1. Western Health and Social Care Trust Epilepsy Emergency Medication Presentation Kerrie Kerrigan: Paediatric Epilepsy Nurse Maura Mackie : Paediatric Epilepsy Nurse Carmel McGinn : Adult Epilepsy Nurse Revised June 2016

2. Western Health and Social Care Trust Administration of Midazolam Oromucosal Solution

3. Western Health and Social Care Trust 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

4. Western Health and Social Care Trust 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

5. Western Health and Social Care Trust 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

6. Western Health and Social Care Trust 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

7. Western Health and Social Care Trust 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 Aim is to prevent status epilepticus

8. Western Health and Social Care Trust Midazolam Solutions are available in different preparations. It is important the individual has the same brand of midazolam as there are different strengths.

9. Western Health and Social Care Trust Midazolam Solutions are available in different preparations. Licensed product SaltStrengthProducts available Buccolam®Yes - for 3 months- 18 years* Midazolam hydrochloride 5mg/1mlPrefilled syringes: 2.5mg/0.5ml 7.5mg/1.5ml, 5mg/1ml 10mg/2ml Epistatus®NoMidazolam maleate 10mg/1ml5ml bottle – 10mg/ml Prefilled syringes: 2.5mg/0.25ml 5mg/0.5ml 7.5mg/0.75ml 10mg/1ml

10. Western Health and Social Care Trust 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

11. Western Health and Social Care Trust 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.

12. Western Health and Social Care Trust 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.

13. Western Health and Social Care Trust 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

14. Western Health and Social Care Trust 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.

15. Western Health and Social Care Trust Recovery Position

16. Western Health and Social Care Trust 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.

17. Western Health and Social Care Trust 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

18. Western Health and Social Care Trust 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]

19. Western Health and Social Care Trust 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] www.nice.org.uk