1. Status of medications commonly used in student emergencies Bette Carr, WI and Carol Tucker, NE

2.  Participants will be able to discuss medications being used in medical emergency situations in the school setting  Participants will be able to identify state consultant colleagues with similar emergency medications issues

3. Discussion today on medications being used in student emergencies FDA approved “Emergency Medications” ◦ Emergency inhalers ◦ Epinephrine auto- injectors ◦ Glucagon ◦ Hydrocortisone (Efcortesol) ◦ Diazepam ◦ Lorazepam ◦ Midazolam (Versed) ◦ Naloxone (EVZIO) ◦ Emergency inhalers ◦ Epinephrine auto- injectors ◦ Glucagon ◦ Hydrocortisone (Efcortesol) ◦ Diazepam ◦ Lorazepam ◦ Midazolam (Versed) ◦ Naloxone (EVZIO)  Epinephrine  Glucagon  Naloxone (EVZIO)  Albuterol  Epinephrine  Glucagon  Naloxone (EVZIO)  Albuterol

4. Considerations:Other considerations: ◦ State statutes, self-carry laws ◦ Local policies ◦ District protocols ◦ Emergency plans ◦ Individualized student orders ◦ State Nurse Practice Act (delegation) ◦ Classroom use ◦ Fieldtrips ◦ After-school activities ◦ Summer School

5.  Wisconsin’s experience ◦ Epinephrine auto-injector 118.2925118.2925  Law allows epi to be given to any student who appears to be having anaphylaxis  Allows stocking  Districts must have a “Plan” written and signed by a physician and posted on the district website  Lacks consistent training  Lacks school nurse involvement

6.  Wisconsin’s experience  Where will the stock be stored?  Will it be taken on fieldtrips?  Will students who currently have their own epi still bring it to school?  Will we train everyone to give epi?  What about a staff member or a visitor who is experiencing anaphylaxis?  How will we notify parents that this is our protocol?

7.  Wisconsin’s experience ◦ Glucagon 118.29118.29  Can be given to any student who is a known diabetic experiencing low blood sugars  Glucagon is rarely stocked  Who will be trained?  Can it be delegated?

8.  Wisconsin’s experience ◦ Just about anything can be given at school and delegated to others…

9.  Nebraska’s experience - Emergency Response to Life-Threatening Asthma or Systemic Allergic Reactions (Anaphylaxis) Protocol (2003) §79305, §79318  Mandated for all schools & Early Childhood Education Centers  Bell to bell  Available for any student/school staff  Protocol must be signed by a physician  Parent/guardian can waive child out of protocol

10.  Nebraska’s experience  EMERGENCY PROTOCOL:  1. CALL 911  2. Summon school nurse if available. If not, summon designated trained, nonmedical staff to implement emergency protocol  3. Check airway patency, breathing, respiratory rate, and pulse  4. Administer medications (EpiPen and albuterol) per standing order  5. Determine cause as quickly as possible  6. Monitor vital signs (pulse, respiration, etc.)  7. Contact parents immediately and physician as soon as possible  8. Any individual treated for symptoms with epinephrine at school will be transferred to medical facility  STANDING ORDERS FOR RESPONSE TO LIFETHREATENING ASTHMA OR ANAPHYLAXIS:  Administer an IM EpiPen Jr. for a child less than 50 pounds or an adult EpiPen for any individual over 50 pounds  Follow with nebulized albuterol (premixed) while awaiting EMS. If not better, may repeat times two, back to back  Administer CPR, if indicated

11.  Nebraska’s experience  No training mandate written into protocol, but is generally carried out annually in schools  Reporting of use of protocol is voluntary  Weaknesses noted in reports: ◦ Protocol is not followed step by step ◦ Parents want to dictate steps of protocol ◦ Rescue squad personnel working in a school are allowed to carry out protocol in their role as school employee but often not as EMS personnel – conflict.

12.  Nebraska’s experience  Not mandated but can be delegated by an RN if deemed non-complex and appropriate for the situation ◦ Most frequent medications questioned for delegation:  Diastat or other seizure medications  Glucagon  Insulin  Giving medication by IV or IM routes

13. Diastat and Versed: Use and Delegation in the School Setting Ann Nichols, NC

14.  Diastat = Valium, Diazepam  Versed = Midazolam

15.  Treatment of status epilepticus  Definition: ◦ A continuous generalized seizure that lasts longer than 30 minutes, OR ◦ Recurrent seizures that occur without full recovery of consciousness between seizures  Sequelae of status epilepticus ◦ Consumes tissue energy stores leading to tissue hypoxia and breakdown ◦ Depletes oxygen and glucose in brain leading to ischemia and brain tissue damage

16. http://dailymed.nlm.nih.gov/dailymed/l ookup.cfm?setid=a84a73a7-8e3a- 4985-8be0-04b3028f5e49 http://dailymed.nlm.nih.gov/dailymed/l ookup.cfm?setid=737361a0-8db1- 4d3c-ba5e-44df3f49fa22  Rectal route; absorption slower due to passage through liver  Benzodiazepine  Onset within 2 minutes, peak concentration 1.5 hours; half-life 46 hours  FDA approved use with manufacturer guidelines  Dose packaged for administration  Intranasal route; direct absorption  Benzodiazepine  Immediate onset, peak concentration 12 minutes; half-life 3 hours  ‘Off-label’ use with no published manufacturer guidelines  Dose packaging for administration not available at this time; in clinical trials

17. In the United States, only rectal diazepam gel, commonly known by the brand name Diastat®, has been approved by the Food and Drug Administration (FDA) for out-of-hospital use for the treatment of acute repetitive seizures or clusters. http://www.epilepsy.com/get-help/managing-your- epilepsy/using-rescue-treatments

18.  http://www.scstatehouse.gov/sess120_2013 -2014/bills/4914.htm http://www.scstatehouse.gov/sess120_2013 -2014/bills/4914.htm  Senators side with SC school nurses on seizure-drug dilemma Senators side with SC school nurses on seizure-drug dilemma

19.  Is being ‘off-label’ an issue?  Is the reaction of the individual student known?  Is the medication pharmacy prepared for administration?  Will administration need to be delegated?  Is delegation of medication administration allowed in the state?  Individual state guidance discussion

20.  Simko, L. C. (2009). Neurologic emergencies. In D. Thomas & L. Bernardo (Eds.), Emergency Nurses Association: Core curriculum for pediatric emergency nursing (2 nd ed., pp. 191- 220). Sudbury, MA: Jones and Bartlett.  Scott RC, Besag FM, Neville BG. Buccal midazolam and rectal diazepam for treatment of prolonged seizures in childhood and adolescence: a randomised trial. Lancet. 1999;353(9153):623-626.  Harbord MG, Kyrkou NE, Kyrkou MR, Kay D, Coulthard KP. Use of intranasal midazolam to treat acute seizures in paediatric community settings. J Paediatr Child Health. 2004;40(9- 10):556-558.  Email communication from Dr. Cindy Devore  http://www.epinet.org.au/downloads/File/EMMP- MZ%20Info.pdf http://www.epinet.org.au/downloads/File/EMMP- MZ%20Info.pdf