Buccal/ Nasal Midazolam Seizure Rescue Medication

Buccal/ Nasal Midazolam

• Seizure Rescue Medication

• Training

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

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 commonly Epistatus

• 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

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

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

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

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

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.

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

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

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

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

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

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

Nasal Route

• Place syringe at the entrance to one nostril

• Slowly push plunger, dripping midazolam

• Alternate between both nostrils

• Replace cap on bottle

Management of Midazolam

• Storage

• Shelf life

• Recording amount

• Recording use

• Recording outcome in the epilepsy care plan

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

Joint Epilepsy Council for the UK and Ireland

• “When Midazolam is prescribed there should be no unreasonable barriers to its use”