Prolonged Epileptic Seizures Treatment Guidelines
(Administration of buccal midazolam & rectal diazepam for
adults who have prolonged epileptic seizures)
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Version 1
Approved by Drugs & Therapeutics Group: April 2016
Date of next review: April 2018
Contents
1. Scope
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2. Background
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3. Controlled Drug Status
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4. Buccal Midazolam
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4.1. Buccal / Oromucosal Midazolam Preparations
4.2. Buccolam®: Licensed Indication/Use
4.3. Epistatus®: Licensed Indication/Use
4.4. Administration of Buccal Midazolam
4.5. Supply of Buccal Midazolam
4.6. Storage of Buccal Midazolam
4.7. Disposal of Buccal Midazolam
4.8. Nurses authority to carry stock buccal midazolam
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5. Rectal Diazepam
5.1. Rectal Diazepam Preparations
5.2. Rectal Diazepam Licensed Indication/Use
5.2.1 Use in the management of patients with a diagnosis of epilepsy
5.2.2 Use in adult detox patients without a diagnosis of epilepsy
5.3. Administration of Rectal Diazepam
5.4. Supply of Rectal Diazepam
5.5. Storage of Rectal Diazepam
5.6. Disposal of Rectal Diazepam
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6. Prescribing
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7. Authorisation to Administer
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8. Documentation
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9. Reporting Adverse Events
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10. Duties & Responsibilities
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11. Training
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12. References & Further Information
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Appendices
Appendix 1: Individual Epilepsy Care Plan
Appendix 2: Administration Technique for Buccolam (Buccal Midazolam Prefilled
Syringe)
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Appendix 3: Administration Technique for Buccal Midazolam Supplied in a Bottle with
Non Prefilled Oral Syringes, e.g. Epistatus
Appendix 4: Administration Technique for Rectal Diazepam
Appendix 5: Information for nurses and carers on the management of seizures in adults
with rectal diazepam without a diagnosis of epilepsy
Appendix 6: Easy Read Buccal Midazolam Leaflet
Appendix 7: Easy Read Rectal Diazepam Leaflet
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1. SCOPE
1.1 This guideline has been developed to enable nurses, trained healthcare professionals and
carers to administer buccal midazolam preparations or rectal diazepam in an emergency for the
medical treatment of status epilepticus.
1.2 This guideline is applicable to:
Sussex Partnership staff working across the Trust who administer buccal midazolam or rectal
diazepam as indicated for the emergency treatment of status epilepticus in inpatient & community
settings.
Sussex Partnership staff that provide training to non Sussex Partnership staff for the
administration of buccal midazolam and rectal diazepam in non NHS establishments, (e.g. relatives
& carers, day centres, care homes), in the community under a care plan.
1.3 The guideline outlines the prescribing, supply, storage and administration of buccal midazolam
and rectal diazepam. The administration of buccal midazolam and rectal diazepam should be given
in accordance with this document.
2. BACKGROUND
2.1 Midazolam is a short acting benzodiazepine. Pharmacokinetic data following administration of
buccal midazolam in adults shows good bioavailability and maximum peak plasma concentration
within 30 minutes. It comes in a sugar free liquid form, which is administered to the buccal cavity
(between the lower cheek and gum in the mouth). It is usually the preferred option for the treatment
of prolonged seizures in Learning Disability services.
2.2 Midazolam administered by the buccal route is indicated for the emergency treatment of status
epilepticus. It is the first-line treatment in children, young people and adults with prolonged or
repeated seizures in a community setting. This is recommended by the Resuscitation Council (UK),
NICE Epilepsy guidelines, National Epilepsy organisations and the Royal College of Paediatrics and
Child Health.
2.3 Diazepam is a long acting benzodiazepine. As a rectal solution it is prescribed to manage status
epilepticus. It is given rectally in the case of status epilepticus to ensure fast absorption of diazepam
without the need for a needle. Rectal diazepam is currently considered a second-line option for
treating prolonged seizures in Learning Disability settings, unless chosen by the patient, due to
considerations around potential use of a rectal product in a community setting & the dignity of the
client. However, it remains the first-line option in substance misuse / alcohol withdrawal settings.
3. CONTROLLED DRUG STATUS
3.1 Midazolam: Midazolam is a Schedule 3 Controlled Drug (CD) and its use is governed by the
Misuse of Drugs Regulations 2001. Legally it is exempt from storage and recording regulations,
although is treated as a full Controlled Drug on Trust inpatient units. This guideline should be viewed
in conjunction with the Medicines Code which offers further advice on CDs & the use of unlicensed
medication or off label medicines use, (i.e. licensed medication but not being used for the intended
indication or patient population).
3.2 Midazolam Prescription Writing Requirements: To be valid, on top of the normal prescription
requirements for prescription only medicines, prescriptions for Schedule 2 and 3 Controlled Drugs
must meet certain prescription writing requirements.
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In summary, buccal midazolam prescriptions must contain the dose, form, strength (where
appropriate) and a total quantity of the preparation in both words and figures.
The BNF and the Medicines Ethics and Practice Guide, published annually by the Royal
Pharmaceutical Society, provide more detailed guidance on these requirements.
3.3 Diazepam Prescription Writing Requirements: Rectal diazepam is a CD Schedule 4 part I:
CD Benz POM. It is exempt from storage, recording and prescription writing regulations over and
above those that apply to all prescription only medications (POM). This guideline should be viewed
in conjunction with the Medicines Code which offers further advice on CDs & the use of unlicensed
medication or off label (licenced but not the indication or patient population that the medication is
being used for) medicines use.
4. BUCCAL MIDAZOLAM
4.1 BUCCAL/OROMUCOSAL MIDAZOLAM PREPARATIONS
The term buccal midazolam will be used throughout this guideline to mean all the different buccal
midazolam preparations available. Buccal midazolam is also known as midazolam oromucosal
solution. It is usually the preferred option for the treatment of prolonged seizures in Learning
Disability services.
There are two main buccal midazolam products in common use:
1. Buccolam®: a pre-filled oral syringe containing 10 mg midazolam (as hydrochloride) in 2 ml
solution. This medication is available in other doses designed for children under 10 years old.
The product has a shelf-life of up to 18 months.
2. Epistatus®: A sugar-free buccal liquid containing 10mg midazolam base in 1ml of sugar
free syrup. The product has a shelf life of up to two years and is presented with oral syringes.
Each pack contains sufficient for four doses.
It is important to note Epistatus® is twice as strong as Buccolam®.
This has potential for administration errors, particularly if switching between brands.
4.2. BUCCOLAM® LICENSED INDICATION/USE
4.2.1 Buccolam® was the first buccal midazolam licensed product. It has a paediatric licence to treat
prolonged, acute convulsive seizures from the ages of 3 months up to and including 17 years. It is
supplied as a single-dose, age-specific, pre-filled needle free oral syringe. Each syringe is colour
coded and contains the prescribed dose for a particular age range. All preparations contain 5mg of
midazolam in 1ml, but are presented in differing volumes. (See below).
4.2.2 Recent NPSA alerts highlighted dosing and administration errors as a result of the wrong type
of syringe used. Care should be taken to ensure that the correct dose is used. The different
Buccolam preparations are outlined below:
Age of patient
10 years and over
(adult dose-unlicenced)
5-9 years
1-4 years
3 months-12 months
Dose of buccal
midazolam
10mg in 2ml
Colour code of Buccolam
syringe & box
orange
7.5mg in 1.5ml
5mg in 1ml
2.5mg in 0.5ml
purple
blue
yellow
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4.2.3 Use of the licensed preparation Buccolam for individuals over the age of 17 years is an ‘off
label/off licence’ use for the product and is outside of the recommendations of the marketing
authorisation. The recommended dose is the same as that for the older child i.e. 10mg (2ml). This
‘off licence’ use is justified in the emergency situation outlined in this guideline.
4.2.4 The prescriber must take full clinical and professional responsibility for the prescribing of an
unlicensed medicine or when a medicine is used off licence. The manufacturer carries no legal
liability for the unlicensed use of their product for any harm that ensues. The prescriber should be
aware that this alters (and increases) their professional responsibility and potential liability, placing
greater responsibility on individual prescribers and the Trust.
4.2.5 Buccal midazolam prescribed by a doctor, dentist or non-medical prescriber may be
administered by Trust nursing staff. Use in these circumstances will be supported by the Trust if
done in accordance to this guideline and in accordance with the Medicines Code.
4.3. EPISTATUS®® LICENSED INDICATION/USE
4.3.1 Epistatus® is an unlicensed product.
4.3.2 There are a number of buccal midazolam preparations which are unlicensed for this indication
and do not have a marketing authorisation (product licence). The only unlicensed buccal midazolam
preparation stocked by the Trust is Epistatus®.
4.3.3 The recommended dose for an adult is 10mg. However it is critical to note that 10mg of
midazolam is contained in 1ml of Epistatus® liquid. This is different to the Buccolam
preparation. Care must be taken to avoid confusion. This ‘off licence’ use is justified in the
emergency situation outlined in this guideline.
4.3.4 The prescriber must take full clinical and professional responsibility for the prescribing of an
unlicensed medicine or when a medicine is used off licence. The manufacturer carries no legal
liability for the unlicensed use of their product for any harm that ensues. The prescriber should be
aware that this alters (and increases) their professional responsibility and potential liability, placing
greater responsibility on individual prescribers and the Trust.
4.3.5 Buccal midazolam prescribed by a doctor, dentist or non-medical prescriber may be
administered by Trust nursing staff. Use in these circumstances will be supported by the Trust if
done in accordance to this guideline and in accordance with the Medicines Code.
4.4. ADMINISTRATION OF BUCCAL MIDAZOLAM
4.4.1 Ensure that the medication is prepared and administered as rescue medication, following the
principles of safe preparation e.g. checking the label, the medicine and the care plan-where
applicable are correct for the individual.
4.4.2 The correct administration technique must be followed.
ADMINSTRATION TECHNIQUE FOR BUCCAL MIDAZOLAM PREPARATIONS:
SEE APPENDIX 2: BUCCOLAM®
SEE APPENDIX 3: EPISTATUS®
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4.5. SUPPLY OF BUCCAL MIDAZOLAM
4.5.1 For non NHS establishments e.g. residential homes
The patient will have their own buccal midazolam (normally prescribed by their GP/Consultant).This
product must contain a pharmacy dispensed label with the patient’s name and clear directions for
use.
4.5.2 For Sussex Partnership inpatient units
There are four means by which buccal midazolam may be obtained. These are outlined below:
1. Patients own medication: brought in to the ward by the client or carers. This medication
cannot be used for any other patient.
2. CD ordered for discharge / leave: Medication supplied by Western Sussex Hospitals Trust.
This must be ordered on a discharge prescription with the original sent to pharmacy to allow
supply to occur. The resulting medication will have directions for use on the label & can be
given to the patient / carer on discharge / leave. This medication cannot be used for any
other patient.
All buccal midazolam ordered for a patient should be ordered for discharge / leave to
ensure that this medication can be taken on any excursions from the ward as a
preventative measure.
To order medication for discharge or leave an original TTO prescription should be
sent to Worthing pharmacy department. The CD book does not need to be sent with
this, however, a photocopy of medication chart will need to be sent if the CD book has
not already been screened by the ward pharmacist.
3. Inpatient CD: Medication supplied by Western Sussex Hospitals Trust. This must be ordered
in the ward CD book. The CD book can either be screened by the ward pharmacist, if
available, or if not a photocopy of the patients chart must be sent with the CD book to the
pharmacy department. This medication cannot be used for any other patient, with the
exception of one dose in emergency as outlined in the Western Sussex Hospitals Controlled
Drugs policy. Inpatient CD should not be ordered as this prevents the medication being used
outside of the unit. It is preferable to order as a CD for leave to allow the medication to be
taken out with the client if needed. Inpatient CD’s MUST NOT be taken into the community
with the client. They are for inpatient use ONLY.
4. Stock CD: Medication supplied by Western Sussex Hospitals Trust. This must be ordered in
the ward CD book. This medication is for inpatient use only.
All buccal midazolam irrespective of origin must be recorded in the correct section of the controlled
drug register.
4.5.3 For Sussex Partnership inpatients due for Discharge / Leave
In the case of discharge or leave, only the following two types of buccal midazolam may be given to
the patient to go home with:
1. Patients own medication: brought in to the ward by the client or carers.
2. CD ordered for discharge / leave: Medication supplied by Western Sussex Hospitals Trust.
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4.6 STORAGE OF BUCCAL MIDAZOLAM
4.6.1 Midazolam has the potential to be misused therefore storage arrangements must ensure that
the products are securely stored but accessible to those who are authorised to administer the
medicine.
4.6.2 If the product is stored on Sussex Partnership premises then the Medicines Code advice on
storage of medication & controlled drugs must be followed. Buccal midazolam must be kept in the
controlled drug cupboard & entered into the controlled drug register in line with the Medicines Code
recommendations.
4.6.3 Buccal midazolam preparations must be stored in accordance with the manufacturer’s
information:
Buccal midazolam unlicensed preparations stored in a bottle should be kept between 15ºC and
25ºC. The cap must be replaced immediately after use otherwise the liquid will evaporate and some
of the midazolam will precipitate. This will be exhibited as white particles in the liquid. The pack must
be discarded if the solution is not clear.
 Buccolam▼: The syringe must be kept in the protective plastic tube until used. The product must
not be refrigerated or frozen.
4.7 DISPOSAL OF BUCCAL MIDAZOLAM
4.7.1 Disposal for Community Patients
The healthcare professional should advise the parent/individual/carer to return expired bottles of
midazolam to a community pharmacy for safe disposal.
A link to a letter for the community pharmacy can be found below:
http://www.sussexpartnership.nhs.uk/node/2406/attachment
4.7.2 Disposal on NHS Premises
Expired stocks of buccal midazolam must be brought to the attention of the ward pharmacist for
destruction.
4.7.3 Return to Pharmacy from NHS Premises
Stocks of buccal midazolam no longer required must be brought to the attention of the ward
pharmacist to return to pharmacy.
4.8. NURSES AUTHORITY TO CARRY STOCK BUCCAL MIDAZOLAM
In exceptional circumstances it may be permissible for nurses to carry stock buccal midazolam
in the community. The following permissions need to be sought as per the following link:
http://www.sussexpartnership.nhs.uk/node/1581/attachment
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5. RECTAL DIAZEPAM
5.1 RECTAL DIAZEPAM PREPARATIONS
5.1 The term rectal diazepam is used throughout this guidance to mean all the different rectal
diazepam preparations available in the UK. It generally remains the first-line option in substance
misuse / alcohol withdrawal settings for the treatment of prolonged seizures.
5.2 RECTAL DIAZEPAM LICENSED INDICATION/USE
5.2.1 Use in the management of patients with a diagnosis of epilepsy
5.2.1.1 Rectal diazepam is available as a number of licensed products, including Desitin® rectal
solution and Stesolid® rectal tubes. It is licensed to treat epileptic and febrile convulsions. Rectal
diazepam may be useful in these indications when a rapid effect is required but where intravenous
injection is impracticable or undesirable and buccal midazolam is not desirable as the first option.
5.2.1.2 Rectal diazepam is generally supplied as either a 5mg or a 10mg tube suitable for rectal
administration.
The dose for adults is usually 0.5mg/kg up to a maximum dose of 30mg in 24 hours. However it is
important to note that each person’s care plan may vary dependent on their needs.
This would usually be prescribed as 10-20mg in the first instance. However consideration
should be given to the needs of the individual patient. This will be outlined in their epilepsy
care plan.
5.2.1.3 Due to the route of administration particular care is required to ensure that the dignity of the
client is maintained.
5.2.2 Use in adult detox’ patients without a diagnosis of epilepsy
5.2.1 Rectal diazepam is available as a number of licensed products, including Desitin® rectal
solution and Stesolid® rectal tubes. It is licensed to treat epileptic and febrile convulsions. Rectal
diazepam may be useful in these indications when a rapid effect is required but where intravenous
injection is impracticable or undesirable and buccal midazolam is not desirable as the first option.
5.2.2 Rectal diazepam is generally supplied as either a 5mg or a 10mg tube suitable for rectal
administration.
This would usually be prescribed as 10-20mg in the first instance up to a maximum dose of
30mg in 24 hours. However consideration should be given to the needs of the individual
patient. See Appendix 5 for further information.
5.2.3 Due to the route of administration particular care is required to ensure that the dignity of the
client is maintained.
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5.3. ADMINISTRATION OF RECTAL DIAZEPAM
5.3.1 Ensure that the medication prepared and administered as rescue medication follows the
principles of safe preparation e.g. checking the label, the medicine and the care plan (where
applicable).
5.3.2 The correct administration technique must be followed.
ADMINSTRATION TECHNIQUE FOR RECTAL DIAZEPAM PREPARATIONS:
SEE APPENDIX 4
5.4 SUPPLY OF RECTAL DIAZEPAM
5.4.1 For non NHS establishments e.g. residential homes
The patient will have their own rectal diazepam (normally prescribed by their GP/Consultant).This
product must contain a pharmacy dispensed label with the patient’s name and clear directions for
use.
5.4.2 For Sussex Partnership inpatient units
There are two means by which rectal diazepam may be obtained. These are outlined below:
1. Patients own medication: brought in to the ward by the client or carers. This medication
cannot be used for any other patient.
2. One –stopped / TTA medication dispensed for use on the ward & discharge / leave:
Medication supplied by Western Sussex Hospitals Trust. The resulting medication will have
directions for use on the label & can be given to the patient / carer on discharge / leave. This
medication cannot be used for any other patient.
All rectal diazepam ordered for a patient should be ordered for discharge / leave to ensure that
this medication can be taken on any excursions from the ward as a preventative measure.
5.4.3 For Sussex Partnership inpatients due for Discharge / Leave
In the case of discharge or leave only the following two types of rectal diazepam may be given to the
patient to go home with:
1. Patients own medication: brought in to the ward by the client or carers.
2. Rectal diazepam ordered for discharge / leave: Medication supplied by Western
Sussex Hospitals Trust.
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5.5 STORAGE OF RECTAL DIAZEPAM
5.5.1 Diazepam has the potential to be misused therefore storage arrangements must ensure that
the products are securely stored but accessible to those who are authorised to administer them.
5.5.2 If the product is stored on Sussex Partnership premises then Medicines Code advice on
storage of medication must be followed.
5.5.3 Rectal diazepam preparations must be stored in accordance with the manufacturer’s
information:
 Do not store above 25 °C.
(Short-term exposure to higher temperatures, e.g. in emergencies, is of no consequence).
5.6 DISPOSAL OF RECTAL DIAZEPAM
5.6.1 Disposal for Community Patients
The healthcare professional should advise the parent/individual/carer to return expired tubes of
rectal diazepam to a community pharmacy for safe disposal.
A link to a letter for the community pharmacy can be found at the following link:
http://www.sussexpartnership.nhs.uk/node/2406/attachment
5.6.2 Disposal on NHS Premises
Expired stocks of rectal diazepam must be brought to the attention of the ward pharmacist for
destruction.
5.6.3 Return to Pharmacy from NHS Premises
Stocks of rectal diazepam no longer required must be brought to the attention of the ward
pharmacist to return to Pharmacy.
6. PRESCRIBING
6.1 Buccal midazolam / rectal diazepam must be prescribed by a doctor, dentist or non-medical
prescriber on either:
an individual epilepsy management/care plan where the GP/consultant has signed to authorise
administration and patient/parent/carer consent to treatment has been obtained (see Appendix 1).
 on the patient’s drug chart whilst an inpatient with reference to the client’s epilepsy care plan (see
Appendix 1).
Either buccal midazolam or rectal diazepam should be prescribed
in order to avoid confusion and potential for accidental overdose.
7. AUTHORISATION TO ADMINISTER BUCCAL MIDAZOLAM / RECTAL DIAZEPAM
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7. AUTHORISATION TO ADMINISTER
7.1 The following staff can administer buccal midazolam / rectal diazepam:
A doctor
A dentist
A registered nurse or dental nurse (in accordance to the prescriber’s directions)
A named carer or person who has attended appropriate training in the administration of buccal
midazolam / rectal diazepam.
8. DOCUMENTATION
8.1 A record of administration must be made on the relevant documentation provided by the service,
i.e. MAR charts for residential placements & drug charts for inpatient services.
8.2 In clinics/clinical areas where buccal midazolam is held as stock on NHS premises, e.g. the
Selden Centre, a record of administration must also be recorded in the CD Register as well as the
patient’s drug chart & medical records. Please note this is not a requirement for rectal diazepam.
9. REPORTING ADVERSE DRUG REACTIONS (ADRs)
9.1 In the event of adverse reaction, immediate action should be taken to minimise the harm to the
patient. Inform the GP of the actions taken and record in the patient’s notes. In the event of any
ADR this should be reported in accordance with the Trust’s incident reporting policy.
9.2 Buccolam is a black triangle drug and is subject to additional national monitoring. This will allow
quick identification of new safety information. Any side effects should be reported to the MHRA by
completing an adverse drug reporting form (Yellow Card https://yellowcard.mhra.gov.uk/ ). All
suspected reactions should be recorded in the notes & drug chart allergy box, in line with the
Medicines Code. Information regarding a suspected ADR should also be disseminated to the
patients GP & consultant, (if currently under secondary care).
9.3 Rectal diazepam is has been licenced for considerably longer than buccal midazolam & as such
only serious or unexpected side effects need be reported via the Yellow Card Scheme,
(https://yellowcard.mhra.gov.uk/). However, all suspected ADRs should be recorded in the notes &
drug chart allergy box in line with the Medicines Code. Information regarding a suspected ADR
should also be disseminated to the patients GP & consultant, (if currently under secondary care).
10. DUTIES AND RESPONSIBILITIES
10.1 Sussex Partnership Trust
The Trust may provide epilepsy training to meet the needs of Sussex Partnership staff and non
Sussex Partnership staff in identified settings where it may be necessary to administer buccal
midazolam and/or rectal diazepam.
10.2 Service Managers
Service managers will need to ensure Sussex Partnership staff that administer buccal midazolam /
rectal diazepam or train others on their administration, attend regular epilepsy update courses
organised by the Trust and maintain competency.
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10.3 Sussex Partnership Staff
10.3.1 All professionals prescribing and administering buccal midazolam and rectal diazepam
should adhere to this guideline. They must act in accordance with their professional code of conduct
and within their own sphere of competence.
10.3.2 Individuals administering buccal midazolam / rectal diazepam and/or providing training to non
Sussex Partnership staff, must be appropriately trained and attend updates.
11. TRAINING
11.1 The training may be delivered by individual healthcare professionals with specialist training in
the management of epilepsy. Training can be disseminated to other non-Sussex Partnership staff to
administer buccal midazolam / rectal diazepam under an individualised care plan.
11.2. For non Sussex Partnership staff, it is the responsibility of the care home to provide their staff
with epilepsy training. This training will not be routinely provided by SPT.
11.3. Family & carers may be provided with epilepsy training on an individual basis as needed.
12. REFERENCES & FURTHER INFORMATION
1. NICE Guideline CG137 The epilepsies: the diagnosis and management of the epilepsies in
adults and children in primary and secondary care, January 2012.
2. Joint Epilepsy Council. A Guideline for the Training Standards for the Administration of
Buccal Midazolam, January 2012.
3. National Society for Epilepsy. Emergency Medication: Using Buccal Midazolam to Treat
Prolonged Seizures. May 201.
4. Resuscitation Council (UK): Standards for Clinical Practice and Training for Dental Practitioners
and Dental Care Professionals in General Dental Practice. December 2012:
http://www.resus.org.uk/pages/MEdental.pdf
5. UL Medicines Limited. Product Profile for Buccal Midazolam 10mg/1ml Liquid. 2015
ViroPharma. Information Sheet ‘How to administer BUCCOLAM▼ (midazolam
oromucosal solution). December 2015.
6. Specials Products. Data Sheet for Epistatus®. Version 9 27/7/2012
7.Penn Specials. Technical Information Leaflet for Penn Midazolam. Midazolam Buccal
Liquid 10mg/ml. August 2010: www.pennpharm.com
8.Holmes G. Buccal route for benzodiazepines in treatment of seizures? Lancet 1999:353:608-009.
9. Scott RC et al. Buccal midazolam and rectal diazepam for treatment of prolonged seizures in
childhood and adolescence: a randomised trial. Lancet 1999;353:623-6.
10. Paediatric Medicines Information Advisory Line FAQ Number 39 – as searched on 11/4/03.
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Appendix 1
Individual Epilepsy Care Plan
For
Name:
Date of birth:
Address:
PiMS:
NHS No:
Date written:
Review Date:
Problems/ diagnosis:
The original copy of this document should be completed by a healthcare professional
The document is designed to be flexible and adaptable. You will not need to complete
every section and are encouraged to delete the parts that are not relevant to this person.
Original devised by Georgina Ward, Paediatric Epilepsy Specialist Nurse – East Sussex
Healthcare. Adapted for the CLDT by Becky Oxendale, CLDN, Sussex Partnership NHS
Foundation Trust.
14
1
Name: …………………………………
Routine Medication:
Drug
Drug
Drug
DOB: ……………………
PiMS: ………………………
Dose
Dose
Dose
Medicines are Subject to change: Medications listed are correct at time of writing. Parents/ carers are reminded of the
importance of informing day services/respite carers/ centres of any changes in treatment/medication or ongoing
concerns/changes in seizure patterns.
Include any information about how medication is usually taken, eg sprinkled on food, tablet swallowed with a drink
Rescue Medication- People who have not had a prolonged seizure (lasting more than 5 minutes) or are not known to
have serial seizures (several short seizures within a 2 hour period) do not generally have rescue medications prescribed.
Please see care plan for actions to be taken if this occurs. This timeframe will be individual to each person, adapt as necessary/
delete as appropriate
Allergies:
Description of seizure(s):
record all details of seizures e.g. goes stiff, cries out, falls, arms make violent jerking
movements, convulses down both sides of body, convulsions usually last 3 minutes.
Seizure Type One:
Usual duration of seizure:
Seizure Type Two:
Usual duration of seizure:
Seizure Type Three:
Usual duration of seizure:
Other Useful Information:
How the person usually recovers:
Triggers for seizures:
(Common triggers for seizures are: tiredness, excitement, stress, missing meals or medication
and having a temperature or illness).
Warning signs that seizures may occur:
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Adapted from the Joint Epilepsy Council guidelines for Administration of Buccal Midazolam in Epilepsy and the Young
Epilepsy Individual healthcare plan by: East Sussex Healthcare December 2013. Author Georgina Ward, Paediatric
Epilepsy Specialist Nurse. Review Date: December 2014. Adapted for the CLDT by Becky Oxendale, CLDN July 2014.
Name: …………………………………
DOB: ……………………
PiMS: ………………………
Delete the Following boxes as appropriate:
Action to be taken during and after an absence seizure:




Absence seizures are usually very brief and often pass unnoticed
If you witness an absence seizure stay with the person for a while to make sure they do not
suffer any injury
Tell the person what has happened
If a person is in the session / conversation, repeat any information they have missed
Record as appropriate.
Delete the Following boxes as appropriate:
Action to be taken during and after a convulsive seizure (with a loss of consciousness):
 Note time (and follow instructions for giving rescue medication (delete as appropriate).
 Cushion head and move things out of the way to prevent injury, loosen restrictive clothing.
 Do not attempt to restrain the convulsive movements, allow the seizure to take its course.
 Provide reassurance and talk calmly.
 If breathing is compromised (colour change/ noisy breathing) move the person onto their side
(recovery position) and monitor closely.
 If the seizure stops within 5 minutes place in the recovery position and allow recovery.
 If the seizure continues for longer than 5 minutes call an ambulance or give rescue medication (see
below) delete as appropriate
 Call Parents/carers. Delete as appropriate
 Record description of the event, noting time and any possible triggers.
Delete the following boxes as appropriate
Action to be taken during and after a focal onset seizure (with an altered level of consciousness):
 Note time
 Guide the person away from danger
 Stay with the person until recovery is complete
 Be calmly reassuring
 Explain anything that they have missed
 Do not restrain the person or act in a way that could frighten them, such as making abrupt
movements or shouting at them
 Don’t assume the person is aware of what is happening or what has happened
 Don’t give them anything to eat or drink until they are fully recovered
 Don’t attempt to bring them round
 Call for an ambulance if the person is injured or of you believe they need urgent medical attention
 Record description of the event, noting time and any possible triggers.
Delete the following boxes as appropriate
Action to be taken during and after a drop seizure:
 Check the person for injury – if concerned about injuries, provide first aid and call an ambulance if
necessary- call parents / carers (see contact details).
 Provide appropriate reassurance & comfort particular to the person, detail any specific interventions.
 Assist the person to their feet, providing reassurance and talking calmly.
 Don’t give them anything to eat or drink until they are fully recovered.
 Record description of the event, noting time of seizure and any possible triggers.


When Should 999 be dialled for emergency help:
If there are no signs of recovery after 5 minutes of administering rescue
medication / if seizure continues for longer than 5 minutes Delete as appropriate
If injury has occurred / concerns about breathing / other concerns
16
Adapted from the Joint Epilepsy Council guidelines for Administration of Buccal Midazolam in Epilepsy and the
Young Epilepsy Individual healthcare plan by: East Sussex Healthcare December 2013. Author Georgina Ward,
Paediatric Epilepsy Specialist Nurse. Review Date: December 2014. Adapted for the CLDT by Becky Oxendale,
CLDN July 2014.
Name: …………………………………
DOB: ……………………
PiMS: ………………………
Delete Boxes as appropriate
When should rescue medication be administered:
If ……………. is having a seizure type ______________as described above lasting longer than
5 minutes.
or if ………. has (number of seizures) of seizures over a …………(state time ie 2 hours) period
Give __________mg of __________________State Brand and strength ie (Buccolam 2.5mgs/ 0.5ml)
Via ______________ie via buccal cavity
This plan has been agreed for emergency treatment by:
Name of Neurologist_____________________________Date ________________
Documented letter to GP dated______________________(attach copy to this plan where possible)
Name and designation of health professional completing this part of form
Signed_________________________________Designation_______________________
Print Name_____________________________
This plan should be reviewed regularly and at least every 2 years. (it is the responsibility of the care
provider to review. If no changes, care providers are able to review and resign this document).
Usual Reactions rescue medication: (e.g.sleepiness, slow shallow breathing, amnesia)
Safety Measures:
Activities that should be avoided: With appropriate supervision there are no activities that should
be avoided, please speak to your GP if you have a specific query.
Activities that require special precaution:
Swimming – one to one supervision whilst in the water.
Horse riding/cycling – wear a helmet and avoid roads.
Climbing – wear protective head gear and supervision at all times.
Showering is preferable to bathing with the door unlocked and someone nearby.
17
Adapted from the Joint Epilepsy Council guidelines for Administration of Buccal Midazolam in Epilepsy and the Young
Epilepsy Individual healthcare plan by: East Sussex Healthcare December 2013. Author Georgina Ward, Paediatric
Epilepsy Specialist Nurse. Review Date: December 2014. Adapted for the CLDT by Becky Oxendale, CLDN July 2014.
Name: …………………………………
DOB: ……………………
PiMS: ………………………
Signature of Parents / Carers.……………………………………...Date………………………..
Print Name …………………………………………………………………………………………...
Signature of Person……………… Delete as appropriate …………..Date………...………………..
Print Name …………………………………………………………………………………………...
Signature of Healthcare professional ………………………………..Date………………………
Print Name …………………………………………………………………………………………...
CONTACT DETAILS
Contact 1 – ………………. Phone Number:…………………………………………….
Contact 2 – ………………. Phone Number: …………………………………………….
Contact 3 - ………………...Home Phone Number: ……………………………………………...
Suggest copies to: Parents / carers, Neurologist, GP, Day-service, Work Placement,
Respite Service / Carer, CLDT.
Delete the following if appropriate
Please record when rescue medication has been administered below ;
DATE TIME
DOSE MEDICATION GIVEN CHECKED PARENTS REQUEST
GIVEN
GIVEN
BY
BY
INFORMED REPLACEMENT
Please note - seizures can present in many different ways. It is impossible to describe every variant. The
descriptions in this care plan are of episodes that have been witnessed. If further advice is needed, please contact
the persons GP or Neurologist.
For more detailed explanations on seizures, you can find information at:
www.epilepsy.org.uk
or
www.epilepsysociety.org.uk
18
Appendix 2: Administration Technique for Buccolam® Buccal Midazolam
(Prefilled Syringe)
Step 1
Hold the plastic tube, break the seal at
one end and pull the cap off. Take the
syringe out of the tube.
Step 2
Pull the red cap off the tip of the syringe
and dispose of it safely.
Step 3
Using the finger and thumb gently pinch
and pull back the patient’s cheek. Put the
tip of the syringe into the back of the
space between the inside of the cheek
and the lower gum.
Step 4
Slowly press the syringe plunger until the
plunger stops.
The full amount of solution should be
inserted slowly into the space between
the gum and the cheek (buccal cavity).
If necessary (for larger volumes and/or
smaller patients), approximately half the
dose should be given slowly into one
side of the mouth, then the other half
given slowly into the other side.
Any unused medicinal product or waste material should be disposed of in accordance with local requirements.
Taken from the Summary of Product Characteristics for Buccolam.
With kind thanks to ViroPharma for their permission to use this information.
Appendix 3: Administration Technique for Buccal Midazolam Supplied in a
Bottle with Non Prefilled Oral Syringes, e.g. Epistatus®
Unlicensed Indication:
The use of buccal midazolam (in place of rectal diazepam) has been reported in the literature to treat
convulsive status epilepticus. It has been used successfully within learning disability residential homes in
the Trust for a number of years.
Presentation:
A buccal liquid (brand name Epistatus®) containing 10mg midazolam base in 1ml of sugar-free syrup.
The product has a shelf life of 2 years and is presented with oral syringes. Each pack contains sufficient
for four doses.
Dosage:
The adult dose of buccal midazolam liquid is 10mg (1mL).
For simplicity, the following regime can also be adopted to calculate dose and volume to administer:
Age of patient
10 years and over
Dose of buccal midazolam
10mg (1.0ml)
Administration of Epistatus® dose:
 Check that bottle is in date
 Hold the bottle upright
 Remove the child-resistant cap by pushing it down and turning it anti-clockwise
 Push the plunger of the empty 1ml oral dispenser (syringe) completely down towards its tip
 Insert the tip of the oral dispenser into the hole in the white plastic bottle adaptor
 Hold the bottle and oral dispenser securely and turn the bottle up-side down
 Pull the plunger out slowly until the oral dispenser contains the prescribed dose (see regime
above)
 Turn the bottle upright
 Remove the oral dispenser from the bottle
 Put about half of the liquid in the oral dispenser between the patient’s gums and cheek (buccal
cavity). Do not let the patient bite the oral dispenser
 Put the remaining liquid between the gums and cheek on the other side of the mouth. If
administration is difficult then squirt the whole dose into one side
 Screw the child-resistant cap back on the bottle immediately to prevent evaporation
 Put the bottle back in the carton containing the remaining oral dispensers
The dose should work within 5 minutes, however if after 10 minutes there is no sign of recovery (gaining
consciousness) then a second dose can be administered but only if prescribed . If this is not the case
then an ambulance must be called.
If a person experiences a prolonged seizure within a 6 hour timeframe from the last dose administered
then an ambulance must be called. If it is after 6 hours then the procedure can be repeated.
20
Appendix 4: Administration Technique for Rectal Diazepam
21
Appendix 5: Information for nurses & Carers on the Management of
Seizures in Adults with Rectal Diazepam
(for use in adult detox’ patients without an epilepsy diagnosis)
Maintain a safe environment and consider the dignity of the patient.
 Note the time that the seizures start
 Cushion the person’s head if possible to prevent injury
Administer rectal diazepam in the range of 10mg -20mg as prescribed, as soon as
possible ideally within 2 minutes of the seizures starting.
If the seizures continue then administer another dose 15minutes after the first dose.
Maximum dose is 30mg per 24 hours. If seizures last longer than 30 minutes then
this is called status epilepticus and is a medical emergency, so get help urgently.
 Remain with the person until they are fully recovered
 Once convulsions have stopped put the person into the recovery position,
check airway and also for injury
 Attend to any personal hygiene needs
 Support to sleep if needed
 Re-orientate the person to their surroundings
 Monitor for any side-effects due to diazepam e.g. effects on respiration
 Document as appropriate and inform the relevant medical team
Do Not
 Restrain the person but guide away from danger
 Put anything in their mouth
 Give any food or drink until the patient has fully recovered from the seizure for
example has regained consciousness and is aware of their surroundings
 Move the person unless they are in direct danger
If you require this document in an alternative format, ie easy read, large
text, audio, Braille or a community language please contact the Pharmacy
Team on 01243 623349 (Text Relay calls welcome).
Approved: February 2016
Review date: February 2018
(See Appendix 4 for administration guidance for rectal diazepam)
22
Appendix 6: Easy Read Buccal Midazolam leaflet
Buccal Midazolam
This is an easy way to read this word… Buc-cal Myddaz-zol-am
What is this leaflet for?
This leaflet is to help you understand more about your
medicine.
Your medicine could look different to the photographs on this
leaflet.
What is the medicine called?
Your medicine is called buccal midazolam.
It can come as Buccolam in a syringe or as Epistatus in a
bottle.
Both work well, and are both given from an oral syringe into the
space between your gum and cheek (buccal cavity) but it is
important to stick to your usual brand.
Sticking with your usual brand will help to make sure you get
the right dose of medicine.
What is buccal midazolam for?
Buccal midazolam is used to help stop seizures or fits if they go
on for too long. If you need some buccal midazolam one of
your carers will help you to have this to stop your seizure.
23
What will buccal midazolam do?
Buccal midazolam should help you to stop having a seizure if it
is given you to when you are fitting.
People only need to take this medicine when they are having a
seizure and not at any other time.
It is normal that many people do not remember having been
given their medication. Your carer should tell you when you
have needed your buccal midazolam to help with your seizure.
What are the side effects of buccal midazolam?
Side effects are effects medicine can have on your body that
are not wanted.
Not everyone taking a medicine will get side effects.
Many side effects will go away with time. Many side effects are
rare.
You might want to talk to your doctor if you have any side
effects.
For example, these are some side effects of buccal midazolam
 Having a headache
 Feeling very tired
 Problems remembering things
 Feeling dizzy and faint
 Feeling confused
 Feeling unsteady on your feet
 Feeling more aggressive or angry
24
Some side effects are more serious.
You should tell someone straight away if you…
 Have a rash or blotches on your skin
 Have trouble breathing
 Feel more angry
 Feel unwell
How and when do I take buccal midazolam?
Because buccal midazolam is only needed when you have a
seizure you will not need to give this medicine to yourself.
If you need buccal midazolam when you have a seizure your
carer will give this to you by placing the oral syringe into the
space between your gum and cheek. The liquid will then start
to help with your seizure.
Can I have a second dose if I need it?
Most seizures stop in about 10 minutes after you have buccal
midazolam. If this doesn’t happen and your doctor has
prescribed this, a second dose can be given.
+1
Information about this will be in your epilepsy care plan and on
your prescription.
25
Are there any reasons I should not have buccal
midazolam?
If you have had a bad reaction to this medication or one like it
which are called benzodiazepines (ben-zo-dye-as-a-peen).
These might be called diazepam (dye-az-eh-pam), clonazepam
(clo-na-zee-pam) or lorazepam (lo-ra-zee-pam).
If you are worried about this let your doctor or pharmacist
know.
Where can I get more information?
This leaflet does not tell you everything about buccal
midazolam.
If you want more information about buccal midazolam…
• you can ask your pharmacist, doctor or nurse for more
information
• you can ask your carer to get more information
• you can phone NHS non-emergency number on 111
• you can visit the website below
http://www.easyhealth.org.uk/sites/default/files/Epilepsy%20%20EH.pdf
Produced February 2016
Review by February 2018
26
Appendix 7: Easy Read Rectal Diazepam leaflet
Rectal Diazepam
This is an easy way to read this word… Rec-tal Dyeaz-eh-pam
What is this leaflet for?
This leaflet is to help you understand more about your
medicine.
Your medicine could look different to the photographs on this
leaflet.
What is the medicine called?
Your medicine is rectal diazepam. It can also be called Stesolid
or Desitin. It is a liquid that comes in a tube.
You may see 1 of these names on your prescription.
What is rectal diazepam for?
Rectal diazepam is used to help stop seizures or fits if they go
on for too long. If you need some rectal diazepam one of your
carers will help you to have this to stop your seizure.
27
What will rectal diazepam do?
Rectal diazepam should help you to stop having a seizure if it
is given you to when you are fitting.
People only need to take this medicine when they are having a
seizure and not at any other time.
It is normal that many people do not remember having been
given their medication. Your carer should tell you when you
have needed your rectal diazepam to help with your seizure.
What are the side effects of rectal diazepam?
Side effects are effects medicine can have on your body that
are not wanted.
Not everyone taking a medicine will get side effects.
Many side effects will go away with time. Many side effects are
rare.
You might want to talk to your doctor if you have any side
effects.
For example, these are some side effects of rectal diazepam
 Having a headache
 Feeling very tired
 Problems remembering things
 Feeling dizzy and faint
 Feeling confused
 Feeling unsteady on your feet
 Feeling more aggressive or angry
28
Some side effects are more serious.
You should tell someone straight away if you…
 Have a rash or blotches on your skin
 Have trouble breathing
 Feel more angry
 Feel unwell
How and when do I take rectal diazepam?
Because rectal diazepam is only needed when you have a
seizure you will not need to give this medicine to yourself.
If you need rectal diazepam when you have a seizure your
carer will give this to you by placing the end of the tube into
your bottom and squeezing the tube so the liquid can get into
your body. The liquid will then start to help with your seizure.
Everyone is different and some people prefer to have their
medication by mouth and others are happy to have medication
in their bottom.
Rectal diazepam cannot be given by mouth, but there are other
medicines to help with fits that can be given by mouth even if
you are having a seizure.
If you would rather have your medicine by mouth you can ask
your doctor to talk about this.
29
Can I have a second dose if I need it?
Most seizures stop in about 10 minutes after you have rectal
diazepam. If this doesn’t happen and your doctor has
prescribed this, a second dose can be given.
Information about this will be in your epilepsy care plan and on
your prescription.
+1
Are there any reasons I should not have rectal
diazepam?
If you have had a bad reaction to this medication or one like it
which are called benzodiazepines (ben-zo-dye-as-a-peen).
These might be called midazolam (myd-daz-zol-am),
clonazepam (clo-na-zee-pam) or lorazepam (lo-ra-zee-pam).
If you are worried about this let your doctor or pharmacist
know.
Where can I get more information?
This leaflet does not tell you everything about rectal diazepam.
If you want more information about rectal diazepam…
• you can ask your pharmacist, doctor or nurse for more
information
• you can ask your carer to get more information
• you can phone NHS non-emergency number on 111
• you can visit the website below
http://www.easyhealth.org.uk/sites/default/files/Epilepsy%20%20EH.pdf
Produced February 2016
Review by February 2018
30