Given that when a child is having a seizure, it can be a stressful situation, it is highly recommended that you familiarize yourself with that child’s seizure emergency care plan before hand
Considerations:
- Given that the medication can be dispensed in different formats and dosages, the school nurse should always review the medication and order upon receiving it at the school
- Given that when a child is having a seizure, it can be a stressful situation, it is highly recommended that you familiarize yourself with that child’s seizure emergency care plan before hand
- NOTE: The student’s Seizure Action Plan should indicate when 911 should be called (i.e. on immediate onset of seizure, after the student has been having a seizure for 5 minutes student hasn’t responded to the rescue medication, etc.)
- Store the Seizure Action Plan in a location that is easily accessible during a seizure
- Store the Seizure Observation Recording Form with the seizure medication
- Secured, but accessible storage of the medication should be considered in the student’s medication administration plan
- The school nurse develop a plan to systematically check the expiration date on the medication to ensure the medication has not expired
- A multi-dose vial of midazolam vial that has been opened accessed (i.e. needle-punctured) should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for the opened vial
- Be sure to ensure the child’s privacy and confidentiality when calling for assistance.
- Do not say the child’s name over the PA system or walkie-talkie
- If possible, have someone assist with removing onlookers and other students to provide the child with privacy
- The medication can be very irritating to the nasal membranes and create a burning sensation, additional adult assistance may be required to administer the medication
- NOTE: The Food and Drug Administration (FDA) has not approved lorazepam or midazolam for administration via this medication route. Since healthcare providers are currently prescribing the medications via this route, if you have questions or concerns, discuss this with the prescribing healthcare provider or the pharmacist
Supplies:
- Seizure Action Plan/Healthcare provider order
- Student Individualized Healthcare Plan
- Seizure Observation Recording Form
- Syringe
- Needle
- Mucosal Atomizer Device (MAD) (Atomizer)
- Prescribed medication
- Gloves
- Bulb syringe
- Sharps container
First aid for a seizure:
- If someone is present, have them call for assistance
- To assist with removing other students/staff from the classroom/area and assist with obtaining the student’s Seizure Action Plan
- Ease the student onto a flat surface such as the floor being sure not to move the student any more than is necessary
- Turn the child onto his/her side to allow vomit/phlegm to be expelled rather than inhaled
- Place something soft under the child’s head to protect them from injury
- Ensure the child’s airway is not obstructed
- Loosen tight clothing around the child’s neck
- Do not restrict the child’s arms or legs
- Ensure there is no furniture or objects close to the child that could injure him/her
- Review the child’s Seizure Action Plan
- Gather the emergency medication and needed supplies in case seizure lasts longer than designated time frame
Procedure:
- Identify that symptoms of prolonged seizure are present and that based on the student’s Seizure Action Plan, emergency medication needs to be given
- Call for assistance, if you have not already done so
- Ask that another school staff person call 911 or emergency medical services if indicated in the student’s Seizure Actin Plan
- Note: The student’s Seizure Action Plan should indicate when 911 should be called (i.e. on immediate onset of seizure, after the student has been having seizure for 5 minutes, student hasn’t responded to rescue medication, etc.)
- Note time of seizure onset on the Seizure Observation Recording Form
- If the student is not already in a side lying position, move the student to a side lying position, if possible
- Explain the procedure to the student at their level of understanding
- If possible, wash your hands
- Assemble the needed supplies and place on a clean surface
- Review the six rights of medication to be sure:
- The right student
- The right medication
- The right dose
- Being given at the right time
- Being given by the right route
- Being given for the right reason
- Check the medication expiration date
- Review the student’s allergy status
- Ensure proper documentation of parent/guardian authorization to administer medication
- Follow the student’s Seizure Action Plan and ensure that the proper amount of time has passed prior to administering the student’s seizure medication
- Put on gloves, if available
- Review the six rights again to be sure that it is:
- For the right student
- The right medication
- The right dose
- Being given at the right time
- Being given by the right route
- Being given for the right reason
- Remove plastic wrap from syringe, needle, and atomizer
- Place the needle onto the syringe, twist to lock into place
- Remove cap from the needle
- Remove the cap from the vial of medication
- Pull back the plunger in the syringe to the number of millimeters (mL) needed for the prescription dose
- Insert the needle into the vial and push the plunger to insert the air into the vial
- Turn the vial of medication upside down
- Pull back on the plunger to withdraw the prescribed amount of medication
- If there are air bubbles in the liquid in the syringe, tap the side of the syringe to bring the bubbles to the top
- Push the plunger just enough to push the bubbles back into the vial
- Pull the plunger back again to draw the right amount of liquid into the syringe
- Pull the needle and syringe out of the vial and verify the dose of medication
- Replace cap on needle
- Twist off or remove the syringe from the needle
- Discard needle into sharps container
- Attach the atomizer tip to the syringe and twist into place
- Look in the student’s nostrils to determine if there is fluid or mucous in the nostrils
- If drainage or mucous is present, use a bulb syringe to remove it
- If bulb syringe is not available, medication can still be administered if drainage or mucus is present
- Using your free hand to hold the crown of the head stable, place the top of the atomizer snugly against the nostril aiming slightly up and outward
- Quickly compress the syringe plunger to deliver half of the medication into the nostril
- Move the device over to the opposite nostril and administer the remaining medication into that nostril
- The student may grimace or appear more restless momentarily after the medication is given
- If the student is not already lying on their side, place the student on their side
- Note the time of medication and document on Seizure Observation Recording Form
- If EMS/911 has not been called yet, call 911 or EMS services if indicated on Student’s Seizure Action Plan
- Stay with the student, monitoring breathing
- If breathing stops, begin rescue breaths
- Instruct someone to bring an AED, if available
- If breathing and heartbeat stop, begin CPR
- Once rescue squad arrives, inform them of medication administered, including type of medication, dose and time
- Remember to dispose of all used equipment and bottles of medicine safely out of the reach of children
- Remove gloves
- Wash hands
- Document the date, time and dose of medication given in addition to what was observed during the seizure on the documentation log
- Follow up with the parent or guardian and healthcare provider, as needed
References:
Butler, S.M., Boucher, E.A., Tobison, J., & Phan, H. (2020). Medication use in schools: Current trends, challenges, and best practices. J Pediatr Pharmacol Ther., 25(1), 7–24. doi: 10.5863/1551-6776-25.1.7
Centers for Disease Control and Prevention. (2019, June 20). Questions about multi-dose vials. Accessed June 23, 2023, from https://www.cdc.gov/injectionsafety/providers/provider_faqs_multivials.html#:~:text=If%20a%20multi%2Ddose%20has,date%20for%20that%20opened%20vial.
Centers for Disease Control and Prevention. (2022, January 2). Seizure first aid. Retrieved June 6, 2023, from https://www.cdc.gov/epilepsy/about/first-aid.htm
Children’s Healthcare of Atlanta, Inc. Intranasal midazolam (Versed). Retrieved June 23, 2023, from https://www.choa.org/~/media/files/Childrens/medical-professionals/nursing-resources/intranasal-versed.pdf?la=en
Children’s Hospital Colorado. (2016, June 6). How to give your child midazolam. . Retrieved June 23, 2023, from https://www.youtube.com/watch?v=yTTAnj_IgMs&t=1s
Epilepsy Foundation of America. (2020). Seizure training for school nurses: Caring for students. [On-demand course]. Retrieved June 23, 2023, from https://learn.epilepsy.com/courses/take/school-nurse-OD-v2a/lessons/45652454-course-introduction
Hartman, A. L., Devore, C. D., Section on Neurology, American Academy of Pediatrics, Council on School Health, American Academy of Pediatrics, & Doerrer, S. C. (2016). Rescue medicine for epilepsy in education settings. Pediatrics, 137(1), 10.1542/peds.2015-3876. https://doi.org/10.1542/peds.2015-3876
Nationwide Childrens. (2023). Intranasal midazolam (Versed®) – vial. Retrieved June 23, 2023, from https://www.nationwidechildrens.org/-/media/nch/family-resources/helping-hands/documents/hhv277.ashx NH Family Voices. (2016, July 15). Intranasal midazolam. Retrieved June 23, 2023, from https://www.youtube.com/watch?v=g-43N5X75XU
Procedure last reviewed: February 24, 2025
Procedure last updated: February 24, 2025
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