Benzodiazepine
Pregnancy: D — cleft palate risk (first trimester); neonatal withdrawal
Midazolam
Brand names: Hypnovel
Adult dose
Dose: Sedation: 2–2.5mg IV over 30 sec, titrate 1mg increments. Status epilepticus: 10mg IM / buccal
Route: IV / IM / Buccal / Intranasal
Frequency: PRN or continuous infusion
Max: No fixed maximum — titrate to clinical response
RSI co-induction: 0.03–0.05mg/kg IV. ICU sedation infusion: 0.02–0.1mg/kg/h. Buccal/IN for seizures: 0.5mg/kg max 10mg.
Paediatric dose
Dose: 0.5 mg/kg
Route: Buccal / IM / IN
Frequency: Single dose for status epilepticus
Max: 10mg
Concentration: 5 mg/ml
Dose adjustments
Renal
Reduce dose — active metabolites may accumulate in severe renal impairment.
Hepatic
Reduce dose in severe hepatic impairment.
Paediatric weight-based calculator
Clinical pearls
- Buccal midazolam is first-line for paediatric seizures in the community and pre-hospital: 0.5mg/kg max 10mg. As effective as IV diazepam.
- Intranasal midazolam via MAD: 0.2mg/kg max 10mg — avoids IV access in distressed children.
- In elderly: halve the dose — prolonged sedation and respiratory depression risk.
- Paradoxical agitation: consider in children and elderly. Treat with small dose physostigmine or wait.
Contraindications
- Acute narrow-angle glaucoma
- Severe respiratory failure or apnoea
- Myasthenia gravis
Side effects
- Respiratory depression — potentiated by opioids
- Hypotension
- Paradoxical agitation (particularly in elderly and children)
- Anterograde amnesia (useful for procedural sedation)
- Pain on IV injection
Interactions
- Opioids: potentiated respiratory depression — reduce both doses by ~30%
- Flumazenil: reversal — 0.2mg IV increments to max 1mg
- CYP3A4 inhibitors (erythromycin, fluconazole): markedly increase midazolam levels
- Alcohol: additive CNS depression
Monitoring
- Respiratory rate
- SpO₂
- sedation level (RASS)
- BP
Reference: BNFc; NICE BNF 84; APLS 6th Edition; RCPCH Seizure Guidelines. Verify against your local formulary and the latest BNF before prescribing.
Related
Curated clinical cross-links plus same-class fallbacks.
Calculators
- Ramsay Sedation Scale · Sedation
- Ramsay Sedation Scale · Sedation Assessment
- Benzodiazepine Conversion Calculator · Drug Conversion
- Withdrawal Assessment Tool (WAT-1) for Paediatric Iatrogenic Withdrawal · Critical Care
- CIWA-Ar — Alcohol Withdrawal Scale · Diagnosis
- Brief Alcohol Withdrawal Scale (BAWS) · Alcohol Withdrawal
Drugs
Same class
Pathways
Same specialty
- New-Onset Atrial Fibrillation · ESC 2020 AF Guidelines; NICE NG196
- Hypertensive Emergency · ESC/ESH 2018 Hypertension Guidelines; NICE NG136
- Bradycardia Management · Resuscitation Council UK ABCDE; ESC 2021 Pacing Guidelines
- Ventricular Tachycardia / Fibrillation · Resuscitation Council UK ACLS; ESC 2022 Ventricular Arrhythmia Guidelines
- Syncope Assessment · ESC 2018 Syncope Guidelines; NICE NG109