Administration of Ready-to-Use Intranasal Seizure Medication

<< NEUROLOGICAL

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
  • Store the seizure emergency plan in a location that is easily accessible during a seizure
  • Be sure to check expiration date on the medication bottle
  • Midazolam can be stored at room temperature and there is no specific expiration date once the medication has been opened
  • Secured, but accessible storage of the medication should be considered in your medication administration plan
  • 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 emergency action plan
  • Documentation log
  • Prescribed medication
  • Gloves
  • Bulb syringe
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First aid for a seizure:

  1. Call for assistance if someone else is present.
  2. Place the child on a flat surface such as the floor being sure not to move the child any more than is necessary
  3. Turn the child onto his/her side to allow vomit/phlegm to be expelled rather than inhaled
  4. Place something soft under the child’s head to protect them from injury
  5. Ensure the child’s airway is not obstructed
  6. Loosen tight clothing around the child’s neck
  7. Do not restrict the child’s arms or legs
  8. Ensure there is no furniture or objects close to the child that could injure him/her
  9. Review the child’s emergency care plan
  10. Gather the emergency medication and needed supplies in case seizure lasts longer than designated time frame

Procedure:                                                  

  1. If possible, wash your hands
  2. Assemble the needed supplies
  3. Put on gloves
  4. Check the vial of medication to ensure that it is:
    • For the right child
    • The right medication
    • The right dose
    • Being given at the right time
    • Being given by the right route, and
    • Not expired
  5. Ensure that the proper amount of time has passed prior to administering the student’s seizure medication
  6. If there is another adult present, have them call EMS/911 as you administer the medication
  7. Look into the child’s nostrils to determine if there is fluid or mucous in the nostrils
  8. If drainage or mucous is present, use a bulb syringe to remove it
  9. When ready to use, open the blister packaging
    • Review medication blister pack for specific directions on how to open
  10. Remove the nasal spray unit carefully
  11. Hold the nasal spray unit with your thumb on the bottom of the plunger and your middle and index fingers on each side of the nozzle
  12. Do not press the plunger yet
    • If you press the plunger now, you will lose the dose
  13. Using your free hand to hold the crown of the head stable, place the tip of the nozzle into one nostril until your fingers, on either side of the nozzle, touches the bottom of the nose
  14. Press the plunger firmly to deliver the dose of the medication
    • Make sure to firmly press the plunger using one motion
    • The student does not need to breathe deeply when you give the medicine
  15. Remove the nozzle from the nostril after giving the dose
  16. Remove gloves
  17. If EMS/911 has not been called yet, call 911 or EMS services
  18. Stay with the child, monitoring breathing
  19.  If breathing stops, begin rescue breaths
  20. If breathing and heartbeat stop, begin CPR
  21. Once rescue squad arrives, inform them of medication administered, including type of medication, dose and time
  22. Remember to dispose of all used equipment and medicine safely out of the reach of children
  23. Wash hands
  24. Document the date, time and dose of medication given in addition to what was observed during the seizure on the documentation log
  25. Follow up with the parent or guardian and healthcare provider, as needed

References:

Bowden, V. R., & Greenberg, C. S. (2012). Pediatric nursing procedures. Chapter 64: Medication Administration: Nasal (Third Edition). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.

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

Hartman, A.L., Devore, C.D.L, American Academy of Pediatrics and the Section on Neurology, et al. (2016). Rescue medicine for epilepsy in education settings. Pediatrics, 137(1):e20153876. Retrieved April 8, 2020, from https://pediatrics.aappublications.org/content/137/1/e20153876.

Holsti, M., Sill, B.L., Firth, S.D., Filloux, F.M., Joyce, S.M., Furnival, R.A. (2007).  Prehospital IN Midazolam for the Treatment of Pediatric Seizures.  Pediatric Emergency Care, 23(3).

Lagae, L. (2011). Clinical practice: The treatment of acute convulsive seizures in children. Eur J Pediatr, Apr;170(4):413-8. doi: 10.1007/s00431-011-1403-z. Epub 2011 Feb 8.

National Association of School Nurses. (2018). School nursing evidence-based clinical practice guideline: Students with seizures and epilepsy. Retrieved April 8, 2020, from https://www.pathlms.com/nasn/courses/8992

Neurelis. (2020). Instructions for use. Retrieved April 9, 2020, from https://www.valtocohcp.com/resources.

Prescriber’s Digital Reference (PDR). 2020. Lorazepam drug summary. Retrieved April 8, 2020, from https://www.pdr.net/drug-summary/Lorazepam-Intensol-Oral-Concentrate-lorazepam-2668.

Wilfong, A. (2020). Management of convulsive status epilepticus in children. In a D.R. Nordli, Jr. (Ed.), UpToDate. Retrieved: April 8, 2020.

Wilfong, A. (2020). Seizures and epilepsy in children: Refractory seizures and prognosis. In a D.R. Nordli, Jr. (Ed.), UpToDate. Retrieved: April 8, 2020.

Wolfe, T.A., Braude, D.A. (2010).  Intranasal Medication Delivery for Children: A Brief Review and Update.  Pediatrics, 126, 532-37.

Wolfe, T.A., Macfarlane, T.C.  (2006).  Intranasal Midazolam Therapy for Pediatric Status Epilepticus.  American Journal of Emergency Medicine, 24, 343–46.

UCB. (2019). Instructions for use NAYZILAM® (midazolam) nasal spray. Available at: https://www.ucb-usa.com/up/ucbusa_com_kopie/documents/Nayzilam_INST.pdf. Retrieved: April 9, 2020

Procedure last reviewed: October 5, 2021
Procedure last updated: October 5, 2021

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