Lecture by Prof.Nabil Housin

1. Midazolam Use in the
Emergency Department
Prof. Med. Nabil H. Mohyeddin
Anesthesiologist& Intensivist
Board certified
Germany, Rostock university

2. 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.

3. Conscious sedation
)Procedural sedation( in the
ED
 Alleviate anxiety
 Provide amnesia
* Pain : not adequately addressed.

4. Clinical indications for sedation in
the ED
 Orthopedic reduction.  Chest tube insertion.
 Cardioversion.  Burn care.
 Wound debridement.  CT scans and other
 Pediatric laceration diagnostic procedures in
repair. children.
 Lumbar puncture.  Peritoneal lavage.
 Abscess incision and  Removal of vaginal or
drainage. rectal foreign body.

5. Drugs for conscious sedation
 Benzodiazepines: Midazolam
 Opioids: Fentanyl, Meperidine.
 Hypnotics agents: Barbiturates, Propofol,
Ketamine.

6. Midazolam
 Rapid onset. (i.v. 1-3 min, i.m. 5 min)
 Shorter duration (10-20 min.)
 No injection pain.
 Existence of antagonist- Flumazenil

7. Pharmacology of midazolam
 Anxiolytic
 Muscle relaxant
 Anticonvulsant
 Sedative
 Hypnotic
 Amnesic

9. 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.

10. 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.

11. 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.

12. Equipment for conscious sedation
monitoring
 Oxygen and mask.
 Pulse oximeter.
 ECG monitor.
 Suction.
 Orotracheal tube.
 Laryngoscope.
 Ambu bag.

13. Summary
 Midazolam: Safe for sedation in ED
 “Titration”: the principle of
administration of midazolam and
flumazenil.

14. 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.

15. Drug interaction
 Drugs that inhibit the metabolism of midazolam
* Cimetidine
* Ranitidine
* Omeprazole
* Macrolide antibiotics
* Oral contraceptives
 Drug that enhance the metabolism of midazolam
* Rifampin