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Rescue Medication and
Seizure Emergency Planning
in Education Settings
Sarah Doerrer, CPNP
Certified Pediatric Nurse Practitioner
The Johns Hopkins Hospital
Department of Neurology
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Disclaimer
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necessarily those of the American Academy of Pediatrics.
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Objectives
 By the end of this talk you should:
o Know what a seizure emergency plan is, why these plans are created,
and what they should contain.
o Know the basics of how to create an effective school seizure action
plan.
o Be familiar with various seizure rescue medications, their side effects,
and the practical considerations that come into play when prescribing
them for the school setting.
o Be familiar with what an Individualized Education Plan (IEP) and 504
plan is and how to utilize them when creating seizure action plans.
o Be able to direct parents to community resources to assist them
should they encounter problems accessing appropriate medical care in
the school setting.
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Epilepsy in Schools
 The lifetime prevalence of epilepsy in US children is
nearly 1%, making it one of the most common neurologic
diagnoses.
 A significant proportion of children with epilepsy never
achieve complete seizure control.
 Due to the Individuals with Disabilities Education Act
(1990) and the Individuals with Disabilities Improvement
Act (2004), the majority of children and adolescents with
epilepsy attend some form of school outside the home.
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Seizure Action Plans
 Ideally, all children with epilepsy should have a plan in place
that reflects advanced thought and collaboration between the
medical home, the school, and the family.
 Seizure action plans can provide medical orders or they may
simply be instructions on how to care for a child during and
after a seizure. They may include information on:
o
o
o
o
Seizure appearance/type
Seizure first aid
Who to contact in the event of a seizure and when to call 911
Seizure rescue medications
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How to Create an Effective
School Seizure Action Plan
Step 1:
Have the family talk directly with the
school and complete the form as they
talk.
“If my child has a seizure at school, who will be
caring for him/her?”
TIP: Many school systems have their own
forms. You can provide the family with a
generic form but notify them that the
school may have its own.
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Seizure Action Plans
 A seizure action plan should be used to facilitate a discussion
between the school and the family.
 A direct conversation between parents and the school:
o Allows parents to learn what resources the school has available
on-site and in the area
• RN? LPN? UAP (Unlicensed Assistive Personnel)?
o Allows the family to learn about school system policies
• Examples:
– Can rescue medication be given in that school district?
– Does 911 have to be called after rescue medication is given?
TIP: It is helpful to familiarize yourself with the local and state regulations and local
school limitations and resources for treating students with seizures. They vary WIDELY.
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Seizure Action Plans
 Finally, a direct conversation between parents and the
school:
o Allows the school to get the most accurate, up-to-date
information, including:
• Seizure appearance—The school gets a first-hand account
and description of seizures from parents who have actually
witnessed the seizures, not a vague, general description
from a neurologist.
• Practical information—Who to contact first, best telephone
numbers, which hospital the parents would prefer their child
be transported to, if necessary.
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How to Create an Effective
School Seizure Action Plan
Step 2:
If rescue medication is desired and
can be administered in the child’s
educational setting, select the best
option.
TIP: Best option = least restrictive for
the child in his/her environment while
ensuring his/her safety
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Seizure Rescue Medication Options
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Rectal Diazepam Gel
Benefits
Drawbacks
Dose comes a in preloaded and
premeasured syringe from the pharmacy
(less room for user error and more
convenient)
Modesty is compromised during
administration (patient must be partially
undressed)
Portable (does not need to be kept
refrigerated)
Administration may be viewed as invasive
Useful when oral administration of rescue
medication is contraindicated (excessive
secretions, vomiting, etc.)
Caregivers may not be comfortable
administering rectal medication
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Lorazepam Oral Solution 2mg/mL
Benefits
Drawbacks
Administered into cheek pocket (buccally),
which many caregivers find preferable to
rectally administered medications
Must be drawn up in a syringe prior to
administration
Modesty is preserved during administration
Must be kept refrigerated
UAP typically cannot administer if it has not
been dispensed in a premeasured syringe
Contraindicated if patient has excessive
secretions or is vomiting
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Midazolam
Benefits
Drawbacks
- 5mg/mL intravenous form can be given
intranasally via an atomizer
- Administration is relatively easy and
modesty is preserved
- Intranasal administration is not yet approved
by the US Food and Drug Administration
- Atomizer is not available at all pharmacies
- UAP is typically not asked to administer this
medicine unless it has been dispensed in a
premeasured syringe
- Because this is a relatively new route of
administration, additional training of school
personnel may be needed
- A 2mg/mL oral syrup can be given buccally
- UAP is typically not asked to administer this
medicine unless it has been dispensed in a
premeasured syringe
- Contraindicated if patient has excessive
secretions or is vomiting
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Clonazepam Orally Disintegrating Tablet
Benefits
Comes as a prepackaged, ready-to-administer,
orally disintegrating tablet
Drawbacks
Available dosages may not be appropriate for
smaller children
Patient may need to be positioned in a specific
way to avoid injury during administration if his
or her teeth are clenched
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Seizure Rescue Medications
 Adverse effects
o Decreased respirations
o Oversedation
o Cardiopulmonary instability
*** These effects can vary in severity depending on the
dose of seizure rescue medication, duration of the seizure,
and interaction with other medications. ***
For this reason, personnel trained in cardiopulmonary
resuscitation should be available if seizure rescue
medication is prescribed.
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Seizure Rescue Medications
Why Are They Necessary?
 It is more difficult to stop a prolonged seizure than a
brief seizure.
 The longer the seizure, the longer the recovery
period.
 Rescue medication prevents progression to status
epilepticus, unnecessary transport to emergency
rooms, and the cost of escalated care.
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Ordering Seizure Rescue Medications
STANDARD ORDER: Give for a seizure lasting >5 minutes.
 Can also be given for seizure clusters or for 2+ seizures
without recovery in between
 When to administer rescue medication can vary based
upon patient history.
o Timing of administration can and should be customized
based on the child’s seizure duration, severity, and
tendency to go into status epilepticus.
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Practical Considerations
 Availability of school nurses
o School nurses are not present in every school.
o In some school systems, rescue medication may only
be given by licensed professionals, necessitating the
hiring of a 1:1 nurse, which is expensive and overly
restrictive.
 Transportation
o Rescue medication may not be able to be given on
school buses.
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Practical Considerations
 Field trips
o Nurses may not be available to attend field trips with
the child.
o If a nurse is not available, parents may have to go,
particularly if rescue medication is prescribed.
 Before and after school activities
o Coaches or parent volunteers may have to administer
medication and be trained in seizure first aid.
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How to Create an Effective
School Seizure Action Plan
Step 3:
Determine when emergency medical
services (EMS) should be activated and
document when this should occur in
the seizure action plan.
TIP: This will change depending on the
needs of the child, the resources available
in the child’s educational setting, and the
family’s wishes.
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How to Create an Effective
School Seizure Action Plan
Step 4:
Encourage parents to be an advocate
for their child.
TIP: When possible, have the parents ask the
school to include the child’s seizure
emergency plan in the IEP or 504
accommodation plan. This will make it more
“visible” and ensure that teachers and other
adults know that the child has epilepsy, as
well as what to do in the event of a seizure.
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What are IEPs and 504 Plans?
 IEP – Individualized Education Plan
o A plan implemented by a school for students with
learning disabilities, necessitating special education
and related services to make educational progress
 504 plan
o A plan that provides students with disabilities that do
not qualify for special education or related services
with accommodations or modifications as well as
some services
o Not all children with epilepsy qualify for a 504 plan.
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IEPs and 504 Plans
 The IEP can include accommodations for before and after
school activities.
 An order for administration of rescue medication can be
incorporated into a child’s IEP or 504 accommodation
plan. However, it does not guarantee that administration
will be safe and/or realistic (eg, on the school bus).
Take Home Message: Incorporating the seizure action plan into
the school accommodation plan will help ensure that adults in
the child’s education setting are aware of the child’s epilepsy
diagnosis and what to do in the event of a seizure.
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Resources for Parents
 Center for Parent Information and Resources
www.parentcenterhub.org/find-your-center
 Family-to-Family Heath Information Centers (F2F HICs)
www.familyvoices.org/page?id=0034
 US Department of Education – Office for Civil Rights
www2.ed.gov/about/offices/list/ocr/aboutocr.html
 Jeanne A Carpenter Epilepsy Legal Defense Fund
www.epilepsy.com/get-help/legal-issues
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Education for Schools
 Offer to educate school personnel about seizure
management, if possible.
 Refer school personnel to educational programs
offered by national or local organizations with
appropriate expertise (eg, Epilepsy Foundation).
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Legal Considerations
 It is recommended that providers who care for children
with epilepsy be aware of local laws regarding
administration of seizure rescue medication by school
personnel and their liability for errors.
 In some jurisdictions, unlicensed volunteers may bear
legal responsibility in the case of a bad outcome, including
tort action.
 An action plan that contains instructions on seizure
management for UAP may ease fears and ensure provision
of appropriate care.
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Summary
How to Create an Effective Seizure Action Plan
Step 1: Have the family
talk directly with the
school to construct the
basis of the plan.
Step 3: Determine and
document when EMS
should be activated.
Step 2: Select the best
rescue medication for
the child, if appropriate.
Step 4: Encourage
parents to advocate for
their children.
Treat with confidence. Trusted answers from the American Academy of Pediatrics.
References
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