1. Buccal/ Nasal Midazolam
Seizure Rescue Medication
Training
LD ESN June 2009

2. 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
LD ESN June 2009

3. 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
LD ESN June 2009

4. 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
LD ESN June 2009

5. 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
LD ESN June 2009

6. 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
LD ESN June 2009

7. 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
LD ESN June 2009

8. 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.
LD ESN June 2009

9. 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
LD ESN June 2009

10. 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
LD ESN June 2009

11. GP’s and specialists are willing to prescribe
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
LD ESN June 2009

12. 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
LD ESN June 2009

13. 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
LD ESN June 2009

14. 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
LD ESN June 2009

15. Place syringe at the entrance to one nostril
Nasal Route
Place syringe at the entrance to one nostril
Slowly push plunger, dripping midazolam
Alternate between both nostrils
Replace cap on bottle
LD ESN June 2009

16. Management of Midazolam
Storage
Shelf life
Recording amount
Recording use
Recording outcome in the epilepsy care plan
LD ESN June 2009

17. Ethical Issues Duty Of Care Consent Invasive Fear of Legal Action
LD ESN June 2009

18. 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
LD ESN June 2009

19. Joint Epilepsy Council for the UK and Ireland
“When Midazolam is prescribed there should be no unreasonable barriers to its use”
LD ESN June 2009