. 0.15-0.2 mg/kg ? 0.75mg/kg/min infusion.
• i.m. 5-15 mg.
• Rapid sequence induction (intubation)
• Combined with opioids (fentanyl, meperidine)
  Respiratory depression, hypoxemia, prolonged
  duration.

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Equipment for conscious sedation monitoring

• Oxygen and mask.
• Pulse oximeter.
• ECG monitor.
• Suction.
• Orotracheal tube.
• Laryngoscope.
• Ambu bag.

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Summary

• Midazolam Safe for sedation in ED
• Titration the principle of administration of
  midazolam and flumazenil.

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NPO for conscious sedation

• No evidence-based guideline for optimal fasting
  duration prior to sedation in the ED.
• ASA recommend 6 hr for solids.
• 2 hr for liquids.
• Balance between urgency and associated risk.

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Drug interaction

• Drugs that inhibit the metabolism of midazolam
• Cimetidine
• Ranitidine
• Omeprazole
• Macrolide antibiotics
• Oral contraceptives
• Drug that enhance the metabolism of midazolam
• Rifampin