Buccal Midazolam Directions- Quick-Guide (For Epileptic Seizures)

What is midazolam?
Midazolam belongs to a group of medicines called benzodiazepines. It is a relation of diazepam. It has traditionally used for sedation. Midazolam can be used to treat a number of different conditions, including seizures. It is prescribed for some but not all epileptics (eg) if a person has a history of longer seizures (also known as fits). If a seizure lasts for more than five minutes, it may be difficult to stop unless treatment is given. It is therefore important that rapid treatment is given to stop the seizures and therefore prevent status epilepticus. Status epilepticus is a condition where a person has a seizure (convulsion or fit) or a series of seizures that last for 30 minutes or more, without a complete recovery of consciousness.

How is buccal midazolam given?

The midazolam solution should be placed against the sides of the gums and cheek so that the medicine is absorbed directly into the bloodstream. This is known as the buccal or oromucosal route. Administer slowly. If the medicine is swallowed accidentally, it might not work as quickly. Nowadays, Buccal Midazolam is prescribed mainly in an easy to use pre-filled syringe eg. Epistatus Pre-filled syringe or Buccolam pre-filled syringe.

Using Buccolam^® pre-filled oral syringes or Epistatus^® pre-filled oral syringes

·         Check the dose and expiry date of the pre-filled syringe provided.

·         Remove the oral syringe from the packaging.

·         Place the syringe into the side of the person’s mouth, between the gums and teeth.

·         If possible, divide the dose so you give half into one cheek and the remaining half into the other cheek.

·         Slowly push the plunger of the syringe down until the syringe is empty.

·         Watch for any breathing difficulties.

·         Confirm that the seizure has stopped.

 

·         Dispose of syringe safely

If the patient is going to a hospital or a medical professional after administering, it is good practice to send the used syringe with the patient so the medical professional can see exactly what has been administered. Also, t aim to record the time the buccal midazolam was administered (this is important in cases where further doses need to be administered).

Never use another person’s Buccal Midazolam for a person it is not prescribed for

Only administer Buccal Midazolam that is specifically prescribed for that patient. NEVER use another person’s buccal midazolam for a patient it is not prescribed for.

How long does it take to work?            

Buccal Midazolam takes a few minutes to work so the seizure is likely to continue for a few minutes after administering. Some of the midazolam may flow out of the side of the mouth (especially as the patient is undergoing seizures); however once the majority stays in the mouth then the patient will get sufficient amount into the bloodstream to work.

When to administer?                               

1^st Dose: Administer if a seizure lasts for five minutes (as the majority (75%) of seizures will expire within five minutes and buccal midazolam may cause severe drowsiness)

The amount of midazolam buccal liquid used depends on weight and age. The dose for children over 10 years and adults is 10mg (1ml)

·         For younger children, doses come in 2.5mg, 5mg and 7.5mg; administer the dose the doctor prescribes

·         The doctor will prescribe the correct dose based on the child’s age and weight so you do not have to worry about picking correct dose. Simply use the buccal midazolam labelled for that patient

2^nd Dose: ONLY GIVE A 2^ND DOSE IF ADVISED BY PRESCRIBING DOCTOR AND AFTER THE ADVISED TIME PERIOD. For adults (and some children), a second dose may be given 10 minutes later if no response is apparent and the patient is breathing normally. If the patients’ breathing becomes shallow, call an ambulance and do not administer a second dose. If a response is not seen after a further 5 minutes, call for assistance. Ambulance staff may repeat the dose if deemed appropriate.

 What to do if a seizure starts again: Generally a 3^rd dose is not advised without medical supervision. An ambulance should be called if seizures continue. The maximum recommended dose in 24 hours is 20mg for adults (or less for children). Please follow the advice given by the initiating specialist.

What are the side effects of buccal midazolam?

• Drowsiness and sedation – recovery is usually fast.
• Amnesia or short-term memory loss – the person may not remember having had a seizure.
• Breathing difficulties – the person is unlikely to have breathing difficulties if midazolam is given at the correct dosage. If breathing difficulties do develop, seek medical assistance.
• Restlessness, agitation and disorientation – these can occur but are usually rare.

Storage
Keep midazolam at room temperature (not in a fridge). Store away from bright light or direct sunlight and away from heat. Always double check expiry date (written on side of pack) and get a replacement prescribed by your GP if nearing expiry.

 It is good practice to have a trained first aider on hand if a person is undergoing a seizure

Disclaimer: This is a general guide; individual patients will have more specific guidance depending on their type of epilepsy and seizure history. Always follow the prescribing doctor’s advice. If a person is prescribed Buccal Midazolam, it is good practice to have written administration instructions or protocol specific for that patient (eg) When to administer? Can a 2^nd dose be administered? After how long?

For comprehensive and free health advice and information call in to Whelehans, log on to www.whelehans.ie or dial 04493 34591. Email queries to info@whelehans.ie. Find us on Facebook.

Thank you: Thank you Great Ormond Street Hospital (London) for some of the Buccal Midazolam guidance in this health blog