How the dose is calculated
Midazolam is dosed as a single mg/kg amount per administration. The buccal/intranasal route is commonly used for community seizure rescue at a higher mg/kg dose; the IV route is titrated more cautiously for status epilepticus or procedural sedation in a monitored setting.
Typical dosing by indication
| Indication | Dose | Frequency | Max |
|---|---|---|---|
| Buccal/intranasal | 0.3 mg/kg | may repeat once at 10 min | 10 mg per dose |
| IV | 0.1 mg/kg | titrate, repeat q5min prn | 5 mg per dose |
Clinical use
- Buccal or intranasal midazolam is widely used as a community seizure-rescue medication, avoiding the social and practical difficulties of rectal diazepam administration outside a healthcare setting.
- The concentrated intranasal/buccal formulation (10 mg/mL) is specifically designed to deliver an adequate dose in a small volume — do not substitute the standard 5 mg/mL injectable solution for buccal/intranasal use where a smaller volume is needed.
- IV midazolam for status epilepticus or procedural sedation is titrated slowly to effect, with continuous monitoring for respiratory depression, particularly when combined with opioids or other sedatives.
- Midazolam's shorter duration of action compared to diazepam can mean more frequent redosing is needed to maintain seizure control or sedation.
Frequently asked questions
Why is buccal/intranasal midazolam preferred over rectal diazepam?
It's socially more acceptable and practical to administer in schools, community, and pre-hospital settings, without needing to undress the patient, while achieving comparable effectiveness for seizure rescue.
What is midazolam used for?
Midazolam is used as a community seizure-rescue medication (buccal/intranasal) and, via the IV route in hospital, for status epilepticus and procedural sedation.
Can the injectable midazolam solution be used intranasally?
The concentrated 10 mg/mL formulation is specifically designed for buccal/intranasal use in a small volume — using the more dilute 5 mg/mL injectable solution instead would require a larger, less practical volume for that route.
Does midazolam need monitoring after it's given?
Yes — respiratory depression is a risk, especially with IV use or when combined with other sedating drugs, so oxygen saturation and breathing should be monitored after each dose.
References
- International League Against Epilepsy (ILAE). Guidelines for the Management of Convulsive Status Epilepticus.
- British National Formulary for Children (BNFc) — Midazolam.
- American Academy of Pediatrics. Guidelines for Monitoring and Management of Pediatric Procedural Sedation.