Midazolam Use in the Emergency Department 三軍總醫院 Conscious sedation



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tarix21.04.2017
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Midazolam Use in the Emergency Department

  • 三軍總醫院


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.



Conscious sedation (Procedural sedation) in the ED

  • Alleviate anxiety

  • Provide amnesia

  • * Pain : not adequately addressed.



Clinical indications for sedation in the ED

  • Orthopedic reduction.

  • Cardioversion.

  • Wound debridement.

  • Pediatric laceration repair.

  • Lumbar puncture.

  • Abscess incision and drainage.



Drugs for conscious sedation

  • Benzodiazepines: Midazolam

  • Opioids: Fentanyl, Meperidine.

  • Hypnotics agents: Barbiturates, Propofol, Ketamine.



Midazolam

  • Rapid onset. (i.v. 1-3 min, i.m. 5 min)

  • Shorter duration.

  • No injection pain.

  • Existence of antagonist- Flumazenil



Pharmacology of midazolam

  • Anxiolytic

  • Muscle relaxant

  • Anticonvulsant

  • Sedative

  • Hypnotic

  • Amnesic





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.



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.



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.



Equipment for conscious sedation monitoring

  • Oxygen and mask.

  • Pulse oximeter.

  • ECG monitor.

  • Suction.

  • Orotracheal tube.

  • Laryngoscope.

  • Ambu bag.



Summary

  • Midazolam: Safe for sedation in ED

  • “Titration”: the principle of administration of midazolam and flumazenil.



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.



Drug interaction

  • Drugs that inhibit the metabolism of midazolam

  • * Cimetidine

  • * Ranitidine

  • * Omeprazole

  • * Macrolide antibiotics

  • * Oral contraceptives

  • Drug that enhance the metabolism of midazolam

  • * Rifampin




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