Download Rescue Medicine for Epilepsy in Education Settings

CLINICAL REPORT
Guidance for the Clinician in Rendering Pediatric Care
Rescue Medicine for Epilepsy
in Education Settings
Adam L. Hartman, MD, FAAP, Cynthia Di Laura Devore, MD, and the SECTION ON NEUROLOGY, COUNCIL ON SCHOOL HEALTH
Children and adolescents with epilepsy may experience prolonged seizures
in school-associated settings (eg, during transportation, in the classroom,
or during sports activities). Prolonged seizures may evolve into status
epilepticus. Administering a seizure rescue medication can abort the seizure
and may obviate the need for emergency medical services and subsequent
care in an emergency department. In turn, this may save patients from the
morbidity of more invasive interventions and the cost of escalated care.
There are significant variations in prescribing practices for seizure rescue
medications, partly because of inconsistencies between jurisdictions
in legislation and professional practice guidelines among potential first
responders (including school staff). There also are potential liability issues
for prescribers, school districts, and unlicensed assistive personnel who
might administer the seizure rescue medications. This clinical report
highlights issues that providers may consider when prescribing seizure
rescue medications and creating school medical orders and/or action plans
for students with epilepsy. Collaboration among prescribing providers,
families, and schools may be useful in developing plans for the use of seizure
rescue medications.
BACKGROUND
Nearly 1% of US children have a lifetime prevalence of epilepsy, making
epilepsy one of the most common neurologic diagnoses.1 With the
advent of the Individuals with Disabilities Education Act (Pub L No. 101476 [1990]) and Individuals with Disabilities Improvement Act (Pub
L No. 108-446 [2004]), the vast majority of children and adolescents
with epilepsy attend some form of school outside the home, and thus,
assurance of the safety of students with epilepsy is an important
aspect of daily school life. Some patients have seizures that are well
controlled by medicines, but a significant proportion will never achieve
complete seizure control.2 Importantly, it is more difficult to stop a
prolonged seizure than a brief seizure, and the longer the seizure, the
longer the recovery period.3 Therefore, it is recommended that school
PEDIATRICS Volume 137, number 1, January 2016:e20153876
abstract
This document is copyrighted and is property of the American
Academy of Pediatrics and its Board of Directors. All authors have
filed conflict of interest statements with the American Academy
of Pediatrics. Any conflicts have been resolved through a process
approved by the Board of Directors. The American Academy of
Pediatrics has neither solicited nor accepted any commercial
involvement in the development of the content of this publication.
Clinical reports from the American Academy of Pediatrics benefit from
expertise and resources of liaisons and internal (AAP) and external
reviewers. However, clinical reports from the American Academy of
Pediatrics may not reflect the views of the liaisons or the organizations
or government agencies that they represent.
The guidance in this report does not indicate an exclusive course of
treatment or serve as a standard of medical care. Variations, taking
into account individual circumstances, may be appropriate.
All clinical reports from the American Academy of Pediatrics
automatically expire 5 years after publication unless reaffirmed,
revised, or retired at or before that time.
DOI: 10.1542/peds.2015-3876
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2016 by the American Academy of Pediatrics
To cite: Hartman AL, Devore CDL, AAP and the SECTION ON
NEUROLOGY, et al. Rescue Medicine for Epilepsy in Education
Settings. Pediatrics. 2016;137(1):e20153876
FROM THE AMERICAN ACADEMY OF PEDIATRICS
personnel be aware of emergency
intervention measures that are
needed in the school setting in the
event of a seizure. Some students
may experience prolonged seizures
(ie, >5 minutes) or clusters of
multiple brief, recurrent seizures
that will require pharmacologic
intervention.4 The goal of this report
is to make prescribing professionals
(physicians, physician assistants,
or nurse practitioners who are
licensed to prescribe medicine in
their state) aware of some of the
issues faced by school personnel
who care for students with an
established diagnosis of epilepsy and
known responses to seizure rescue
medications. A recent report from
the United Kingdom recommended
better integration between schools,
providers, and families of students.5
Similar issues have been discussed
regarding school-based management
of asthma, diabetes, and food
allergies.6–8
SCHOOL ACTION PLANS FOR STUDENTS
WITH EPILEPSY
All students with special health
care needs, including children with
epilepsy, warrant advanced thought
and planning by a team of the
medical home, the school home, and
the family home before attending
school. Seizure management can be
challenging for school personnel,9
especially when school nurses are
not available and unlicensed assistive
personnel (ie, people working in the
school setting who volunteer to be
trained by a school nurse to assist a
child or adolescent through an action
plan) are available until medical
help arrives. Ideally, school nurses
rely on prescribing professionals for
medical orders to manage children
with epilepsy in the school setting.
School nurses may then write
effective action plans based on those
medical orders in simple language,
such as “If you see this …, then do
this….” for use by school unlicensed
assistive personnel whom the
2
school nurse has trained to assist a
child in the school nurse’s absence.
However, in settings where there
are no school nurses, some schools
may ask prescribing professionals
to provide them with an action plan
instead of technical medical orders,
and some may even ask prescribing
professionals to provide training to
unlicensed assistive personnel or
other school staff. In those instances,
prescribing professionals may be
the ones to create a school action
plan or to modify a generic one (ie,
from www.epilepsyfoundation.org)
and modify customizable action plan
templates. An important component
of these plans is communication from
school personnel to the family and/
or physician about the frequency of
reporting seizure rescue medication
use (both to make them aware of a
lowered seizure threshold and to
reassess the adequacy of standing
medication doses). Links to other
information on epilepsy in school
also can be found on the American
Academy of Pediatrics Council on
School Health Web site (www2.aap.
org/sections/schoolhealth, under
“Resources”).
There are certain factors for
prescribing professionals to consider
when writing a seizure action
plan.10 In general, seizure rescue
medications are given once a seizure
has lasted 5 minutes to prevent
progression to status epilepticus, but
this can be modified on the basis of
observations made by those caring
for the patient at home and school.4
For example, some patients have
short seizures that, if allowed to
continue for longer than 1 minute,
will result in status epilepticus. In
this case, the provider may prescribe
seizure rescue medications to be
given as soon as the seizure begins.
In considering what to include in
medical orders or an action plan, the
prescribing professional typically will
account for concomitant medications
and past reactions to different
medicines. Other factors to consider
include an understanding of when a
child is safe to remain in school after
a seizure or when further medical
care outside of the school setting is
indicated.
SEIZURE RESCUE MEDICATION
OPTIONS
Prescribing professionals have a
number of medication options, each
with distinct properties. Standard
medication references are available
for further information on each drug.
Rectal Diazepam Gel
One of the most widely used seizure
rescue medications, rectal diazepam
gel is particularly useful for patients
when oral administration of a
seizure rescue medication may be
contraindicated.11–16 However, it
requires a patient to be partially
undressed, which can be viewed as
problematic for the patient, school
staff, and other students, especially
in partially conscious students when
there is no ready means of privacy
to preserve the patient’s dignity.
Families may appreciate consultation
about these issues before formulation
and implementation of an action plan.
Furthermore, school nurses may not
always be available to administer
the medication, such as on the school
bus or athletic field, leaving the
medication administration to other
personnel who may be unwilling or
uncomfortable with engaging in an
activity that could be viewed as an
intimate or invasive interaction with
a child.
Midazolam
Midazolam is increasingly being
used by emergency medical services
because of its short elimination halflife (2.5 hours), allowing patients
to be more awake when they arrive
in the emergency department.
An oral syrup (2 mg/mL) is also
available and can be used for buccal
administration, with the patient
lying on his or her side, provided
FROM THE AMERICAN ACADEMY OF PEDIATRICS
the patient does not have copious
secretions or emesis during the
seizure.17 Some pharmacies have also
adapted the use of syringes to deliver
the intravenous form of midazolam
intranasally (eg, via an atomizer),
and this has been demonstrated to
be effective when administered by
family caregivers.18,19 One attractive
feature of midazolam is that it avoids
the inconveniences and emotional
discomfort associated with rectal
diazepam gel. Premeasured syringes
may improve the safety of this
medication in school settings (ie,
similar to rectal diazepam gel).
Unlicensed assistive personnel
typically are not asked to administer
this medicine if it has not been
dispensed in a premeasured syringe
(similar to rectal diazepam gel). If the
intranasal formulation is prescribed,
then additional training of school
personnel may be considered
because this is a relatively new route
of administration.
Lorazepam
Lorazepam is another
benzodiazepine available as an
oral solution (2 mg/mL) and can
be used for oral administration,
provided the patient does not
have copious secretions or emesis
during the seizure.20 However, it is
recommended that lorazepam be
refrigerated, making it less practical
for settings outside of school.
Similar to midazolam, premeasured
syringes may improve the safety of
this medication in school settings.
Unlicensed assistive personnel
typically are not asked to administer
this medicine if it has not been
dispensed in a premeasured syringe
(similar to rectal diazepam gel).
Clonazepam Orally Disintegrating
Tablet
Available as an orally disintegrating
tablet in different doses, clonazepam
is another option.21 Prescribers may
include specific instructions about
positioning a child on his or her side
to drain secretions, as well as how to
PEDIATRICS Volume 137, number 1, January 2016
safely position the medication into
the buccal mucosa to avoid injury by
a patient’s clenched teeth.
PRACTICAL ISSUES IN EDUCATIONAL
SETTINGS
Initial considerations of both the
type and timing of seizure rescue
medication administration include
the cognitive awareness of the
student and other students in that
setting, as discussed previously.
Medical intervention does not stop
with the initial administration of
the seizure rescue medication.
Adverse effects of all seizure rescue
medications include decreased
respirations, oversedation, and
cardiopulmonary instability, which
may vary in severity depending on
the duration of the seizure, dose of
the seizure rescue medication, and
interactions with other medicines.22
Schools generally appreciate
guidance from the prescribing
professional about management of
potential adverse effects of seizure
rescue medications, either outlined
in medical orders to a school nurse or
in simple language of an action plan
for unlicensed assistive personnel.
As with any medical emergency,
the availability of cardiopulmonary
resuscitation–trained personnel
is suggested. With seizure
rescue medications, prescribing
professionals may provide guidance
about the types of situations in which
school personnel should seek further
medical assistance if the student’s
seizure does not stop or if there is
a concern for further seizure- or
treatment-related complications.
On one hand, this is particularly
important for a child who is not
responding to treatment. On the
other hand, specific guidance may
be helpful for a child with frequent
seizure activity where recurrent
transportation to an emergency
department is neither feasible nor
desirable or even when school nurses
are not the ones attending to the
child. The recommended duration of
basic observation after administering
a seizure rescue medication can
account for practical circumstances
(eg, staffing availability in the school
or classroom) and ultimately may
determine whether administration
of a seizure rescue medication in the
school setting is indeed both safe and
realistic.
As noted previously, staffing varies
between schools. School nurses are
not available in every jurisdiction
and, even when available, may not
always be immediately available to
assist in the case of a seizure. For
example, in some areas, a single
nurse may be assigned to a group
of schools. In this situation, the
nurse’s ability to respond in a timely
fashion depends on factors such as
distances between school buildings,
nurse-to-student ratios, and
available assistance within a school
to leave the health office uncovered
to respond to a child in need.
Availability of school nurses also
becomes an issue when prescribing
seizure rescue medications because
administration of medicine by others
may be illegal in some jurisdictions.
In states with strict licensure
laws, for example, schools without
school nurses might be required
to hire a one-on-one private duty
nurse (licensed practical nurse or
registered nurse) for the student to
deliver the seizure rescue medication.
Conversely, one-on-one nursing is
expensive, and furthermore, hovering
over a child waiting for a seizure
to occur is highly restrictive and
interferes with the child’s ability to
socialize and participate in normal
classroom activities. Finally, the
school setting encompasses not only
the classroom during the school
day but also bus transportation,
activities before and after school,
and off-campus activities, such as
athletics and field trips. Aspects
of the individual action plan that
include transportation to and from
school activities can be included in
the Individualized Education Plan
3
(IEP) to optimize student safety.23
In certain circumstances, safety
may be greater in school-based
transportation than private vehicles.
Furthermore, availability of school
nurses or properly trained staff may
not be consistent in every situation,
and the action plan may account
for this factor. Questions as to
whether school nurses are available
to create action plans, administer
seizure rescue medications, and
provide training to unlicensed
assistive personnel or whether
prescribing professional medical
orders are going to be managed only
by unlicensed assistive personnel
are best answered for prescribing
professionals by principals or
other heads of school. Information
from an individual action plan
may be included in an IEP or 504
accommodation.
LEGAL CONSIDERATIONS
Fears concerning potential liability
are real. Thus, it is recommended
that providers who care for children
with epilepsy (including prescribing
professionals, nurses, and school
personnel) be aware of local laws
regarding administration of seizure
rescue medications by school
personnel and their personal liability
for errors. In some jurisdictions,
unlicensed volunteers who assist
a child during a seizure may bear
legal responsibility in the case of a
bad outcome, including potential
tort action. In addition, if school
transportation services have been
contracted out to local private
companies, transportation workers
may not be employees of the school
district. This may raise additional
potential liability issues beyond
those borne by school districts,
with some private transportation
companies prohibiting the
involvement of their employees in
the case of a medical emergency. In
these situations, an action plan that
contains instructions on seizure
4
management for unlicensed assistive
personnel (for both the school
district and private agencies) may
ease fears and ensure the provision
of appropriate care. Furthermore,
education of school administrators
and Boards of Education by
prescribing professionals may
heighten awareness for school
districts to consider matters such
as the willingness to assist students
with special health care needs in
their selection of health office staff
and contractors for student services
in general.
services, depending on the patient
and available resources.
5. Prescribing professionals can
educate school personnel about
seizure management or may direct
them to educational programs
offered by national or local
organizations with appropriate
expertise.
6. Details of the individual action
plan and transportation can
be included in the IEP or 504
accommodation.
LEAD AUTHORS
SUMMARY
Although care for a child with
epilepsy varies because of
inconsistencies between jurisdictions
in legislation, professional practice
guidelines, and potential liability
issues, children with epilepsy
warrant advance planning for
medical emergencies.
Key Points
1. It is important for prescribing
professionals to familiarize
themselves with the local and
state regulations and local school
limitations and resources for
treating students with seizures.
2. Children with prescriptions for
seizure rescue medications may
benefit from an individualized
action plan that is developed
collaboratively among the family,
the prescribing professional, and
the school.
3. An individualized action plan
will be most effective if it takes
into consideration the possible
options for the least restrictive
medication choice (ie, buccal or
nasal route) for the child in his or
her environment while ensuring
the child’s safety.
4. An individualized action plan
can also include details of when
to activate emergency medical
Adam L. Hartman, MD, FAAP
Cynthia Di Laura Devore, MD, FAAP
CONTRIBUTING AUTHOR
Sarah C. Doerrer, CPNP
SECTION ON NEUROLOGY EXECUTIVE
COMMITTEE, 2013–2014
Peter B. Kang, MD, FAAP, Chairperson
Donald Gilbert, MD, FAAP
Andrea Gropman, MD, FAAP
Adam L. Hartman, MD, FAAP
Sucheta Joshi, MD, FAAP
Sonia Partap, MD, FAAP
EX-OFFICIO
Paul Fisher, MD, FAAP, Immediate Past
Chairperson
STAFF
Lynn Colegrove, MBA
COUNCIL ON SCHOOL HEALTH EXECUTIVE
COMMITTEE, 2013–2014
Jeffrey Okamoto, MD, FAAP, Chairperson
Mandy Allison, MD, MSPH, MEd, FAAP
Richard Ancona, MD, FAAP
Elliott Attisha, DO, FAAP
Cheryl De Pinto, MD, MPH, FAAP
Breena Holmes, MD, FAAP
Christopher Kjolhede, MD, MPH, FAAP
Marc Lerner, MD, FAAP
Mark Minier, MD, FAAP
Adrienne Weiss-Harrison, MD, FAAP
Thomas Young, MD, FAAP
IMMEDIATE PAST CHAIR
Cynthia Di Laura Devore, MD, FAAP
LIAISONS
Beth Mattey, MS, RN, NCSN – National Association
of School Nurses
FROM THE AMERICAN ACADEMY OF PEDIATRICS
Mary Vernon-Smiley, MD, MPH, MDiv – Centers for
Disease Control and Prevention
Veda Johnson, MD, FAAP – School-Based Health
Alliance
Linda Grant, MD, MPH, FAAP – American School
Health Association
STAFF
Madra Guinn-Jones, MPH
ABBREVIATION
IEP: Individualized Education
Plan
REFERENCES
1. Russ SA, Larson K, Halfon N. A
national profile of childhood epilepsy
and seizure disorder. Pediatrics.
2012;129(2):256–264
2. Brodie MJ, Barry SJ, Bamagous
GA, Norrie JD, Kwan P. Patterns
of treatment response in newly
diagnosed epilepsy. Neurology.
2012;78(20):1548–1554
3. Shinnar S, Berg AT, Moshe SL,
Shinnar R. How long do new-onset
seizures in children last? Ann Neurol.
2001;49(5):659–664
4. Pellock JM. Overview: definitions and
classifications of seizure emergencies.
J Child Neurol. 2007;22(suppl
5):9S–13S
elementary schools. J Sch Health.
2013;83(12):876–884
7. Clarke W, Deeb LC, Jameson P, et
al; American Diabetes Association.
Diabetes care in the school and
day care setting. Diabetes Care.
2012;35(suppl 1):S76–S80
16. Brown L, Bergen DC, Kotagal P, Groves
L, Carson D. Safety of Diastat when
given at larger-than-recommended
doses for acute repetitive seizures.
Neurology. 2001;56(8):1112
8. Portnoy JM, Shroba J. Managing food
allergies in schools. Curr Allergy
Asthma Rep. 2014;14(10):467
17. Scott RC, Besag FM, Neville BG. Buccal
midazolam and rectal diazepam for
treatment of prolonged seizures
in childhood and adolescence:
a randomised trial. Lancet.
1999;353(9153):623–626
9. Olympia RP, Wan E, Avner JR. The
preparedness of schools to respond
to emergencies in children: a national
survey of school nurses. Pediatrics.
2005;116(6). Available at: www.
pediatrics.org/cgi/content/full/116/6/
e738
10. Glauser TA. Designing practical
evidence-based treatment plans for
children with prolonged seizures and
status epilepticus. J Child Neurol.
2007;22(suppl 5):38S–46S
11. O’Dell C, O’Hara K, Kiel S, McCullough
K. Emergency management of seizures
in the school setting. J Sch Nurs.
2007;23(3):158–165
12. Kriel RL, Cloyd JC, Pellock JM, Mitchell
WG, Cereghino JJ, Rosman NP; The
North American Diastat Study Group.
Rectal diazepam gel for treatment
of acute repetitive seizures. Pediatr
Neurol. 1999;20(4):282–288
13. Dreifuss FE, Rosman NP, Cloyd
JC, et al. A comparison of rectal
diazepam gel and placebo for acute
repetitive seizures. N Engl J Med.
1998;338(26):1869–1875
5. Cross JH, Wait S, Arzimanoglou A, et
al. Are we failing to provide adequate
rescue medication to children
at risk of prolonged convulsive
seizures in schools? Arch Dis Child.
2013;98(10):777–780
14. O’Dell C, Shinnar S, Ballaban-Gil KR, et
al. Rectal diazepam gel in the home
management of seizures in children.
Pediatr Neurol. 2005;33(3):166–172
6. Cicutto L, To T, Murphy S. A randomized
controlled trial of a public health
nurse-delivered asthma program to
15. Terry D, Paolicchi J, Karn M.
Acceptance of the use of diazepam
rectal gel in school and day
PEDIATRICS Volume 137, number 1, January 2016
care settings. J Child Neurol.
2007;22(9):1135–1138
18. Harbord MG, Kyrkou NE, Kyrkou
MR, Kay D, Coulthard KP. Use of
intranasal midazolam to treat acute
seizures in paediatric community
settings. J Paediatr Child Health.
2004;40(9-10):556–558
19. Holsti M, Dudley N, Schunk J, et
al. Intranasal midazolam vs rectal
diazepam for the home treatment of
acute seizures in pediatric patients
with epilepsy. Arch Pediatr Adolesc
Med. 2010;164(8):747–753
20. Bebin EM. Additional modalities for
treating acute seizures in children:
overview. J Child Neurol199813(suppl
1):S23–S26; discussion S30–S32
21. Troester MM, Hastriter EV, Ng
YT. Dissolving oral clonazepam
wafers in the acute treatment of
prolonged seizures. J Child Neurol.
2010;25(12):1468–1472
22. Pellock JM, Shinnar S. Respiratory
adverse events associated with
diazepam rectal gel. Neurology.
2005;64(10):1768–1770
23. American Academy of Pediatrics.
American Academy of Pediatrics:
Committee on Injury and Poison
Prevention. School bus transportation
of children with special health care
needs. Pediatrics. 2001;108(2):516–518
5