Policy and Procedure Manual

VERSED TRAINING
ALS
PROCEDURE:
1. Instructor must obtain course outline, test, and answer sheet from Nor-Cal EMS.
2. Must complete minimum one hour training on Midazolam (Versed), as defined in approved training packet.
3. Successfully perform a return demonstration using Versed with the Skills: Synchronized Cardioversion
protocol.
4. Successfully complete the Versed Post-Test with a score of 90%.
MIDAZOLAM (Versed)
(NOT IN EMT-II SCOPE)
Indications: GOAL: Uncontrolled major motor seizures lasting longer than 2 minutes, status
epilepticus, recurrent seizures without lucid interval, acute anxiety (behavioral
emergencies), or sedative prior to cardioversion or while using transcutaneous pacing.
Dosage: 1. Administer ½ the dose for patients with respiratory disease or age > 60 years.
2. Cardioversion: Premedicate by titrating to effect in 0.5 mg increments over 3-5
minutes, to a MAXIMUM of 2.0 mg slow IVP.
‣ Versed pre-treatment is not indicated in patients under 20 Kg.
3. I.V.: Titrate 2.0 mg slow IV push over 2 minutes, with 2 minute breaks between
increments until seizure stops OR to a MAXIMUM of 10 mg/dose. After 10 minutes, if
recurrent or persistent symptoms, MR X 1 to a MAXIMUM of 20 mg with BHPO.
‣ Do not give whole dose if seizure stops during IVP administration.
4. I.M.: 0.2 mg/kg IM, to a MAXIMUM of 10 mg/dose. After 10 minutes if recurrent or
persistent seizures, MR X 1 to a MAXIMUM of 20 mg with BHPO.
‣
Route of
Administration:
Trade Name:
Classification:
Actions:
Contraindications:
Side Effects:
Special
Considerations:
Slow IV push (1mg/minute), or deep IM.
Versed
Benzodiazepine
Versed is a short acting Benzodiazepine, with duration of action of 2 hours after IV dose.
It produces CNS depression, and easily crosses the blood brain barrier to cause deep
sedation. It is 3 to 4 times as potent as Valium. It has NO analgesic effects.
Pregnancy, patients in shock or coma, known ETOH ingestion, and respiratory
depression.
Respiratory depression and/or arrest are possible if given rapid IVP. Hypotension
and tachycardia, especially in older adults.
‣ Beware that Versed is available in 2 strengths. Provider agencies should stock 5
mg/ml strength (2 ml = 10 mg vial or syringe).
‣ Have airway equipment ready, and watch for possible respiratory depression/arrest.
‣ The effects of Midazolam may be potentiated when combined with the use of ETOH
or other CNS depressants.
‣ BHPO in patients with respiratory diseases such as COPD and CHF.
‣ (MICN ONLY!!) Flumazenil (Mazicon) reverses the side effects of Versed; may
administer if approved for use by base hospital and Nor-Cal EMS.
‣ It is not possible to “observe” amnesic effect vs. sedation effect.
Policy & Procedure Manual – Educational Programs Module
Originated: January 1, 2002
Last Revision: March 1, 2004
Versed Training - #501, Page 1 of 4

VERSED TRAINING, cont.
ONGOING ASSESSMENT:
1. General - Respiratory depression and apnea must be identified promptly with visual inspection, and careful
continuous observation to allow prompt detection and appropriate intervention for emesis, hypersalivation,
airway malposition, etc.
2. Pulmonary Ventilation - Sedative medications depress ventilatory drive and may decrease airway patency
by relaxation of oral/pharyngeal soft tissue. Pulmonary ventilation should be monitored to provide the
earliest indication of inadequate air exchange. Observation of spontaneous respiratory activity or continuous
auscultation of breath sounds usually can monitor ventilatory function.
3. Oxygenation – Pulse oximetry must be used on a continuous basis to provide the earliest warning of
hypoxemia. There may be a delay of a minute or more between the onset of apnea and the first decrease in
oximeter reading, particularly if the patient is breathing supplemental oxygen. Therefore, pulse oximetry
should never replace direct observation of the patient.
4. Hemodynamics – Sedation medications may directly depress cardiac function. In addition, they may impair
the ability of the autonomic nervous system to compensate for hemodynamic changes. Monitoring of blood
pressure should be monitored at frequent intervals, with continuous cardiac monitoring.
5. Level of Consciousness – Patients whose only response is to withdrawal from painful stimuli are very
sedated, approaching a state of deep sedation, and special care must be taken to ensure the patency of the
airway, adequacy of pulmonary ventilation, and hemodynamic stability. Deep sedation is not the desired
effect in the prehospital setting. Immediate action is needed before patient may loose independent airway
control and stops breathing.
EQUIPMENT: Assure the following equipment is readily available prior to medication administration:
1. Continuous pulse oximetry.
2. BVM device (ambu bag with seal easy mask).
3. Cardiac monitor.
4. Non-invasive blood pressure monitor.
5. Suction equipment with assorted catheters, including yaunkers.
6. Assure age specific devices available per the ALS Standard Drug and Equipment protocol.
MANAGEMENT OF COMPLICATIONS: Since it is impossible for the Paramedic to observe the amnesic
effect of Midazolam, and the possibility of sedation/deep sedation exists, it is imperative to understand how to
deal with these and other undesired effects.
1. Possible Allergic Reactions - Anaphylaxis, rash, hives redness, edema, wheezing, stridor, itching, edema,
hypotension, syncope, respiratory distress, sneezing, apnea. See Allergic Reaction/Anaphylaxis protocol.
2. Bradycardia – Always consider a patient’s baseline heart rate when diagnosing bradycardia. Patients with
ischemic heart disease are at higher risk for ventricular dysrhythmias. Bradycardia is a heart rate < 60 BPM
and treatment is recommended if patient is symptomatic. See ACLS: Bradycardia.
3. Hypoventilation and hypoxemia – Small decreases in oxygen saturation correlate to large decreases in
arterial oxygen levels. A decrease in oxygen saturation from pulse ox of 95% to 90% correlates to a
decrease in arterial oxygenation from 80 to 60 mmHg (normal is 80-100 mmHg). Any drop in oxygen
saturation needs immediate investigation. Hypoventilation occurs when the patient enters a deep state of
sedation or when sedation causes a decrease in work of breathing in a patient who is in a compensated
respiratory state. Obstruction of airway by secretions or foreign bodies (tongue, loose teeth, denture, or
airway adjuncts). When patients’ hypoventilate, their ability to exchange oxygen and carbon dioxide
decreases. Oxygen intake decreases, causing hypoxemia. Carbon dioxide exhalation decreases, causing
hypercarbia. Hypoxemia causes decreased oxygen delivery to the tissues, causing tissue hypoxia. Cardiac
muscle becomes irritable and likely to generate dysrhythmias and ectopic beats when hypoxic. Reduction in
respiratory rate (bradypnea): 10 years to Adults, a respiratory rate of less than 10/min. Respiratory
depression must be assessed and treated quickly, because of the patient’s high risk for further deterioration.
Contact base hospital immediately and follow the Inadequate Oxygenation/ Ventilation algorithm.
VERSED TRAINING, cont.
Policy & Procedure Manual – Educational Programs Module
Originated: January 1, 2002
Last Revision: March 1, 2004
Versed Training - #501, Page 2 of 4

ASSOCIATED ALS PROTOCOLS FOR VERSED TRAINING: It is recommended to review the
following protocols, specifically where Versed is administered:
6. ACLS: Electrical Cardioversion
7. SKILLS: Synchronized Cardioversion – Biennial Competency
8. Altered Neurological Function (Non)Traumatic)
9. Pediatric Formulary
10. Pediatric Tachycardia
11. Pediatric Altered Neurological Function
12. Pediatric Overdose: Poisoning
13. Pediatric Overdose: Organophosphate
VERSED TRAINING, cont.
Policy & Procedure Manual – Educational Programs Module
Originated: January 1, 2002
Last Revision: March 1, 2004
Versed Training - #501, Page 3 of 4

INADEQUATE OXYGENATION/VENTILATION ALGORITHM:
INADEQUATE VENTILATION
(by observation/auscultation) or hypoxemia (by pulse oximetry) is identified
Is spontaneous
Breathing
present?
Instruct patient to take a “Deep Breath.”
If no response, apply physical stimulus.
Repeat instructions to take a “Deep Breath.”
YES
BREATHING?
NO
MICN ONLY!!!
CONSIDER
REVERSAL
AGENTS
APPLY supplemental oxygen.
CHECK airway reflexes.
ASSESS breath sounds.
ESTABLISH an airway:
Jaw thrust
Nasal/Oral airway
Problem
Resolved?
NO
REASSES
SClinical
status, is
patient
breathing?
YES
CONTINUE supplemental oxygen.
MONITOR vital signs and ventilation.
YES
NO
ASSESS ventilatory adequacy, level of
consciousness, vital signs, skin color,
lung sounds, airway reflexes, pulse
oximetry.
APPLY positive pressure
ventilation with BVM.
CONSIDER intubation.
CODE
BLUE?!
Policy & Procedure Manual – Educational Programs Module
Originated: January 1, 2002
Last Revision: March 1, 2004
Versed Training - #501, Page 4 of 4