Emergency Management of Seizures

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Emergency Management of Seizures

• Administration ofEpistatus Midazolam Buccal
  Liquid

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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

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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

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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

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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

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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

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When to give Buccal Midazolam

• Children with epilepsy who require the
  administration of emergency medication should
  have an individual Seizure Management Plan
• As stated on childs 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

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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.

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Administration of Buccal Midazolam (Between
teeth and gums)

• Equipment required
• Prescribed Buccal Midazolam Medication
• Oral syringes included in carton
• Seizure Management Plan
• Tissues
• Check
• Childs airway if no obvious problem with airway
  proceed
• Childs 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

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• 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 childs Seizure Management Plan
• Turn the bottle upright and remove syringe from
  the bottle
• Replace cap on bottle immediately

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If child is seated and has no head support on
their chair Support the childs head by standing
behind them holding their chin Be careful not to
press on the childs throat If childs head is
supported hold chin to keep their head steady

• Gently open the childs mouth by holding their
  chin and gently applying downward pressure on
  their lower lip

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Insert the syringe horizontally into the back of
the childs 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
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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

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Side Effects of Buccal MidazolamEpistatus

• Common side effects
• Severe Drowsiness
• Rare side effects
• Agitation
• Restlessness
• Disorientation

• Overdose call 999
• Excessive sleepiness
• Confusion
• Hypotension (low blood pressure)
• Shallow breathing
• Excitation

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Side Effects of Buccal MidazolamBuccolam

• Common side effects
• Severe Drowsiness
• Nausea Vomiting
• Shallow Breathing

• Rare side effects
• Rash

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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

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Record Keeping

• Record
• Date and time drug was administered on record
  sheet
• In childs 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

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