Guidance for the use of buccal midazolam or rectal diazepam
in the treatment of epileptic seizures
Version:
V2
Author
Lilian Baxendale
Designation:
Pharmacist
Responsible Director:
Dr Sharon Binyon
Target Audience:
Staff working on behalf of CWPT who are administering
buccal midazolam or rectal diazepam in the treatment
of epileptic seizures
Approved By:
Drugs and Therapeutics Committee
Approval Date:
17th March 2016
Next Review Date:
March 2019
______________________________________________________
If printed, copied or otherwise transferred from the Intranet, Trust-wide Corporate Business
Records will be considered ‘uncontrolled copies’. Staff must always consult the most up to PDF
version which is on the Intranet.
Page 1 of 35
CONTENTS
1.
Introduction
2.
Definitions
3.
Duties / Responsibilities
4.
Process
5.
Consultation
6.
Training and Support
7. References
8. Trust Associated Documents
9. Appendices
Appendix 1 – Guidance for the care of a person experiencing a seizure
Appendix 2 – Example Epilepsy Management Plan
Appendix 3 - Good Practice Guidelines: For Paid Carers who Administer
Buccal Midazolam
Page 2 of 35
1. Introduction
This document details the procedures to be followed when rectal diazepam or
buccal midazolam are administered in the treatment of epileptic seizures. It also
contains guidance on the management of epileptic seizures. It is not intended for
use in the emergency treatment of seizures of a person who does not have
epilepsy e.g. seizures due to alcohol withdrawal. These people should be treated
by following the Trust resuscitation guidelines.
Information in this document does not override clinical judgement or professional
liability.
NICE (The National Institute for Health and Care Excellence) has published
Quality Standards on “The epilepsies in adults (QS26)” and “The epilepsies in
children and young people” (QS27). These documents link to published guidance
and key documents.
The NICE Guideline CG 137 (The epilepsies: the diagnosis and management of
the epilepsies in adults and children in primary and secondary care) state that
buccal midazolam or rectal diazepam should only be prescribed for use in the
community for children, young people and adults who have had a previous
episode of prolonged or serial convulsive seizures (NB the definition of
“prolonged” or length of time since previous episode will vary according to
whether it is a child or adult who is being considered). Buccal midazolam should
be administered as first-line treatment in children, young people and adults with
prolonged or repeated seizures in the community; rectal diazepam should be
administered if preferred or if buccal midazolam is not available.
2. Definitions
1.1. Buccal- This is a cavity in the side of the mouth between the lower cheek
and the gums. Medication is rapidly absorbed through the mucous
membranes into the blood stream.
3. Duties / Responsibilities
3.1. Consultants and their medical team are responsible for approval and
review of each individual’s Epilepsy Management Plan. This may also
involve a specialist practitioner and input from acute Trust services, and/or
the patients GP. If the individual is under the care of a neurologist outside
of CCWPT this neurologist would be responsible for developing the
Epilepsy Management Plan
Page 3 of 35
3.2. Staff (i.e. staff members who are competent in the administration of
buccal midazolam or rectal diazepam, or a paid carer who is assessed as
competent to administer these medicines) who administer buccal
midazolam or rectal diazepam in the treatment of epileptic seizures are
responsible for following each individual’s epilepsy management plan.
4. Process
4.1. Process for the administration of Buccal Midazolam
4.1.1. An individual seizure management plan should be in place (example
plan Appendix 2).
4.1.1.1. The seizure management plan should include: • Name
• Seizure descriptions and possible triggers
• Details of the person’s consent (or carer’s if appropriate) for
the administration of buccal midazolam (if the person is unable
to give consent, details of the outcome of a best interests
meeting should be documented)
• When buccal midazolam should be given
• Dose to be given
• How the person usually responds to treatment
• Whether a repeated dose can be given and after what time
interval
• Maximum number of doses that can be given in 24 hours
• When an ambulance should be called
• Who else to contact/inform of the seizure
4.1.2. At all times staff/carers should act within the person’s care
plan/seizure management plan.
4.1.3. Ensure the person has maximum privacy and dignity and this is
retained throughout.
4.1.4. There should be a process in place to ensure that the bottle is
checked regularly to ensure that the expiry date has not passed and
that the liquid is clear.
4.1.5. Historically there was only one strength of buccal midazolam, 10mg
in 1ml, specifically designed for the treatment of seizures. These
products were unlicensed, and include Epistatus and UL Medicines
Buccal Midazolam.
4.1.6. A new product, Buccolam, which contains midazolam 5mg in 1ml is
licensed for the acute management of seizures in children. This
product is available in pre-filled syringes. There is a risk of confusion
due to the different strength of this product from those previously
available.
Page 4 of 35
4.1.7. To avoid confusion on writing FP10 prescriptions, buccal
midazolam should be prescribed by brand. The strength and
dose should always be stated.
4.1.8. Following review across the health economy, children newly initiated
on buccal midazolam will be prescribed Buccolam; there will be a
phased transfer of all children from the unlicensed product to
Buccolam. Patients/carers will have to receive appropriate training,
highlighting the difference in strength and hence volume required to
administer the prescribed dose before the transfer.
4.1.9. No formulation of buccal midazolam is currently licensed in adults; a
review regarding the transfer of adults to Buccolam will take place
following completion of the phased child transfer.
4.1.10. If the unlicensed products are used, the person, next of kin and
carers should be made aware of the unlicensed status of these
brands.
4.1.11. The contents of midazolam ampoules should not be used for
buccal administration.
4.1.12. Prepare the individual (and parent/carer as appropriate) for the
procedure in advance, as this will not be possible during a seizure.
4.1.13. Obtain informed consent by discussing the procedure specific to
the needs the individual taking into consideration their cognitive
development - again in advance - it will not be possible to obtain
consent during a seizure.
Page 5 of 35
4.1.14. Procedure for the administration of buccal midazolam
(steps 5 and 6 not required if Buccolam is the prescribed product)
No.
1.
2.
3.
4.
5.
6.
7.
8.
Action
Hand decontamination will be done,
as per Trust Policy, prior to carrying
out any procedure – if possible. It is
recognized that this is an emergency
procedure.
Note the time seizure starts and if
possible write it down. Follow the
person’s specific care plan or
Epilepsy Management Plan (EMP)
or protocol for instruction on when
medication should be given – usually
5 minutes after start of seizure.
Check when the person last had
buccal midazolam as rescue
treatment, ensuring that the
minimum time interval between
treatments has elapsed.
Check the prescription
sheet/pharmacy label against the
drug, dosage and expiry date.
Take extra care to check the
strength of the product is correct.
Withdraw prescribed dose of buccal
midazolam from bottle using oral
syringe provided.
Replace cap on bottle immediately.
If the cap is not replaced
immediately the liquid will evaporate
and some of the buccal midazolam
will precipitate, showing as white
particles in the liquid. The pack must
not be used if the liquid is not clear.
Rationale
To minimize cross infection and
promote health
Support the head, open the person’s
mouth, place syringe into buccal
cavity and administer half the
contents.
Repeat above step, administering
the remainder of the contents to the
buccal cavity on the other side of the
To increase the area for
absorption of medication, which
may increase speed of
absorption
To increase the area for
absorption of medication, which
may increase speed of
To ensure accurate and effective
delivery of the medication to the
person
To ensure accurate and effective
delivery of the medication to the
person
To ensure accurate and effective
delivery of the medication to the
person
To ensure accurate and effective
delivery of the medication to the
person
To ensure medication is effective
Page 6 of 35
No.
Action
mouth.
9.
10.
11.
12.
13.
14.
NB: If person is on their side (for
example lying in recovery position,
or a focal seizure is forcing them
onto their side) give all the medicine
into the buccal cavity that they are
lying on. Do not attempt to give half
in each side.
When Buccal Midazolam is
administered for the FIRST TIME,
please ring an ambulance.
Ensure the person is allowed
sufficient recovery time.
Do not give a subsequent dose if the
dose is expelled unless the care
plan/Epilepsy Management Plan
(EMP)/protocol details otherwise.
Monitor for any adverse effects,
effectiveness or lack of effectiveness
of the dose. Follow the care
plan/EMP/protocol if dose ineffective
If the seizure does not stop within 10
minutes of giving Buccal Midazolam
the person will need to go to hospital
immediately.
Thank the person, family/carer for
their cooperation.
15.
Record the procedure, care,
outcome and actions in the person’s
care records.
16.
Record the time of administration
and effects of buccal midazolam in
the care plan/EMP (and prescription
sheet if used), adding signature.
Rationale
absorption
To minimize risk of medication
being lost, swallowed or inhaled
To ensure safety of person
having the medication for the first
time
To ensure person’s safety
following administration of
medication
To minimize risk of person
receiving incorrect/extra dose
To ensure person’s safety
following administration of
medication
To ensure the person can receive
further treatment under medical
supervision
To promote and maintain positive
relationships with the person and
family/carer.
To maintain best practice
regarding record keeping (NMC
2008)
To ensure good communication
Page 7 of 35
Dial 999 for an ambulance: • if you have concerns about the individual’s breathing
• if they become injured and you have concerns for their
safety
• or as indicated in the seizure management plan
• if you have administered more than the prescribed dose
4.1.15. Background information (see individual Data Sheets for full
details)
Midazolam is a short acting benzodiazepine. It has been used for the acute
management of seizures, as an alternative to rectal diazepam1 2. The NICE
CG20 guideline stated3 “For many individuals and in many circumstances, buccal
midazolam is more acceptable than rectal diazepam and is easier to administer.
It should be used according to an agreed protocol drawn up by the specialist and
only used following training.”
Initial effects become apparent after approximately 5 minutes, but may take up to
10 minutes.
Paradoxical reactions e.g. agitation, restlessness and disorientation have been
reported following administration. Somnolence may occur for up to 2 hours; if this
lasts longer than two hours this should be documented and consideration should
be made as to whether future doses should be reduced to a level that reduces
somnolence but stops seizures.
Contraindications include hypersensitivity to the active substance, benzodiazepines
or to any excipients, myasthenia gravis, severe respiratory insufficiency, sleep
apnoea syndrome, severe hepatic impairment
Dosage should be individualised (e.g. if a child’s weight is markedly different
from that expected for a particular age band). See the current BNF/BNF for
Children for suggested doses. It is not licensed for use in children under 3
months. Although the BNF for Children/BNF state that these doses can be
repeated once after 10 minutes, it is important to consider the impact of a delay
in dialling 999 on the person experiencing a seizure. Repeat doses should only
be administered if necessary and agreed in the seizure management plan.
Contact the specialist epilepsy nurse or consultants with experience in the
1
Scott RC, Besag FM, Neville BG. Buccal midazolam and rectal diazepam for treatment of prolonged seizures in
childhood and adolescence; a randomised trial. The Lancet 1999; 353:623-26
2
McIntyre J, Robertson S, Norris E , et al. Safety and efficacy of buccal midazolam versus rectal diazepam for emergency
treatment of seizures in children: a randomised control trial. The Lancet 2005; 366:205-210
3
National Institute for Health and Clinical Excellence (NICE) 2004 CG20 The epilepsies: the diagnosis and management
of the epilepsies in adults and children in primary and secondary care
Page 8 of 35
management of epilepsy if you would like further advice on selecting a dose or
dosage interval.
Midazolam is classified as a Schedule 3 Controlled Drug. The main implications
of this classification are on writing an outpatient or discharge prescription.
These prescriptions must now state the dose, form, strength and a total quantity
in words and figures. They will only be valid for 28 days (I.e. the prescription
must be dispensed within 28 days of the date on the prescription). Midazolam
does not need to be stored in a CD cupboard, and records do not need to be
kept in a Controlled Drug Register.
If midazolam is required for inpatient use, it must be ordered in the CD order
book.
Page 9 of 35
4.2. Process: Rectal diazepam
4.2.1. An individual epilepsy management plan should be in place (see
example plan Appendix 2).
4.2.2. This epilepsy management plan should include: • Name
• Seizure descriptions and possible triggers
• Details of the person’s consent for the administration of rectal
diazepam (if the person is unable to give consent, details of
the outcome of a best interests meeting should be
documented)
• When rectal diazepam should be given
• Dose to be given
• How the person usually responds to treatment
• Whether a repeated dose can be given and after what time
interval
• Maximum number of doses that can be given in 24 hours
• When an ambulance should be called
• Who else to contact/inform of the seizure
4.2.3. At all times staff/carers should act within the care plan/seizure
management plan.
4.2.4. Ensure that the person has maximum privacy and dignity and this is
retained throughout.
4.2.5. Consideration should be given as to whether rectal diazepam can be
administered by a person of the opposite sex to the individual. If this
is deemed to be inappropriate for the individual, this should be
documented in the care plan and staffing arrangements made
accordingly.
4.2.6. There should be a process in place to ensure that the rectal
diazepam packaging is checked regularly to ensure that the expiry
date has not passed.
4.2.7. Prepare the individual (and parent/carer as appropriate) for the
procedure in advance, as this will not be possible during a seizure.
4.2.8. Obtain informed consent by discussing the procedure specific to the
needs the individual taking into consideration their cognitive
development - again in advance - it will not be possible to obtain
consent during a seizure.
Page 10 of 35
4.2.9. Procedure for the administration of rectal diazepam
No.
1
2
3
4
5
6
7
8
9
10
11
Action
Hand decontamination will be done, as
per Trust Policy, prior to carrying out any
procedure – if possible. It is recognized
that this is an emergency procedure.
Note the time seizure starts and if
possible write it down. Follow the
individual’s specific care plan or Epilepsy
Management Plan (EMP) or protocol for
instruction on when medication should be
given – usually 5 minutes after start of
seizure.
Check when the person last had rectal
diazepam as rescue treatment, ensuring
that the minimum time interval between
treatments has elapsed.
Check the prescription sheet/pharmacy
label against the drug, dosage and expiry
date.
Rationale
To minimize cross
infection and promote
health.
To ensure accurate
and effective delivery
of the medication to
the individual
To ensure accurate
and effective delivery
of the medication to
the individual
To ensure accurate
and effective delivery
of the medication to
the individual
Lie the adult on their side (or according to To make the person
care plan). If the person is a child, refer to as comfortable as
individual protocol. Ensure the dignity of
possible and
the person is maintained throughout.
maintain dignity
Put on disposable gloves.
To minimize cross
infection
Remove the cap on the tube and gently
To ensure the correct
insert the entire length (or half if three
dose is administered
years of age or younger) of the nozzle
into the rectum, pointing the spout
downwards and squeezing the tube firmly
between index finger and thumb.
Keep the pressure on the tube for a few
To ensure the correct
seconds.
dose is administered
Keeping the tube squeezed, withdraw
To ensure the correct
tube from rectum. Press the buttocks
dose is administered
together gently for a time.
Dispose of tube and gloves as per waste To ensure
disposal policy.
environment is
protected
Ensure the person is allowed sufficient
To ensure
Page 11 of 35
recovery time.
12
13
Monitor for any adverse effects,
effectiveness or lack of effectiveness of
the dose. Follow the epilepsy
management plan (EMP)/protocol if dose
ineffective (if there is no specific
guidance and the dose is ineffective, dial
999 for an ambulance.)
Thank the person, family/carer for their
cooperation.
14
Record the procedure, care, outcome
and actions in the individual’s care
records.
15
Record the time of administration and
effects of rectal diazepam in the care
plan, EMP (and prescription sheet if
used), adding signature.
individual’s safety
following
administration of
medication
To ensure
individual’s safety
following
administration of
medication
To promote and
maintain positive
relationships with the
person and
family/carer
To maintain best
practice regarding
record keeping (NMC
2008)
To ensure good
communication
Dial 999 for an ambulance: • if you have concerns about the individual’s breathing
• if they become injured and you have concerns for their
safety
• or as indicated in the seizure management plan
• if you have administered more than the prescribed dose
4.2.10. Background information
(see current Summary of Product Characteristics (SPCs) for full
information)
Rectal diazepam is a benzodiazepine licensed for the treatment of seizures. It
has a rapid onset of action (within 5 minutes). Paradoxical reactions e.g.
agitation, restlessness and disorientation have been reported following
administration. It is not licensed for use in children under 1 year of age.
Contraindications include Myasthenia Gravis, hypersensitivity to
benzodiazepines, severe or acute respiratory insufficiency/depression, sleep
apnoea syndrome, severe hepatic insufficiency.
Dose:
See the current BNF/BNF for Children for suggested doses. The dose should be
individualised; lower doses have been shown to be effective. Although dosage
Page 12 of 35
intervals are listed, it is important to consider the impact of a delay in dialling 999
on the person experiencing a seizure. Contact the specialist epilepsy nurse or
consultants with experience in the management of epilepsy if you would like
further advice on selecting a dose or dosage interval.
5. Consultation
This guidance has been developed in consultation with consultant
paediatricians and learning disability psychiatrists, and specialist nurses,
building on work with the previous Epilepsy Learning Disability Specialist
Nurses; the Drugs and Therapeutics Committee.
6. Training and Support
Training should be as described in the Joint Epilepsy Council document “A
guideline on training standards for the administration of buccal
midazolam”.
It is recommended that all carers should have received training in epilepsy
awareness and the administration of rectal diazepam/buccal midazolam
as rescue medication. Joint Epilepsy Council (JEC) guidelines recommend
that this training should be updated every 2 years. Administration should
be in line with the Trust Medicines Policy.
Unqualified social care staff must have received training in Epilepsy
Awareness, buccal midazolam administration and rectal diazepam
administration.
It is regarded as best practice that qualified nurses should have received
training in buccal midazolam administration.
7. References
•
•
•
•
•
•
•
•
•
•
•
•
Summary of Product Characteristics Stesolid©. eMC accessed 03/02/2016
Summary of Product Characteristics:Diazepam Rectubes© eMC accessed
03/02/2016
NICE Guideline CG 137. The epilepsies: the diagnosis and management of
the epilepsies in adults and children in primary and secondary care) 2012
NICE QS26. The epilepsies in adults 2013
NICE QS27. The epilepsies in children and young people 2013
BNF for Children 2015 2016
BNF 70
Report to Drugs and Therapeutics Committee 13th September 2013. Buccal
Midazolam products-patient safety. D Tait.
www.epilepsy.org.uk
A Guideline on training standards for the administration of buccal midazolam.
Joint Epilepsy Council
Learning Disability Policy no 12. 2003 South Warwickshire PCT
Administration of Epistatus© Buccal Midazolam – 10mg (Base) in 1ml sugar
free syrup to people who have epilepsy. Colchester Learning Disabilities
Service
Page 13 of 35
•
Policy on the safe administration of Epistatus© (Buccal Midazolam – 10mg in
1ml SF Syrup) to People who have Epilepsy. Humber Mental Health tNHS
Trust 2006.
8. Trust Associated Documents
• The Trust Medicines Policy and Associated Guidelines
• The Trust Resuscitation Policy
Page 14 of 35
Appendix 1
Guidance for the care of a person experiencing a seizure
When attending a person experiencing a seizure it is important for the carer to manage
the situation in an appropriate and competent manner.
The aim is to minimise the risk of injury to the individual and others in the immediate
vicinity and minimise the levels of embarrassment and anxiety.
It is good practice to have a seizure description and management plan for all people with
epilepsy.
1. Seizure types:
Seizures can be individual to the person, and may not follow the descriptions below.
Anyone who is responsible for the care of someone with epilepsy should have had a
basic training in epilepsy, in line with the Joint Epilepsy Council (JEC) guidelines.
A generalised seizure, which affects the whole brain, may present as an “absence” or a
“tonic/clonic” seizure or a variety of others – myoclonic/tonic/atonic etc. There is
complete loss of consciousness/awareness.
A focal (partial) seizure affects part of the brain and can be simple or complex in nature.
The signs and symptoms for each type of seizure are different.
1.1. Generalised seizure
•
Absence seizure
This type of seizure is most common in children but can be seen in adults. The
person may stare blankly into space and have slight twitching or eyelid fluttering.
Objects being held may be dropped. They are unaware of their “absence”. This
may be mistaken by others as daydreaming. There may be motor involvement,
e.g. head dropping, walking.
•
Tonic/clonic seizure
Typically, the seizures will present as convulsions. The person will
become unconscious. The person may have an aura (e.g. fatigue or headache)
which is familiar to him/her, but may not be able to communicate this.
(a) Tonic Phase
The body will stiffen. If standing, they will fall. The jaw will fix shut and the
tongue or lips may be bitten and bleeding. Respiration may arrest
Page 15 of 35
temporarily causing cyanosis and tachycardia. Pupils will be dilated and
unreactive to light.
(b) Clonic Phase
Muscle contractions of the entire body, resulting in jerky movements. Eye
rolling, facial grimacing and excessive salivation may occur. The person
may be incontinent of urine. These seizures may vary in length and are
individual to each person.
On recovery, the individual will usually be tired and want to sleep. There
may be a period of confusion.
•
Tonic seizure
Muscles stiffen possibly causing a sudden fall.
•
Atonic seizure
A sudden brief loss of muscle tone, which may result in a fall if standing.
Recovery is quick.
•
Myoclonic seizure
A brief contraction in muscles of a part of the body, causing a jerky
movement. The movement may be isolated or repetitive. The jerking could be
severe enough to make the individual fall.
1.2.
Focal (Partial) Seizure
Simple Focal (Partial) Seizure
Consciousness is not impaired and the seizure is confined to either rhythmical
twitching of a limb or part of a limb or to unusual sensations such as pins and
needles in a distinct part of the body.
Complex Focal (Partial) Seizure
This may start with an “aura” or warning which may be visual, auditory, taste, etc.
The person may have twitching, numbness, sweating,dizziness, nausea,
disturbances to hearing, vision, smell, or a strong sense of déjà vu. The person
may appear conscious but responsiveness may be impaired.
These seizures may be varied in length and may be accompanied with abnormal
movements such as plucking at clothing or smacking of lips.
The person may wander about aimlessly and behave irrationally or appear to be
confused.
A complex focal (partial) seizure may develop into a secondary generalized
seizure. The person will become unconscious and will usually have a tonic clonic
seizure.
A seizure description should be included in the person’s care plan or other
documentation related to their epilepsy.
Page 16 of 35
2
Care of the person experiencing a seizure
At all times the epilepsy management plan/protocol should be followed. The
points below give general instructions for care, which may be superceded by instructions
in the management plan.
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Remain calm.
Do not move the person unless they are in immediate danger. Remove
dangerous objects away from them.
Place a small pillow or other form of padding under the person’s head (if lying on
the floor).
Time and record seizures.
Do not attempt to restrain convulsive movements of the limbs.
Loosen restrictive clothing.
Leave dentures in. Do not force anything between the teeth.
The caregiver should be aware of any medication which has been prescribed for
the emergency management of seizures and the criteria for administration.
Maintain close observation and dial 999 for an ambulance if seizure is prolonged,
significant injury has occurred, they have trouble breathing, or as detailed in the
management plan.
If the person is lying down, place in the recovery position as soon as the seizure
is finished, if possible.
As the person recovers from the convulsion explain to them what is happening.
Remain with the person for at least 30 minutes after recovery, or as detailed in
the management plan.
Treat any injuries if sustained.
As soon as possible remove soiled clothing and make the person comfortable.
Fully record the event, including timings wherever possible.
Page 17 of 35
Appendix 2
Example Epilepsy Management Plan
Epilepsy Care Plan
Name
Date of Birth
Address
Telephone
Epilepsy Care Plan date
This care plan is intended to be used as a complete document: non-relevant pages may be
removed if clinically appropriate. Mandatory pages are 1 and either 13, 14 or 15 (i.e. the
relevant emergency plan).
Circle below the page numbers that are included in this plan
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Page 18 of 35
People involved in care:
Family/Carer
Community
nurse:
Address
Address
Telephone
Telephone
Care Provider
GP
Address
Address
Telephone
Telephone
Consultant
Other
Address
Address
Telephone
Telephone
Name D.O.B dd/mm/yy
NHS No
Epilepsy Management Plan date
This management plan is intended to be used as a complete document: non-relevant pages
may be removed if clinically appropriate.
Page 19 of 35
Epilepsy Medication
Dose
Times
Name
Rescue medication
Name
Dose
Please check medication recording sheet for most up to date list of medication
used to treat other health conditions.
Name D.O.B dd/mm/yy
NHS No
Epilepsy Management Plan date
This management plan is intended to be used as a complete document: non-relevant pages may
be removed if clinically appropriate.
Page 20 of 35
Seizure descriptions:
Type A
Before seizure
During seizure
Duration:
After seizure
Type B
Before seizure
During seizure
Duration:
After seizure
Name D.O.B dd/mm/yy
NHS No
Epilepsy Management Plan date
This management plan is intended to be used as a complete document: non-relevant pages may
be removed if clinically appropriate.
Page 21 of 35
Type C
Before seizure
During seizure
Duration:
After seizure
Type D
Before seizure
During seizure
Duration:
After seizure
Name D.O.B dd/mm/yy
NHS No
Epilepsy Management Plan date
Page 22 of 35
This management plan is intended to be used as a complete document: non-relevant pages may
be removed if clinically appropriate
Triggers:
Additional information
e.g. frequency/pattern
Sudep discussed?
Yes
No
If no, document reason in notes
name D.O.B dd/mm/yy
NHS No
Epilepsy Management Plan date
This management plan is intended to be used as a complete document: non-relevant pages may
be removed if clinically appropriate.
Page 23 of 35
Seizure Diary :Year …….
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sept
Oct
Nov
Dec
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Name D.O.B dd/mm/yy NHS No
Epilepsy Management Plan date
This management plan is intended to be used as a complete document: non-relevant pages may
be removed if clinically appropriate.
Page 24 of 35
First Aid for Seizures involving a fall or loss of consciousness
If ………………… has a seizure please…
Do this
9 Make. comfortable
9 Make sure the airway is clear
9 Support and protect the head
9 Move objects that could be
harmful
DO NOT
Put anything in his/her
mouth
Restrain any movements
Move him/her unless in
danger
Give anything to eat or
drink until he/she is fully
awake
9 Loosen tight clothing and
remove any glasses
9 Talk to him/her and give
reassurance
9 Follow the emergency
protocol
Following a seizure…
9
9
9
Put him/her in the recovery position when the movements have stopped
Stay with him/her. until he/she is fully awake but forat least 30
minutes
Record details in file and diary
Name D.O.B dd/mm/yy
NHS No
Epilepsy Management Plan date
This management plan is intended to be used as a complete document: non-relevant pages may
be removed if clinically appropriate.
Page 25 of 35
First Aid for Focal (Partial) Seizures
If …………………………. has a seizure
Do this
DO NOT
9 Guide him/her away from
any danger
Restrain him/her
9 Stay with him/her until fully
recovered
9 Be calm and reassuring
Act in a way that could
frighten him/her
Attempt to bring him/her
round
Assume that he/she. is
aware of what is happening
Give anything to eat or
drink until he/she is fully
awake
9 Explain anything he/she may
have missed
9 Follow the emergency
protocol
Following a seizure…
9
9
Explain anything he/she may have missed
Record details in file and diary
name D.O.B dd/mm/yy
NHS No
Epilepsy Management Plan date
This management plan is intended to be used as a complete document: non-relevant pages may
be removed if clinically appropriate.
Page 26 of 35
If ………….has an increase in the frequency of seizures please record them on the
seizure chart and contact GP, consultant or epilepsy nurse for advice.
Capacity assessment/best interests decision
Please include here details of any relevant decisions made.
Additional Information
Name D.O.B dd/mm/yy
NHS No
Epilepsy Management Plan date
This management plan is intended to be used as a complete document: non-relevant pages may
be removed if clinically appropriate
Page 27 of 35
SUDEP Information sheet
What is SUDEP?
Sudden Unexpected Death in Epilepsy is when a person with epilepsy dies
suddenly with no other cause to their death found. People with a learning
disability and epilepsy have a higher risk of SUDEP. The risk is lowered in those
with well controlled seizures.
An audit identified the following risk factors for SUDEP:
•
•
•
•
•
If you are a young adult
If you do not take your epilepsy medication as directed
If there are sudden changes to your epilepsy medication
If you only have seizures at night when you are sleeping or when
you wake up
If you have tonic clonic seizures
Ways to reduce your risk of SUDEP:
•
•
•
•
•
Take your epilepsy medication when you should.
Have clear guidelines of epilepsy medication changes from your GP,
Consultant or epilepsy nurse.
Keep an accurate diary of your seizures, the frequency, duration
and description if possible.
Do not drink too much alcohol
Access epilepsy services
It is not yet certain whether alarms or monitors, which may alert others if you are having a
seizure, are effective in preventing SUDEP. Please discuss with your doctor/nurse/care team
if you are considering buying one. More information is available online at:
https://www.sudep.org/alarms-and-monitors
name D.O.B dd/mm/yy
NHS No
Epilepsy Management Plan date
This management plan is intended to be used as a complete document: non-relevant pages may
be removed if clinically appropriate.
Page 28 of 35
Record o
Name
Name D.O.B dd/mm/yy
Date of training
Training provided by
NHS No
Epilepsy Management Plan date
This management plan is intended to be used as a complete document: non-relevant pages may
be removed if clinically appropriate.
Page 29 of 35
Emergency Epilepsy Plan
Emergency Protocol –NO PRN (rescue) medication
……………….. is not prescribed any PRN medication
CALL AN AMBULANCE (dial 999) (request a paramedic ambulance) if
he/she
has a convulsive seizure (“jerks” or “thrashes”) that lasts longer than
or
or
or
or
……..
has another seizure without recovering
has injured himself/herself
becomes cyanosed ( blue around lips)
If you become concerned about him/her
Other advice: Signed
Prescribing Doctor
Signed
Nurse
date
date
Signed
Patient
Signed
Carer
Name D.O.B dd/mm/yy NHS No
Epilepsy Management Plan date
This management plan is intended to be used as a complete document: non-relevant pages may
be removed if clinically appropriate.
Page 30 of 35
Emergency Epilepsy Plan
Emergency Protocol– with PRN medication
Protocol for the administration of Rectal Diazepam
Seizure type/s:
Usual duration of seizure:
After how long or how many seizures
should rectal diazepam be given?
Dose of rectal diazepam (in mgs)
When to call for an ambulance.
Who to contact/inform (e.g. family member,
carer)
Special instructions
Review date:
Signed
Prescribing Doctor
Signed
Nurse
date
date
Signed
Patient
Signed
Carer
Name D.O.B dd/mm/yy NHS No
Epilepsy Management Plan date
This management plan is intended to be used as a complete document: non-relevant pages may
be removed if clinically appropriate
Page 31 of 35
Emergency Epilepsy Plan
Emergency Protocol– with PRN medication
Protocol for the administration of Buccal Midazolam (Specify
Brand)
Seizure type/s:
Usual duration of seizure:
Brand name of Midazolam
After how long or how many seizures
should Buccal Midazolam be given?
Dose of Buccal Midazolam (in mgs)
When to call for an ambulance
Who to contact/inform (e.g. family
member, carer)
Special instructions (e.g. should procedure be
witnessed, situations when Midazolam should not be
used)
IMPORTANT!!!!!
When Buccal
Midazolam is
administered for the
FIRST TIME, dial 999
for an ambulance.
Review date:
Signed
Prescribing Doctor
date……
Signed
Patient
Signed
Nurse
date……
Signed
Carer
Name D.O.B dd/mm/yy NHS No
This management plan is intended to be used as a complete
Epilepsy Management Plan date
document: non-relevant pages may be removed if clinically appropriate
Page 32 of 35
Appendix 3 Good Practice Guidelines: For Paid Carers who Administer Buccal
Midazolam
Good Practice Guidelines: For Paid Carers who Administer Buccal Midazolam
Liquid
•
Buccal Midazolam is a licensed medication used outside its licence for the
emergency treatment of epilepsy.
•
Any concerns and side effects must be reported to the prescribing doctor.
•
Midazolam is available in multi-dose bottle with syringes under the brand names
of Epistatus /Suptamid and generic buccal midazolam liquid made by UL
Medicines
•
Midazolam is a schedule 3 controlled drug.
The implications of this are: Prescriptions must be dispensed within 28 days of
issue.
There are no storage implications for Midazolam. However, we would
recommend it is stored in a locked cupboard and a record of stock is kept for
monitoring.
•
All carers who are expected to administer Buccal Midazolam should be suitably
trained (as per JEC (Joint Epilepsy Council) guidelines) by a designated nurse.
•
Paid carers should have attended an epilepsy awareness training session in the
last 2 years or appropriate fresher (JEC standards)
•
Staff must also have completed own organisation medication and first aid
training.
Buccal Midazolam training will not be given to staff who do not meet this
standard.
Page 33 of 35
Training will be provided to small groups of carers, with individual time spent on
service users emergency protocols.
•
All patients prescribed buccal midazolam should have an epilepsy management
plan (EMP) that includes an emergency protocol that clearly defines when/how
much to administer.
•
Carers should maintain accurate
administration of buccal midazolam.
records
of
seizure
activity
and
the
Organisational Responsibilities
o
o
o
o
o
o
o
o
•
Organisations should have clear policies and procedures in place for the
management of epilepsy and emergency treatments
The organisation that employs the carers should provide supervision and
support to carers in the course of their duties.
Organisations are responsible for arranging /facilitating epilepsy
awareness and buccal midazolam training and refreshers for their staff.
Organisations must ensure that any staff who are nominated to attend
buccal midazolam training have attended epilepsy awareness training and
meet organisational standards in medication and first aid before attending
session
To facilitate appropriate risk assessments.
Follow medication policies; ensure medication is correctly labelled, stored,
in date and disposed of correctly.
Regularly check that medication is in date, has not crystallized or gone
cloudy. Discard and replace if required.
Ensure EMP’s / emergency protocol is in date and reviewed; the epilepsy
team must be contacted one month prior to EMP review date to arrange
review date.
Carers responsibilities
o To attend all training as directed.
o To always adhere to organisational policies and procedures.
o To follow the EMP (epilepsy management plan) and emergency protocol.
o Work within individual competence, identifying and reporting any gaps in
skills and competence
Page 34 of 35
•
Epilepsy Team Responsibilities
o To offer medical/nursing review of epilepsy and treatment
o Keep abreast of any developments in epilepsy management and use of
buccal midazolam
o To implement and review management plans and emergency protocols as
required
o Offer access to epilepsy awareness training and buccal midazolam
training
o Ensure all training meets national standards
o Provide documents for monitoring use of buccal midazolam
Supporting information/guidance
JEC: A Guideline on the training standards for the administration of Buccal Midazolam
EMP
Emergency protocol
Procedure for the administration of buccal midazolam
Stock record for Buccal Midazolam Liquid
Record of trained staff
Evaluation Sheet and record of use of epistatus
Epistatus drug information
(document originally produced by the Epilepsy Team, Learning Disability Service, Caludon Centre)
Page 35 of 35