Buccal/ Nasal Midazolam

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Buccal/ Nasal Midazolam

• Seizure Rescue Medication
• Training

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Learning Outcomes

• You will
• Be able to recognise prolonged and serial
  seizures and respond appropriately
• Be able to describe the appropriate conditions
  required to participate in the administration
• Be able to demonstrate through simulation the
  procedure for administering midazolam

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What is Midazolam?

• Is the pharmaceutical name for this drug, from a
  family of similar drugs called Benzodiazepines
• Other names and formulations for Midazolam
  include Hypnoval and most commonly Epistatus
• Midazolam is licensed as a sedative it is used in
  hospitals and clinics before clinical procedures.
  
• In the brain it acts as an effective anti
  epileptic

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How was Midazolam developed for community use?

• Used as a sedative since 1988?
• Used in epilepsy since 1997
• Community use developed in paediatric services/
  school age children
• Gradual introduction in to adult learning
  disability
• Now the most common form of rescue medication
• Recommendations for use in NICE and Paed SIGN,
  included in most formularies

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How Does Midazolam Work?

• Slowly dripped into nasal/buccal cavity
• Absorbed through mucosal skin surfaces
• Good blood supply to these areas
• Travels via the heart and lungs to the brain
• Boosts GABA and dampens down seizure activity

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Effects of Midazolam

• Effective anti epileptic within 10 minutes
• Can cause sedation/ severe drowsiness
• Recovery rates vary
• May irritate nasal passages or cause discomfort
  to gums
• Can (rarely) depress breathing
• Can (rarely) cause restlessness/ hyper activity
• Over use can cause dependence and be ineffective

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Indications for use

• Midazolam is prescribed where the individual has
  a history of seizures which are prolonged/ serial
  , most commonly with people who also have LD
• Prolonged seizures are around 5 minutes for tonic
  clonic seizures. Serial seizures occur one after
  the other with no recovery between

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Indications for Use 2.

• Midazolam is used as a rescue medication early on
  in the development of the seizure/s to try to
  prevent status epilepticus, improve outcome from
  seizure/s and quality of life
• Status Epilepticus is a continued state of
  seizure lasting for 30 minutes.

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Convulsive Status Epilepticus

• A continuous Tonic Clonic seizure or repeated
  Tonic Clonic seizures lasting 30 minutes
• This can be life threatening and requires medical
  attention

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Non Convulsive Status Epilepticus

• Any seizure can develop into status
• Complex partial status relatively common in
  Learning disability.
• This condition can be difficult to diagnose,
  consciousness is often impaired but not lost
  completely.
• Can continue for long periods.
• Can adversely affect health in vulnerable people

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General Information

• Most people with LD requiring rescue med are
  prescribed midazolam (Epistatus)
• GPs and specialists are willing to prescribe
• Carers and relatives need instruction in its use
• For paid care staff recognised training and a
  signed protocol are essential

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Midazolam Liquid

• Sugar free
• Child proof bottle
• 4x1ml oral syringes
• 10mg in 1ml of liquid
• Adult dose usually 10mg
• Can be given while sitting upright
• Epistatus not Licensed at all

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Considerations about method of administration

• Buccal versus Nasal Route
• Type of Seizure
• Level of consciousness
• Positioning of the individual
• How much saliva is produced
• Preparation for giving

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Buccal Route (side of mouth)

• Insert syringe into the mouth, between the lower
  gum and cheek
• Point syringe to back of mouth on insertion then
  angle downwards into the buccal cavity
• Slowly push syringe down until empty
• Replace cap on bottle

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Nasal Route

• Place syringe at the entrance to one nostril
• Slowly push plunger, dripping midazolam
• Alternate between both nostrils
• Replace cap on bottle

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Management of Midazolam

• Storage
• Shelf life
• Recording amount
• Recording use
• Recording outcome in the epilepsy care plan

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Ethical Issues

• Duty Of Care
• Consent
• Invasive
• Fear of Legal Action

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Why do we use midazolam in the community?summary

• We know that early treatment for seizures is more
  effective preventing SE
• We may be preventing brain damage even death
• We may be preventing other poor health (e.g
  aspiration infection)
• Prevents disruption, decreasing hospitalisation
• Best outcomes,individual, family and carer

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Joint Epilepsy Council for the UK and Ireland

• When Midazolam is prescribed there should be no
  unreasonable barriers to its use