Buccal/ Nasal Midazolam

1. Buccal/ Nasal Midazolam Seizure Rescue Medication Training LD ESN June 2009

2. Learning Outcomes You will • Be able to recognise prolonged and serial seizures and respond appropriately • Be able to describe the appropriate conditions required to participate in the administration • Be able to demonstrate through simulation the procedure for administering midazolam LD ESN June 2009

3. What is Midazolam? • Is the pharmaceutical name for this drug, from a family of similar drugs called Benzodiazepines • Other names and formulations for Midazolam include Hypnoval and most commonlyEpistatus • Midazolam is licensed as a sedative it is used in hospitals and clinics before clinical procedures. • In the brain it acts as an effective anti epileptic LD ESN June 2009

4. How was Midazolam developed for community use? • Used as a sedative since 1988? • Used in epilepsy since 1997 • Community use developed in paediatric services/ school age children • Gradual introduction in to adult learning disability • Now the most common form of rescue medication • Recommendations for use in NICE and Paed SIGN, included in most formularies LD ESN June 2009

5. How Does Midazolam Work? • Slowly dripped into nasal/buccal cavity • Absorbed through mucosal skin surfaces • Good blood supply to these areas • Travels via the heart and lungs to the brain • Boosts GABA and dampens down seizure activity LD ESN June 2009

6. Effects of Midazolam • Effective anti epileptic within 10 minutes • Can cause sedation/ severe drowsiness • Recovery rates vary • May irritate nasal passages or cause discomfort to gums • Can (rarely) depress breathing • Can (rarely) cause restlessness/ hyper activity • Over use can cause dependence and be ineffective LD ESN June 2009

7. Indications for use • Midazolam is prescribed where the individual has a history of seizures which are prolonged/ serial , most commonly with people who also have LD • Prolonged seizures are around 5 minutes for tonic clonic seizures. Serial seizures occur one after the other with no recovery between LD ESN June 2009

8. Indications for Use 2. • Midazolam is used as a rescue medication early on in the development of the seizure/s to try to prevent status epilepticus, improve outcome from seizure/s and quality of life • Status Epilepticus is a continued state of seizure lasting for 30 minutes. LD ESN June 2009

9. Convulsive Status Epilepticus • A continuous Tonic Clonic seizure or repeated Tonic Clonic seizures lasting 30 minutes • This can be life threatening and requires medical attention LD ESN June 2009

10. Non Convulsive Status Epilepticus Any seizure can develop into status • Complex partial status relatively common in Learning disability. • This condition can be difficult to diagnose, consciousness is often impaired but not lost completely. • Can continue for long periods. • Can adversely affect health in vulnerable people LD ESN June 2009

11. General Information • Most people with LD requiring rescue med are prescribed midazolam (Epistatus) • GP’s and specialists are willing to prescribe • Carers and relatives need instruction in it’s use • For paid care staff recognised training and a signed protocol are essential LD ESN June 2009

12. Midazolam Liquid • Sugar free • Child proof bottle • 4x1ml oral syringes • 10mg in 1ml of liquid • Adult dose usually 10mg • Can be given while sitting upright • Epistatus not Licensed at all LD ESN June 2009

13. Considerations about method of administration Buccal versus Nasal Route • Type of Seizure • Level of consciousness • Positioning of the individual • How much saliva is produced • Preparation for giving LD ESN June 2009

14. Buccal Route (side of mouth) • Insert syringe into the mouth, between the lower gum and cheek • Point syringe to back of mouth on insertion then angle downwards into the buccal cavity • Slowly push syringe down until empty • Replace cap on bottle LD ESN June 2009

15. Nasal Route • Place syringe at the entrance to one nostril • Slowly push plunger, dripping midazolam • Alternate between both nostrils • Replace cap on bottle LD ESN June 2009

16. Management of Midazolam • Storage • Shelf life • Recording amount • Recording use • Recording outcome in the epilepsy care plan LD ESN June 2009

17. Ethical Issues • Duty Of Care • Consent • Invasive • Fear of Legal Action LD ESN June 2009

18. Why do we use midazolam in the community?summary • We know that early treatment for seizures is more effective preventing SE • We may be preventing brain damage even death • We may be preventing other poor health (e.g aspiration infection) • Prevents disruption, decreasing hospitalisation • Best outcomes,individual, family and carer LD ESN June 2009

19. Joint Epilepsy Council for the UK and Ireland “When Midazolam is prescribed there should be no unreasonable barriers to its use” LD ESN June 2009