Midazolam as intranasal or buccal route

Q: What is the dose of Midazolam to give intranasally if no IV or IM route is available?

Answer: if its an emergency and no IV line is established or (let say) if no syringe is available even to give intramuscularly (IM), midazolam can be given intranasally using the injectable solution of 5 mg/mL as a metered spray of 0.1 mL containing 0.5 mg, three to five times per nostril, and can be repeated, to a total dose of 10 mg for adults.

It can also be given buccally as 0.2 mg/kg, or a total of 10 mg altogether, once in adults.

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References:

1. McKee HR, Abou-Khalil B. Outpatient pharmacotherapy and modes of administration for acute repetitive and prolonged seizures. CNS Drugs 2015; 29:55.

2. Dittrich TD, Vock D, Fisch U, et al. Efficacy and Tolerability of Intranasal Midazolam Administration for Antiseizure Treatment in Adults: A Systematic Review. Neurocrit Care 2024; 41:632.

3. Kay L, Merkel N, von Blomberg A, Willems LM, Bauer S, Reif PS, Schubert-Bast S, Rosenow F, Strzelczyk A. Intranasal midazolam as first-line inhospital treatment for status epilepticus: a pharmaco-EEG cohort study. Ann Clin Transl Neurol. 2019 Dec;6(12):2413-2425. doi: 10.1002/acn3.50932. Epub 2019 Nov 4. PMID: 31682078; PMCID: PMC6917318.

4. Armijo JA, Herranz JL, Pena Pardo MA, Adín J. Midazolam intranasal y bucal en el tratamiento de las convulsiones agudas [Intranasal and buccal midazolam in the treatment of acute seizures]. Rev Neurol. 2004 Mar 1-15;38(5):458-68. Spanish. PMID: 15029526.