Buccal/ Nasal Midazolam Seizure Rescue Medication

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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”

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