FIELD REFERENCE
Full criteria & treatment guidance
Indications
- Active seizures or an explicitly authorized sedation/behavioral/pacing/intubated-patient pathway. Apply indication-specific age, BP and base-contact rules.
Contraindications & local exclusions
- Injectable midazolam label: known drug hypersensitivity or acute narrow-angle glaucoma. Open-angle glaucoma is a separate precaution requiring appropriate treatment.
Precautions
- Respiratory depression, apnea and airway obstruction require continuous monitoring and immediate ventilation capability. Opioids/other CNS depressants increase risk; do not generalize one sedation dose to another indication. The injectable label warns against administration in shock or coma, or acute alcohol intoxication with depressed vital signs, and calls for particular care with uncompensated acute illness/fluid-electrolyte disturbance. These warnings are separate from the label’s formal hypersensitivity/narrow-angle-glaucoma contraindications. Apply the exact OCEMS indication, perfusion and medical-direction limits; do not reinterpret this as a universal seizure-treatment exclusion.
- These are selected safety checks, not a complete prescribing monograph. Product labeling and OCEMS authorization answer different questions; confirm the actual product, patient population and applicable order.
Check before giving
- Be ready to assist ventilation and protect the airway if respiratory depression occurs.
- Adult seizure: contact base if activity continues for 5 minutes after the first IM dose or second IV/IN/IO dose (10 mg total by any route).
Use in OCEMS
- Used in active/recurrent seizures and specific pacing, airway, and behavioral-emergency pathways.
- A seizure dose does not authorize all sedation uses. Select the condition order and its blood-pressure, repeat-dose, and base-contact rules.
Adult / adolescent
| Indication / route | Dose & limits |
|---|---|
| Active seizure — preferred | 10 mg IM once, before attempting new IV/IO access. |
| Seizure — alternative | 5 mg IV/IN/IO if IM cannot be delivered or IV/IO already exists; may repeat once after about 3 minutes for ongoing/recurrent activity. |
| Pacing distress | When systolic BP is above 90: up to 5 mg IV slowly titrated. If IV cannot be obtained, 5 mg IN divided between nostrils; may repeat once after about 3 minutes. |
| Toxic delirium interfering with loading | SO-M-030: 5 mg IV, repeat once in 5 minutes if no improvement; OR 10 mg IM/IN once. For patients older than 65, consider 5 mg IM/IN, repeat once in 5 minutes if needed. |
| Specified airway sedation — I-15 / SO-M-080 | 5 mg IV/IO/IM once for the listed jaw-tone/airway-placement or pre-existing tube-tolerance indication when systolic BP is above 90. Follow the complete airway order. |
Pediatric
- Seizure SO-P-075: 0.2 mg/kg IM once, maximum 10 mg. Alternative when IM cannot be given or IV/IO is already present: 0.1 mg/kg IN/IV/IO, maximum 5 mg; repeat once after 3 minutes for continued/recurrent seizures.
- Base contact is required for all pediatric seizure patients, whether transported or not; pediatric-capable base preferred.
- SO-P-070 toxic delirium interfering with loading: contact base (pediatric-capable preferred) for a possible 0.2 mg/kg IM/IN one-time order, maximum 10 mg. This is not an independent pediatric standing-order sedation dose.
- SO-P-120 pre-existing, correctly positioned ETT that is poorly tolerated: with systolic BP above 80, consider 0.1 mg/kg IV/IO/IM once, maximum 5 mg. Base contact is required. Reassess BP; if it falls below 80, give 20 mL/kg saline, maximum 250 mL, and reassess. Monitor oxygenation/ventilation and do not extubate after sedation under this pathway.
- I-20 marks pediatric cardioversion sedation as base-order treatment; use that specific order rather than another indication’s regimen.
Pediatric weight table — Ongoing seizure — preferred IM route
- SO-P-075 pediatric dose: 0.2 mg/kg IM once.
- 0.2 mg/kg IM once; maximum 10 mg. The IM first-line regimen is distinct from the lower alternate-route dose.
- Base contact is required for every pediatric seizure patient, including non-transported patients. Monitor ventilation and prepare BVM support.
- Calculated examples for the exact weights shown, using the named standing-order/procedure formula. Do not round the patient’s weight to the nearest row. For another weight, calculate from the stated formula and apply the limits. These are not the rounded I-20 weight-band volumes.
- Volumes are mathematical examples rounded to at most three decimal places. Verify the vial concentration, dose, and measurable syringe volume before administration; follow agency preparation/rounding practice.
| Exact weight | Dose — IM once | Volume at 5 mg/mL |
|---|---|---|
| 3 kg | 0.6 mg | 0.12 mL |
| 4 kg | 0.8 mg | 0.16 mL |
| 5 kg | 1 mg | 0.2 mL |
| 6 kg | 1.2 mg | 0.24 mL |
| 8 kg | 1.6 mg | 0.32 mL |
| 10 kg | 2 mg | 0.4 mL |
| 12 kg | 2.4 mg | 0.48 mL |
| 15 kg | 3 mg | 0.6 mL |
| 20 kg | 4 mg | 0.8 mL |
| 25 kg | 5 mg | 1 mL |
| 30 kg | 6 mg | 1.2 mL |
| 35 kg | 7 mg | 1.4 mL |
| 40 kg | 8 mg | 1.6 mL |
| 45 kg | 9 mg | 1.8 mL |
| 50 kg | 10 mg | 2 mL |
| 60 kg | 10 mg | 2 mL |
Pediatric weight table — Ongoing seizure — alternate IN/IV/IO
- SO-P-075 pediatric dose: 0.1 mg/kg IN/IV/IO.
- When IM cannot be delivered or IV/IO is already present: 0.1 mg/kg IN/IV/IO; maximum 5 mg per dose. May repeat once after 3 minutes for continued or recurrent seizure.
- Base contact is required for all pediatric seizure patients. This is not the 0.2 mg/kg IM first-line dose.
- Calculated examples for the exact weights shown, using the named standing-order/procedure formula. Do not round the patient’s weight to the nearest row. For another weight, calculate from the stated formula and apply the limits. These are not the rounded I-20 weight-band volumes.
- Volumes are mathematical examples rounded to at most three decimal places. Verify the vial concentration, dose, and measurable syringe volume before administration; follow agency preparation/rounding practice.
| Exact weight | Dose — IN/IV/IO | Volume at 5 mg/mL |
|---|---|---|
| 3 kg | 0.3 mg | 0.06 mL |
| 4 kg | 0.4 mg | 0.08 mL |
| 5 kg | 0.5 mg | 0.1 mL |
| 6 kg | 0.6 mg | 0.12 mL |
| 8 kg | 0.8 mg | 0.16 mL |
| 10 kg | 1 mg | 0.2 mL |
| 12 kg | 1.2 mg | 0.24 mL |
| 15 kg | 1.5 mg | 0.3 mL |
| 20 kg | 2 mg | 0.4 mL |
| 25 kg | 2.5 mg | 0.5 mL |
| 30 kg | 3 mg | 0.6 mL |
| 35 kg | 3.5 mg | 0.7 mL |
| 40 kg | 4 mg | 0.8 mL |
| 45 kg | 4.5 mg | 0.9 mL |
| 50 kg | 5 mg | 1 mL |
| 60 kg | 5 mg | 1 mL |
Pediatric weight table — Toxic delirium interfering with loading
- SO-P-070 pediatric dose: 0.2 mg/kg IM/IN once.
- Possible base-ordered dose: 0.2 mg/kg IM/IN once, maximum 10 mg, for the specific toxic-delirium/loading indication.
- Base contact and direction are required; a calculated dose does not create independent standing-order sedation authority.
- Calculated examples for the exact weights shown, using the named standing-order/procedure formula. Do not round the patient’s weight to the nearest row. For another weight, calculate from the stated formula and apply the limits. These are not the rounded I-20 weight-band volumes.
- Volumes are mathematical examples rounded to at most three decimal places. Verify the vial concentration, dose, and measurable syringe volume before administration; follow agency preparation/rounding practice.
| Exact weight | Dose — IM/IN once | Volume at 5 mg/mL |
|---|---|---|
| 3 kg | 0.6 mg | 0.12 mL |
| 4 kg | 0.8 mg | 0.16 mL |
| 5 kg | 1 mg | 0.2 mL |
| 6 kg | 1.2 mg | 0.24 mL |
| 8 kg | 1.6 mg | 0.32 mL |
| 10 kg | 2 mg | 0.4 mL |
| 12 kg | 2.4 mg | 0.48 mL |
| 15 kg | 3 mg | 0.6 mL |
| 20 kg | 4 mg | 0.8 mL |
| 25 kg | 5 mg | 1 mL |
| 30 kg | 6 mg | 1.2 mL |
| 35 kg | 7 mg | 1.4 mL |
| 40 kg | 8 mg | 1.6 mL |
| 45 kg | 9 mg | 1.8 mL |
| 50 kg | 10 mg | 2 mL |
| 60 kg | 10 mg | 2 mL |
Pediatric weight table — Poorly tolerated pre-existing ETT
- SO-P-120 pediatric dose: 0.1 mg/kg IV/IO/IM once.
- For a correctly positioned, pre-existing ETT that is poorly tolerated and systolic BP above 80: 0.1 mg/kg IV/IO/IM once; maximum 5 mg.
- Base contact is required. Monitor oxygenation, ventilation, and BP; follow SO-P-120 for hypotension and do not extubate after sedation under this pathway.
- Calculated examples for the exact weights shown, using the named standing-order/procedure formula. Do not round the patient’s weight to the nearest row. For another weight, calculate from the stated formula and apply the limits. These are not the rounded I-20 weight-band volumes.
- Volumes are mathematical examples rounded to at most three decimal places. Verify the vial concentration, dose, and measurable syringe volume before administration; follow agency preparation/rounding practice.
| Exact weight | Dose — IV/IO/IM once | Volume at 5 mg/mL |
|---|---|---|
| 3 kg | 0.3 mg | 0.06 mL |
| 4 kg | 0.4 mg | 0.08 mL |
| 5 kg | 0.5 mg | 0.1 mL |
| 6 kg | 0.6 mg | 0.12 mL |
| 8 kg | 0.8 mg | 0.16 mL |
| 10 kg | 1 mg | 0.2 mL |
| 12 kg | 1.2 mg | 0.24 mL |
| 15 kg | 1.5 mg | 0.3 mL |
| 20 kg | 2 mg | 0.4 mL |
| 25 kg | 2.5 mg | 0.5 mL |
| 30 kg | 3 mg | 0.6 mL |
| 35 kg | 3.5 mg | 0.7 mL |
| 40 kg | 4 mg | 0.8 mL |
| 45 kg | 4.5 mg | 0.9 mL |
| 50 kg | 5 mg | 1 mL |
| 60 kg | 5 mg | 1 mL |
Pediatric weight bands — cardioversion sedation
- I-20 pages 1–10: base hospital order required for cardioversion sedation; the chart lists IN/IV/IM and 5 mg/mL. Confirm the specific order and timing.
- Published band doses below are distinct from seizure and toxic-delirium regimens. Do not extrapolate outside the bands.
| I-20 weight band | Base-ordered dose | Concentration |
|---|---|---|
| 3–5 kg | 0.4 mg | 5 mg/mL |
| 6–7 kg | 0.6 mg | 5 mg/mL |
| 8–9 kg | 0.8 mg | 5 mg/mL |
| 10–11 kg | 1 mg | 5 mg/mL |
| 12–14 kg | 1.2 mg | 5 mg/mL |
| 15–18 kg | 1.5 mg | 5 mg/mL |
| 19–23 kg | 2 mg | 5 mg/mL |
| 24–29 kg | 2.5 mg | 5 mg/mL |
| 30–36 kg | 3.5 mg | 5 mg/mL |
| 37–49 kg | 4.5 mg | 5 mg/mL |
Preparation & reassessment
- Stock is 5 mg/mL; verify route, dose, indication, previous doses, and timing.
- Monitor oxygenation and ventilation. Seizure orders direct BVM assistance when ETCO₂ is 50 mmHg or more.
- I-15 and the full behavioral order differ in some repeat-dose details; this page uses the indication-specific SO-M-030 wording. For airway sedation, open the linked SO-M-080 / SO-P-120 rather than reusing another row.
VISUAL FIELD REFERENCE
Adult seizure: preferred IM versus alternative routes
Adult & pediatric guidance · ALS
Adult seizure indication only. Pacing, airway, toxic-delirium, and pediatric regimens are separate.
Preferred IM
10 mg IM once, before attempting new IV/IO access.
Alternative IV / IN / IO
5 mg IV/IN/IO if IM cannot be delivered or IV/IO already exists; may repeat once after about 3 minutes for ongoing/recurrent activity.
- Be ready to assist ventilation and protect the airway if respiratory depression occurs.
- Adult seizure: contact base if activity continues for 5 minutes after the first IM dose or second IV/IN/IO dose (10 mg total by any route).
Selected checkpoints; read the complete guide for criteria, exclusions, doses, and ongoing care. I-15 · I-20 · SO-M-040 · SO-P-075 · SO-C-020 · SO-M-030 · SO-M-080 · SO-P-120 · SO-P-070
UNDERSTAND THE CARE
Why sedation is not one interchangeable regimen
The guide includes several condition-specific uses with different doses, routes, pressure limits and authorization. State the actual indication before calculating a dose. A seizure regimen cannot establish authority for behavioral sedation, pacing discomfort or treatment of a poorly tolerated existing airway.
Applying the guidance
Confirm prior doses, concentration and elapsed time. The preferred IM seizure pathway differs from the alternate routes and should not be turned into a combined repeat sequence. Maintain airway and ventilation monitoring and document the effect on breathing and consciousness. Pediatric seizure contact remains required even if the child improves or is not transported.
Dose, concentration and volume
Diagram text & teaching checkpoints
- Indication
- Seizure, pacing, airway or behavioral order.
- Eligibility
- Age, pressure and contact requirements.
- Preparation
- Route, concentration and prior doses.
- Response
- Ventilation, consciousness and target symptom.
Sources for this explanation
Original OCMedic teaching synthesis of the references below. Educational expansion updated ; this is not a new independent clinical-review date. Source-specific dates and limitations remain in the full guidance.
- I-15 — Adult / Adolescent Standing Order Drug Guide
- I-20 — Pediatric Medication Volume Dose by Weight
- SO-M-040 — Seizure / Convulsions - Adult / Adolescent
- SO-P-075 — Seizure / Convulsion - Pediatric
- SO-C-020 — Symptomatic Bradycardia - Adult/Adolescent
- SO-M-030 — Psychiatric / Behavioral Emergencies
- SO-M-080 — Sedation for Endotracheal or LMA Intubation - Adult / Adolescent
- SO-P-120 — Pre-Existing Endotracheal Intubation Requiring Sedation - Pediatric
- SO-P-070 — Psychiatric / Behavioral Emergencies - Pediatric
- Product label — MIDAZOLAM HYDROCHLORIDE injection, solution
- Name / formulation reference — Medication name and formulation terminology
Track the seizure sequence across crews
During an active seizure, several clinicians may prepare equipment and medication at the same time. Keep one shared record of route, dose and administration time so a preferred IM regimen is not inadvertently combined with the alternate-route repeat sequence. The condition order, not the availability of a second route, determines the next medication step.
For example, a receiving ALS crew arrives after another clinician has administered midazolam. Before preparing another dose, establish what was actually delivered and whether activity is ongoing, recurrent, or has stopped without a return of consciousness. Include oxygenation, ventilation and any airway assistance in the report. An ambiguous “medication given” should be resolved rather than treated as no prior dose.
Use the adult seizure order’s contact trigger when activity persists, and retain the separate pediatric contact requirements. Pacing, behavioral and airway indications have their own conditions; a dose that was appropriate for seizure control does not create permission for subsequent sedation under another indication.