Epilepsy Emergency Medication Presentation Kerrie Kerrigan: Paediatric Epilepsy Nurse Maura Mackie : Paediatric Epilepsy Nurse Carmel McGinn : Adult Epilepsy Nurse Revised June 2016

Administration of Midazolam Oromucosal Solution

Learning Objectives Develop an understanding of Midazolam and how it works Develop an awareness of the Epilepsy emergency medication plan/ care plan Demonstrate the correct procedure for the safe and effective administration of Midazolam Demonstrate appropriate first aid for seizures and knowledge of when to call an ambulance Learning Objectives At the end of the session participants should understand 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 Recognise potential difficulties

Midazolam Oromucosal Solution Used to prevent epileptic seizures developing into status epilepticus First line treatment for prolonged seizures in the community (NICE 2012) Prescribed on a named patient basis by Consultant Paediatrician, Consultant Neurologist, Consultant Psychiatrist or GP Buccal Midazolam Most seizures (75%) in children stop within 5 minutes but occasionally they go on for longer. If a single seizure or group of seizures lasts for 30 minutes or more it is called status epilepticus. Occasionally very prolonged seizures can be damaging to the child. To try and prevent prolonged seizures buccal midazolam is prescribed. Midazolam is similar to diazepam and has been used for decades as a premedication before operations, dental treatments and other procedures. It is short acting, and it will cause sedation, amnesia and relaxation. During the past five years it has been used orally for the emergency treatment of prolonged seizures as an alternative to rectal diazepam which has been used since 1971. This as yet is an unlicensed use but there is good evidence to support its use Epistatus is an oral preparation which is manufactured specifically for this purpose. It is presentlt prescribed on an named patient basis by a consultant paediatrician, consultant neurologist or GP.

How Midazolam Solution 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 within approximately 5 minutes 80% seizures stop within 10 minutes Has a half life of 90 minutes Almost completely cleared from body within 6 hours How buccal Midazolam Works Buccal midazolam is administered in the buccal cavity between the lower gum and cheek it passes across the mucosal membranes and is absorbed into the blood stream, from here it travels directly to the brain were it works at the nerve cell junctions. It reduces brain excitability and suppresses seizure activity. It normally acts after approximately 5 minutes resulting in 80% of seizures stopping within 10 minutes. It has a half life of 90 minutes and is almost completely cleared from body within 6 hours.

Potential Side Effects Common side effects can include: Drowsiness Disorientation Agitation Amnesia Rare side effects can include: Excessive sleepiness Hypotension (low blood pressure) Shallow breathing Side Effects of buccal Midazolam Buccal midazolam may slow down a child’s breathing and can make a child sleepy although very occassionally they will become hyperactive instead. Common side effects include Severe Drowsiness Rare side effects Agitation Restlessness Disorientation Overdose – call 999 Excessive sleepiness Confusion Hypotension (low blood pressure) Shallow breathing Excitation

When is Midazolam Oromucosal Solution 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 Midazolam may be needed When is buccal Midazolam Prescribed? Buccal midazolam will normally be prescribed by the consultant paediatrician, each child who requires buccal midazolam will have an individual emergency epilepsy action plan stating when buccal midazolam should be administered. The following are general guidelines only Prolonged seizures When the seizure lasts longer than normal for the child, the time will be clearly stated on the child’s individual epilepsy action plan Recurring seizures This is when one seizure follows another without the person regaining consciousness Seizure clusters These are seizures that recur over a time with the child regaining consciousness in between, they can continue all day and are not a medical emergency but do require treatment, depending on the time between seizures buccal Midazolam may be needed to stop the seizures Aim is to prevent status epilepticus

Midazolam Solutions are available in different preparations Midazolam Solutions are available in different preparations. It is important the individual has the same brand of midazolam as there are different strengths.

Midazolam Solutions are available in different preparations. Licensed product Salt Strength Products available Buccolam® Yes - for 3 months- 18 years* Midazolam hydrochloride 5mg/1ml Prefilled syringes: 2.5mg/0.5ml 7.5mg/1.5ml, 10mg/2ml Epistatus® No maleate 10mg/1ml 5ml bottle – 10mg/ml 2.5mg/0.25ml 5mg/0.5ml 7.5mg/0.75ml

The Emergency Medication Plan The Epilepsy Emergency Medication plan should include: Individual’s details Usual seizure type requiring emergency medication When to give emergency medication Dose of medication When to call 999 Consent and agreement by appropriate persons When to give Epistatus ® buccal midazolam As stated on child’s individual Epilepsy Action Plan, each child with epilepsy that requires the administration of emergency medication should have an individual action plan which will document at which stage emergency medication is required as this will be different for individual children. Epilepsy Action plan should include Child’s details including photograph 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 medication If and when a second dose can be given When to call paramedic services Contact details for parents/carers

Individual Care Plan Should be available for all staff to view and agreed by: Person with parental responsibility/carer School teacher, respite/day centre manager etc. Doctor/named nurse Copy to be held parent/carer & named nurse Copy must be kept with the emergency medication in a safe place, at room temperature. Updated yearly or more frequently if required by the Named Nurse. Only those staff trained in administration of rescue medication can give this to the individual. A list of these names must be kept by the manager/ principle. In School Epilepsy Action Plan should be in place & available it should be agreed by, Parent/carer, School Principal, Doctor & School Nurse should all have copies of the action plan. It is the responsibility of the parent/carer to ensure all medication is in date and any used medication is replaced. All medication should be sent home at the end of the academic year and replaced at the start of the new school year. The parent/carer & with school nurse, the plan should be updated yearly or more often if required due to change in medication etc. All school staff should be aware of who is responsible for first aid within the school and the school should have a number of staff trained in CPR. If a seizure occurs in school the parent/carer should be informed of seizure ASAP and a record made of the seizure which should include action taken.  

Prior to use of Midazolam Oromucosal Solution Provide appropriate First Aid and Time the seizure. Check the airway and clear any excess saliva away with a tissue (or nasal secretions if using intranasally) Check the individual’s details with their emergency medication plan and product available. Check Expiry date of midazolam solution Check If using midazolam solution that it is clear and there are no white particles. Administration of buccal Midazolam (Epistatus)(Between teeth and gums) Collect all the required equipment, including buccal midazolam & the child’s epilepsy action plan. Check child’s airway if no obvious problem with airway proceed with the administration of buccal midazolam, Check the child's identity with action plan, check buccal midazolam expiry date and ensure the liquid is clear with no white particles. If there is any evidence of white particles the buccal midazolam should be discarded and an ambulance called immediately. If possible the child should be placed on their side, if this is not possible proceed as follows.

Administration of Midazolam using the buccal route Remove cap from prefilled syringe. If using midazolam solution draw up prescribed amount. Insert the syringe into the space between the inside of the cheek and the teeth (Buccal cavity) Slowly administer approx. half the liquid Repeat the process in the opposite side If the individual is lying on their side, insert all the midazolam into the lower side Gently hold lips together for approximately 30 seconds Record time midazolam was administered Place in the recovery position as soon as seizure has stopped Stay with the individual and provide reassurance

Administration of Midazolam using the intranasal route Remove cap from prefilled syringe or if using midazolam solution, draw up prescribed amount. Gently insert the tip of the syringe into the entrance of one nostril. Slowly push plunger, dripping midazolam. Alternate between both nostrils until full dose has been administered as prescribed. Record time midazolam was administered. Place in the recovery position as soon as seizure has stopped. Stay with the individual and provide reassurance.

Recovery Position Recovery Position This slide demonstrates the recovery position

Call an Ambulance if …… You think the individual needs urgent medical assistance If the emergency medication fails to have effect, any breathing difficulties, recovery is slow or an injury is sustained. Do not give a second dose of midazolam unless this has been indicated by a consultant and documented within the EEMP/ careplan. 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 action 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 If you are in doubt or have any concerns at all you should call an ambulance immediately

After Administration Of Midazolam Observe individual: Breathing & colour Response to medication Any injuries Remain with individual & offer reassurance Dispose of equipment safely & wash hands Inform parent/carers as per plan Record all details as per local policy After Care Observe child Breathing & colour, if there are any breathing difficulties following the seizure call an ambulance immediately Progress of seizure, time the seizure and follow guidelines on action plan 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 parent/carer as per action plan

Online resources www.medicinesforchildren.org.uk www.youngepilepsy.org.uk www.epilepsyaction.org.uk www.nice.org.uk The epilepsies: the diagnosis and management of the epilepsies in adults and children in primary and secondary care. NICE guidelines [CG137]

Online resources www.medicinesforchildren.org.uk www.youngepilepsy.org.uk www.epilepsyaction.org.uk www.nice.org.uk The epilepsies: the diagnosis and management of the epilepsies in adults and children in primary and secondary care. NICE guidelines [CG137]