Prolonged seizure / status epilepticus in adults (Primary Care)

Epilepsy is one of the most common serious neurological conditions in the world. In Scotland there are approximately 54, 000 people with active epilepsy affecting all ages.

Management of prolonged seizures including status epilepticus.Emergency treatment should be sought or given once a seizure has persisted, or there are a serial of seizures, for five minutes or more. Generalised tonic-clonic status epilepticus is a medical emergency with significant morbidity and mortality which can be exacerbated by inadequate or delayed treatment.

Immediate measuresGenerally once five minutes of seizure activity have passed, treatment should be given as quickly as possible. Initial management of such prolonged seizures should be with benzodiazepines and buccal midazolam is regarded as the first-line treatment option in the community. When given promptly this relatively simple procedure can prevent major disruption to daily life by avoiding emergency hospital attendance.

Buccal midazolam should be prescribed when the risk of status epilepticus is considered to be greater than the risk of administering buccal midazolam. This risk can be generally determined in terms of the frequency of epileptic seizures, their type and severity, including duration.

This guideline is set against a background of buccal midazolam 10mg/mL oromucosal solution being unlicensed for the control of serial and/or prolonged seizures in adults. Epistatus is the midazolam oral solution 10mg/mL preparation of choice in NHS Highland, see: formulary. This is for clinical and safety reasons and to ensure patients and their carers receive the product they have been trained to administer and are familiar with. Therefore, Epistatus should be prescribed by brand name.

The guideline is designed to ensure that midazolam is prescribed and administered only when:

  • The prescriber is aware of the medication’s unlicensed status.
  • The patient has given informed consent or is subject to the Adults with Incapacity (Scotland) Act 2000.
  • The treatment forms part of the patient’s individual care plan
  • The non-healthcare professionals undertaking midazolam administration have received appropriate training as part of their wider epilepsy knowledge and training.
SHARED CARE

As midazolam in this context is ‘unlicensed’ it is expected that the initial recommendation for its use will be made by a consultant neurologist, consultant learning disability psychiatrist, specialist epilepsy nurse or a general practitioner with a special interest in epilepsy. Subsequent prescribing will be undertaken by general practitioners as part of shared care covered by the patient’s care plan and according to the general practitioner’s discretion.

PURPOSE OF GUIDELINE

The purpose of this guideline is to give guidance to staff on the use of buccal midazolam as emergency rescue medication for the treatment of prolonged seizures and convulsive status epilepticus.

WHO THE GUIDELINE APPLIES TO

Administration of buccal midazolam is an emergency procedure, but it does not require a nursing or medical qualification. It can therefore be administered at home, in social care and other non health settings and is a procedure that may safely be undertaken by any worker or carer who has received up to date training in epilepsy and the administration of buccal midazolam. It is expected that all staff who undertake training will carry out the procedure safely and appropriately. Prior agreement to training and implementation of the policy will have been agreed with the employing agency. For employed staff it is the employers’ responsibility to ensure that named individuals are taught to administer buccal midazolam in conjunction with training about epilepsy and that the training is adequate and up to date.

Health professionals will lead on this training. All training provided should be in line with the Joint Epilepsy Council training standards. This guideline applies to: 

  • Social services staff within day and residential services
  • Health services staff within residential and support services
  • Parents and carers where in agreement
  • Private and voluntary sector service providers where in agreement
  • Staff within further or continuing education establishments

Advice:

  • Ideally the person administering the medication should know the individual.
  • If possible two people should be present both for individual support and to facilitate the continued monitoring of the patient while summoning emergency assistance.
  • If the person administering the medication feels unsure, is concerned in any way regarding the person’s seizure(s) or if the use of medication is appropriate they should contact relevant emergency medical services (i.e. 999, NHS24, GP or ambulance service).
  • According to the job description and supervision of the employing agency all non health persons administering buccal midazolam do so as a caring person and not as a medically trained practitioner

Indications for prescribing buccal midazolam

Buccal midazolam must be prescribed by a medical practitioner with clear guidelines giving all relevant details as part of an individual care plan and it should be administered in accordance with the patient’s treatment protocol.

In general, emergency treatment should be given once a seizure has persisted, or there are serial seizures, for more than five minutes. The reason for this is that many seizures spontaneously resolve within 5 minutes, and the administration of midazolam may not, on balance, be of benefit.

However, there is often an important exception to the 5 minute delay and carers may be advised to administer midazolam immediately to patients who are known to suffer prolonged seizures. It should be documented on the patients’ individual care plan when to administer buccal midazolam.

Consent

Wherever possible, consent for administration should be gained in advance from the person receiving the medication.

Where the person does not have capacity to consent (itself subject to formal assessment) a Certificate of Incapacity under Section 47 of the Adults with Incapacity (Scotland) Act 2000 should be completed. A Certificate of Incapacity is required even if the individual has a welfare guardian who can consent to medical treatment on their behalf.

Midazolam Treatment Protocol

The healthcare professional who initiates the treatment of buccal midazolam is responsible for completing the treatment protocol in conjunction with others involved in the care of the  individual.

Treatment Protocol for the Administration of Midazolam 10mg/mL Oromucosal Solution

The treatment protocol should include:

  • A brief description of the individual’s expected seizure patterns including nature of seizures, frequency, duration, pre-disposing factors, recovery and specific first aid instructions
  • Precise instructions for administration
  • When and if a second dose may be given
  • When emergency assistance should be sought
  • Who should be informed and when
  • Awareness of supporting documentation

Prescription
If in agreement with the care plan, the medical practitioner will prescribe midazolam oromucosal solution indicating the dosage required as per the treatment protocol. As midazolam is classed as a Schedule 3 controlled drug the prescription should be written in accordance with the prescription requirements for Schedule 3 controlled drugs.
Epistatus® (Oral Midazolam 10mg/mL solution) Prescription Request

Dosage for the Prevention of Status Epilepticus

  • Adult dose: 10mg, then 10mg after 10 minutes if required (BNF 72)
  • Prescribe Epistatus (midazolam) 10mg/1mL oromucosal solution. Epistatus is the brand of choice in NHS Highland.

Administration of buccal midazolam

  • The normal route of administration will be the buccal route. Using the oral syringe provided, administer, over a period of 2-3 seconds, about half of the prescribed dose to each buccal cavity (cavity between the gums of the lower jaw and the cheek). If the patient is very difficult to control, then administer the whole dose, over a period of 4-5 seconds, to one buccal cavity.
  • There may be an exceptional reason to prefer the intranasal route e.g. excessive salivation. Midazolam should be dripped into each nostril.

Time of onset and duration of action
Initial effects become apparent after approximately 5 minutes. About 80% of seizures are terminated by buccal midazolam within 10 minutes.

A second dose should only be given 10 minutes after the first dose if the patient is still experiencing seizures. This must have been previously agreed and documented in the care plan. 

A person may remain drowsy or significantly sedated for several hours after administration of midazolam.

A second course of treatment must not be administered sooner than 12 hours after the first course. If a second course of treatment is required within a 24 hour period, midazolam should be administered as per the protocol and an ambulance should be phoned.

Monitoring the effects of midazolam
Observe colour and check that the chest and abdomen are moving appropriately with breathing. If there is concern about these, or there is a delay in regaining consciousness seek emergency medical assistance as detailed in individual’s treatment protocol.

Adverse effects of midazolam
People can experience different effects from midazolam:

  • Confusion, drowsiness and appear tired.
  • Agitated, restless and excitement, they may appear more alert and want to move around.
  • Unsteady on their feet

Record of administration
Record the administration of midazolam on the appropriate documentation for your organisation.
If there is a seizure chart in use, record the seizure on the chart.

Storage of midazolam

  • Epistatus (midazolam 10mg/mL oromucosal solution) both the pre-filled syringes and 5mL bottle of solution should be stored below 25°C
  • Epistatus 5mL bottle of solution - the cap on the bottle should be replaced as soon as possible after use. This is because the liquid will evaporate and some of the active ingredient will precipitate, this will appear as white particles in the liquid. The pack must be discarded if the solution is not clear.
  • It is not a legal requirement under the controlled drugs regulations to store midazolam in a locked cupboard. However, midazolam (a benzodiazepine) has significant potential for misuse or abuse therefore; it is recommended that midazolam is stored in a secure location, ideally in a locked cupboard. 

Additional information for healthcare professionals/prescribers

Midazolam interactions
Plasma midazolam concentrations are markedly increased by co-administration of antibacterials (erythromycin, clarithromycin) and antifungals (ketoconazole, itraconazole, and fluconazole). Reduce the midazolam dose by 50% to 75% when these drugs are co-administered.

Midazolam dosage adjustment because of these interactions is more likely to be relevant in a hospital inpatient setting as opposed in a community setting.

Avoid concomitant use of midazolam with HIV protease inhibitors (eg ritonavir) due to the risk of extreme sedation and respiratory depression.

Refer to the current edition of the BNF for midazolam interactions.

Monitoring following administration of buccal midazolam in a hospital inpatient setting
If attended by a nurse/doctor the patient’s vital signs should be monitored every 15 minutes for the first hour, then every 30 minutes for the next three hours.
Monitor:

  • respiratory rate
  • pulse
  • blood pressure
  • temperature
  • skin colour

If a healthcare professional is in attendance in a community setting ensure there is appropriate level of supervision of the patient.

Treatment of overdose
Overdose can be treated with the benzodiazepine antagonist flumazenil which can only be administered intravenously by a doctor. The dose of flumazenil should be checked in the current edition of the BNF.

Flumazenil: Reversal of sedative effects of benzodiazepines in anaesthesia and clinical procedures.

  • BY INTRAVENOUS INFUSION
  • Adult
    • 200 micrograms over 15 seconds,
    • then 100 micrograms every 1 minute if required;
    • maximum 1mg per course

Management of prolonged seizures
Please refer to the Management of prolonged seizures in an inpatient setting for further information.

Trainer Competency

Trainers should have a medical or nursing qualification (RNLD, RGN, RSCN, RMN) and experience of working with people with epilepsy. Trainers must have experience in delivering training to adult students or evidence of teaching practice. Trainers should be able to demonstrate regular updates to knowledge and review of practice

Components of Training for Carers
1. Epilepsy Awareness

  • What is epilepsy
  • Facts about epilepsy
  • Classification of seizures
  • Care Planning
  • First aid management of seizures
  • Treatment and medication of epilepsy
  • Psychosocial issues
  • Monitoring and recording

2. Buccal Midazolam

  • Treatment Protocol
  • Preparation effects and dosages of midazolam
  • Indications for administration - status epilepticus and its prevention, prolonged seizures, serial seizures and seizure clusters
  • Medication administration
  • Potential problems in administration and usage
  • Practical demonstration and practice
  • Recording
  • Awareness of local policies

3. Assessment

  • Question and answers

4. Training Evaluation

Certification
Only where the participant is assessed as having achieved a satisfactory level of learning will a certificate of attendance be issued.

It remains the responsibility of the participant’s employer to monitor and assess workplace competence, as the trainer will be unable to assess individuals in the course of their work.

Training updates should be given every two years. If the participant has not used the procedure in a work situation in one year, an interim refresher course is recommended. It is the responsibility of the employing agency to organise training updates.

References

Abbreviations

Abbreviation Meaning
HIV Human Immunodeficiency Virus
RNLD Registered Nurses Learning Disabilities
RGN Registered General Nurse
RSCN Registered Sick Children's Nurse 
RMN Registered Mental Nurse

Last reviewed: 30 August 2017

Next review: 30 August 2020

Author(s): Clinical Pharmacist - Mental Health, Specialist Epilepsy Nurse, Consultant Learning Disability Nurse.

Version: 4.0

Approved By: Policies, Procedures and Guidelines Subgroup of ADTC

Reviewer Name(s): Clinical Pharmacist

Document Id: TAM432