Midazolam Use by Intranasal Administration (mid-aye-zole-lam)

Children use midazolam as part of their treatment plan to manage seizures. This handout explains how midazolam works and how to give the medicine by way of the nose — a method called intranasal administration. 

Since every child’s needs are different, it is important that you follow the advice from your child’s own doctor, nurse or pharmacist. Speak to them if you have any questions about this medicine. 

Midazolam is a medicine that works on the central nervous system to relax and control seizure activity.

Children often use midazolam (also known as Versed®) to treat prolonged seizures. Midazolam is also used when successive seizures prevent a child from regaining full consciousness. 

The medicine enters the child’s nose and coats the lining of the nasal cavity, which is called the nasal mucosa. The body absorbs the medicine through the nasal membranes. The child does NOT need to sniff it into the lungs.

Supplies you’ll need:

• Midazolam 5 mg/mL
• Vial access device (single-use)
• Luer-lock syringe (1 mL or 3 mL, reusable )
• MAD (mucosal atomization device, reusable for up to 30 days)
• Alcohol wipe (single-use)

Instructions

Before giving your child midazolam, check the nose. If there is a lot of nasal drainage, clear your child’s nose with a tissue. Then follow these instructions:

1. Remove the dust cap from the top of the midazolam vial to expose the rubber seal. 
2. Remove the vial access cannula from its packaging.
3. Attach the vial access cannula to the syringe, then remove the cover of the vial cannula to reveal the sharp tip.
4. Firmly insert the tip of the vial access cannula through the center of the rubber seal on the midazolam vial.
5. Turn the vial upside down while keeping a firm hold on the syringe. Hold the vial with your non-dominant hand. (If you’re right-handed, hold it with your left hand.) Then grasp the end of the syringe and the plunger with your dominant hand.
6. Pull back on the syringe plunger to remove from the vial the amount of medicine required to treat your child—plus an extra 0.1 ml of medicine to account for the empty space in the MAD. Keep the tip of the vial access cannula in the medicine while withdrawing medicine from the vial.
7. When the desired amount of medicine is in the syringe, gently tap the side of the syringe with your finger to dislodge any air bubbles. Eject any air remaining at the top of the syringe into the vial.
8. Remove the syringe from the vial. The blue tip of the vial access cannula will stay in the midazolam vial.
9. Twist to remove the vial access cannula from the syringe. 
10. Attach the MAD to the midazolam syringe. Clean the outside of the MAD with an alcohol wipe if this is a repeat use.
11. Hold your child’s head stable and place the tip of the MAD in one nostril until it’s snug.
12. Aim the syringe up and out. (The top of the MAD should point toward the top of the ear on the same side of the head as that nostril.)
13. Rapidly push the plunger and deliver half of the medicine in the syringe. If you don’t push the plunger fast enough, the medicine will NOT aerosolize. This will likely cause your child to swallow the medicine.
14. Deliver the remaining medicine into the other nostril using the same technique.

For additional assistance, see the Gillette Patient Education video Midazolam, Intranasal Administration

Children appear to tolerate intranasal administration of midazolam well. The most common side effects include:

• Nasal irritation
• Bad taste 
• Cooling/burning sensation in nose or throat
• Other side effects might include drowsiness, dizziness, unsteady gait and confusion. Sleepiness could be a side effect from the medicine or an after-effect of the seizure.
• Some children might have slow or shallow breathing after taking midazolam. Monitor closely if breathing is slow or shallow. Be prepared to call emergency services if necessary.

• Seizure activity continues after giving midazolam.
• The child doesn’t respond or regain consciousness after a seizure stops.
• You’re alarmed by the child’s color or breathing.
• You’re alarmed by the high frequency or severity of the seizures.
• The child has signs of an allergic reaction, such as rash, hives or wheezing.
• Other: _________________________________

• Before giving midazolam, ask your doctor if you should give repeat doses if the medicine leaks from the nostrils after you give it.
• Check the color, clarity and expiration date of midazolam before using it. Midazolam should be clear with no particles floating in the syringe. Do not use it beyond its expiration date.
• Draw up the dose immediately before you use it. After giving it, discard any unused medicine in the syringe or the vial.
• You may reuse the syringe. After each use, clean it with warm water and soap. Allow it to air dry.
• You may reuse the MAD atomizer within 30 days of its first use.
  • After giving midazolam:
    With the syringe you used to dispense the medicine, draw up 1 mL tap water and flush the MAD atomizer.
    Clean the outside of the atomizer with an alcohol wipe.
    Allow the MAD to air dry.
  • Before reusing the MAD to give midazolam:
    Clean the outside of the atomizer with an alcohol wipe.
    Draw up the midazolam as directed and give it to the child.

When 30 days have passed after your first use of the MAD, discard it and begin using a new one. Document your use of midazolam in the seizure diary you received from your Neurology team.

To get more MAD atomization devices, contact your home pharmacy. If your home pharmacy cannot provide or obtain MAD atomizers, you can buy them online from Amazon.com and Mountainside Medical.