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
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.