FIELD REFERENCE
Full criteria & treatment guidance
Key cautions & base contact
- The preferred 10 mg IM regimen is a one-time dose; do not automatically repeat it.
- Anticonvulsant treatment can be followed by respiratory depression. Maintain airway and ventilation support.
When this treatment pathway applies
- Use for an ongoing seizure or repeated seizure activity without return of consciousness. Turn the patient to the side, protect the airway, and suction when necessary.
- Give the preferred IM medication before spending time establishing new vascular access.
Midazolam
- Preferred: 10 mg IM once.
- If IM cannot be delivered, or IV/IO access is already present: 5 mg IV/IN/IO. May repeat once about 3 minutes later for continued or recurrent seizure activity.
- Contact base if seizure continues for 5 minutes after the first IM dose or second IV/IN/IO dose (a total of 10 mg by any route).
Monitor oxygenation, ventilation & glucose
- Use SpO₂ and waveform capnography when available. For room-air SpO₂ below 95%, give high-flow mask oxygen or nasal cannula at 6 L/min as tolerated, watching for aspiration.
- If ETCO₂ is at least 50 mmHg, assist ventilation with BVM.
- Check glucose: treat at or below 60 mg/dL, or at 61–80 mg/dL when hypoglycemia is suspected. Use D10 up to 250 mL IV titrated to response, or glucagon 1 mg IM without IV access. Oral glucose requires consciousness and intact airway reflexes.
Reassess & transport
- Reassess seizure activity, airway protection, ventilation, oxygenation, and mental status after treatment. Document dose/route/timing and glucose.
- Provide ALS transport to the nearest ERC, with base contact as indicated. The IO dextrose exception requires unconsciousness, glucose below 60, failed IV access, and no response to IM glucagon.
VISUAL FIELD REFERENCE
Adult seizure: two distinct midazolam routes
Adult / adolescent · ALS
For ongoing seizure or repeated seizure activity without recovery of consciousness.
- 10 mg · once
Preferred IM pathway
Preferred: 10 mg IM once.
Give the preferred IM medication before spending time establishing new vascular access.
- 5 mg · one repeat allowed
Alternative IV / IN / IO pathway
If IM cannot be delivered, or IV/IO access is already present: 5 mg IV/IN/IO. May repeat once about 3 minutes later for continued or recurrent seizure activity.
- Contact base if seizure continues for 5 minutes after the first IM dose or second IV/IN/IO dose (a total of 10 mg by any route).
- Anticonvulsant treatment can be followed by respiratory depression. Maintain airway and ventilation support.
Selected checkpoints; read the complete guide for criteria, exclusions, doses, and ongoing care. SO-M-040
UNDERSTAND THE CARE
Why route choice and dose history need to be spoken aloud
The preferred IM pathway and alternate-route pathway are deliberately different. State what has already been given, by which route and when before preparing any repeat. Obtaining new vascular access should not displace the preferred initial treatment described in the order.
Applying the guidance
Reassessment separates seizure activity, recovery of consciousness and respiratory function. Keep suction and airway support ready, check glucose and use available waveform capnography as directed. Persistent activity after the listed treatment interval requires base contact. Continued altered consciousness also needs assessment rather than an assumption that every abnormal finding is simply recovery from the seizure.
Putting it together
Teaching example: a second clinician arrives after the preferred IM dose. Announce the route, dose and time before any additional preparation, then assess continued activity and the exact escalation/contact criteria.
Diagram text & teaching checkpoints
- Indication
- Ongoing seizure or recurrence without recovery.
- Route
- Preferred IM versus alternate-route instructions.
- Monitoring
- Airway, breathing, glucose and consciousness.
- Escalation
- Use elapsed time and actual treatment history.
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.
Keep three clocks in the seizure handoff
Track the witnessed seizure timeline, the medication timeline and the recovery timeline separately. Record when activity was first seen, whether it continued or recurred without recovery, and whether the onset time is uncertain. Record each medication dose with its route and administration time. Then describe cessation or persistence of activity, level of consciousness and breathing after treatment.
This prevents a handoff from resetting the medication sequence. An incoming clinician who hears only “still seizing” may not know that the preferred IM dose has already been administered. Say that explicitly, including the elapsed time, before preparing another medication. The alternative-route repeat instructions do not create an extra automatic dose after the one-time IM regimen.
Use the observed treatment history to identify the stated base-contact trigger. At the same time, continue the separate airway, oxygenation, ventilation and glucose assessments. A change in consciousness is meaningful, but it should not replace an account of breathing adequacy or the glucose result. Documenting these parallel observations makes persistent seizure activity, respiratory compromise and the response to glucose treatment distinguishable to the receiving team.
Sources: SO-M-040