Emergency Management of Seizures

1. Emergency Management of Seizures Administration ofEpistatus ® Midazolam Buccal Liquid

2. Learning Objectives To Develop an understanding of What Buccal Midazolam is and how it works When Buccal Midazolam is used in epilepsy The emergency action plan for epilepsy Demonstrate and describe the correct procedure for the safe and effective administration of Buccal Midazolam To recognise potential difficulties

3. Buccal Midazolam Used to prevent epileptic seizures developing into status epilepticus Status epilepticus An epileptic seizure or series of seizures that continues for 30 minutes or more An alternative to rectal diazepam Prescribed on a named patient basis by consultant paediatrician, consultant neurologist or GP

4. How Buccal Midazolam Works Passes across the mucosal membranes and is absorbed into the blood stream Travels directly to the brain Works at nerve cell junctions Reduces brain excitability Suppresses seizure activity Acts after approximately 5 minutes 80% seizures stop within 10 minutes Has a half life of 90 minutes Almost completely cleared from body within 6 hours

5. Side Effects of Buccal Midazolam Common side effects Severe Drowsiness Rare side effects Agitation Restlessness Disorientation Overdose – call 999 Excessive sleepiness Confusion Hypotension (low blood pressure) Shallow breathing Excitation

6. When is Buccal Midazolam Prescribed Prolonged seizures When seizure lasts longer than normal for the person Recurring seizures When one seizure follows another without the person regaining consciousness Seizure clusters Recurring seizures over a time with person regaining consciousness in between Can continue all day Not a medical emergency but requires treatment Depending on time between seizures buccal Midazolam may be needed Aim is to prevent Status Epilepticus

7. When to giveEpistatus ® buccal midazolam Children with epilepsy who require the administration of emergency medication should have an individual Seizure Management Plan As stated on child’s individual Seizure Management Plan Action plan should include Usual seizure pattern – what happens before, during and after a seizure Known triggers Individual emergency protocol for child When to give emergency medication Dose of Buccal Midazolam medication If and when a second dose can be given When to call paramedic services

8. Storage of Buccal Midazolam Store at room temperature Replace cap immediately otherwise the liquid will evaporate and some of the sweetener will precipitate The liquid will become milky Pack must be discarded if the liquid is not clear Buccal Midazolam should be stored with the Seizure Management Plan.

9. Equipment required Prescribed Buccal Midazolam Medication Oral syringes included in carton Seizure Management Plan Tissues Check Child’s airway if no obvious problem with airway proceed Child’s identity, medication and drug dosage with Seizure Management Plan Expiry date of Buccal Midazolam Liquid is clear with no white particles If possible place the child on their side Administration of Buccal Midazolam (Epistatus)(Between teeth and gums)

10. Remove the bottle and syringe from the box • Hold the bottle upright • Remove the child resistant cap by pushing down and turning anti-clockwise • Insert the tip of the syringe into the hole in the white plastic bottle adaptor • Hold the bottle and syringe securely and tip upside down allowing the gel to run to the top of the bottle • Pull the syringe out slowly until the syringe contains the prescribed amount of Buccal Midazolam as per child’s Seizure Management Plan • Turn the bottle upright and remove syringe from the bottle • Replace cap on bottle immediately

11. If child is seated and has no head support on their chair • Support the child’s head by standing behind them holding their chin • Be careful not to press on the child’s throat • If child’s head is supported hold chin to keep their head steady • Gently open the child’s mouth by holding their chin and gently applying downward pressure on their lower lip

12. Insert the syringe horizontally into the back of the child’s lower gums and cheek • To locate the Buccal cavity gently tilt the syringe upwards • Very slowly administer half the liquid • Repeat the process in the opposite cavity • If the child is lying on their side, insert all the buccal midazolam into the lower side. • Gentle hold lips shut for approximately 30 seconds • Record time Buccal Midazolam was administered • Place in the recovery position as soon as possible If there is excess salivation Buccal Midazolam can be administered into each nostril

14. After Care Observe child Breathing & colour Progress of seizure Response to medication Initial effect in approximately 5 minutes 80% of seizures stop within 10 minutes Any injuries Remain with child & reassure Dispose of equipment safely Wash hands Inform parents/carers as per seizure management plan

15. Call an Ambulance if …… You think the pupil needs urgent medical assistance The seizure does not stop following administration of all prescribed emergency medication as per seizure management plan The child does not regain consciousness following the seizure It is the first time Buccal Midazolam has been administered to child Any difficulty in breathing following seizure Child is injured during the seizure Indicated on Action Plan

16. Record Keeping Record Date and time drug was administered on record sheet In child’s notes & home diary Why drug was given How long seizure lasted How many seizures occurred Details of what occurred before, during and after seizure After the incident a debriefing session should take place with all staff involved