Attach this document to your Epilepsy Management Plan if Midazolam is prescribed

Attach this document to your Epilepsy Management Plan if Midazolam is prescribed. This Emergency Plan should be completed by the prescribing doctor in consultation with the person and/or their family or carer. It must be attached to their epilepsy management plan which has been signed by their doctor. The Epilepsy Foundation recommends this plan be reviewed and signed by the person’s doctor annually.

Emergency Medication Management Plan
Midazolam (only to be administered by a trained person)

Midazolam Management Plan for (name):      
Date:      	Date of birth:      
Administration method: BUCCAL  INTRANASAL  Nasal atomiser  or Drip 

1. FIRST DOSE Midazolam

First dose =       mg       ml

For single seizures:  As soon as a       (seizure type) begins  If the       (seizure type) continues longer than       mins

For clusters of seizures:  When       (number)       (seizure type) occur/s within       mins       hrs  Other (please specify):       Special instructions:      

2. SECOND DOSE Midazolam

Second dose =       mg       ml

 Not prescribed OR  If the       (seizure type) continues for another       mins following the first dose  When another       (number)       (seizure type) occur/s within       mins       hrs following the first dose  Other (please specify):       Special instructions:      

3. Maximum number of Midazolam doses to be given in a 24-hour period

Maximum number:      

4. Dial 000 to call the ambulance:

 Prior to administering Midazolam  If the seizure has not stopped       minutes after giving the Midazolam  Other (please specify):      

5. Describe what to do after Midazolam has been administered:

     

6. Prescribing doctor or specialist
Name of doctor:      
Telephone:      	Date:      

Signature

Insert jpeg here

7. Family/carers to complete
Any special instructions e.g. storage of medication, when on outings etc. or people to contact if emergency medication is given.      
Name:      	Relationship:      
Telephone:      	Date:      
Email:      

Signature

Insert jpeg here

Recommended midazolam storage information: Keep out of reach of children Protect from light and store at room temperature (below 25° C) Regularly check the expiry date.