Intranasal Administration of Seizure Medication via Atomizer

Emergency Intervention, Neurological

Pursuant to 167.625. Will’s law — definitions — epilepsy or seizure disorder, individualized emergency health care plan, requirements — immunity from liability, when. — 1. This section shall be known and may be cited as “Will’s Law”.

2. As used in this section, the following terms mean:

(1) “Individualized emergency health care plan”, a document developed by a school nurse, in consultation with a student’s parent and other appropriate medical professionals, that is consistent with the recommendations of the student’s health care providers, that describes procedural guidelines that provide specific directions about what to do in a particular emergency situation, and that is signed by the parent and the school nurse or the school administrator or the administrator’s designee in the absence of the school nurse;

(2) “Individualized health care plan”, a document developed by a school nurse, in consultation with a student’s parent and other appropriate medical professionals who may be providing epilepsy or seizure disorder care to the student, that is consistent with the recommendations of the student’s health care providers, that describes the health services needed by the student at school, and that is signed by the parent and the school nurse or the school administrator or the administrator’s designee in the absence of the school nurse;

(3) “Parent”, a parent, guardian, or other person having charge, control, or custody of a student;

(4) “School”, any public elementary or secondary school or charter school;

(5) “School employee”, a person employed by a school;

(6) “Student”, a student who has epilepsy or a seizure disorder and who attends a school.

3. (1) The parent of a student who seeks epilepsy or seizure disorder care while at school shall inform the school nurse or the school administrator or the administrator’s designee in the absence of the school nurse. The school nurse shall develop an individualized health care plan and an individualized emergency health care plan for the student. The parent of the student shall annually provide to the school written authorization for the provision of epilepsy or seizure disorder care as described in the individualized plans.

(2) The individualized plans developed under subdivision (1) of this subsection shall be updated by the school nurse before the beginning of each school year and as necessary if there is a change in the health status of the student.

(3) Each individualized health care plan shall, and each individualized emergency health care plan may, include but not be limited to the following information:

(a) A notice about the student’s condition for all school employees who interact with the student;

(b) Written orders from the student’s physician or advanced practice nurse describing the epilepsy or seizure disorder care;

(d) Whether the student may fully participate in exercise and sports, and any contraindications to exercise or accommodations that shall be made for that particular student;

(e) Accommodations for school trips, after-school activities, class parties, and other school-related activities;

(f) Information for such school employees about how to recognize and provide care for epilepsy and seizure disorders, epilepsy and seizure disorder first aid training, when to call for assistance, emergency contact information, and parent contact information;

(g) Medical and treatment issues that may affect the educational process of the student;

(h) The student’s ability to manage, and the student’s level of understanding of, the student’s epilepsy or seizure disorder; and

(i) How to maintain communication with the student, the student’s parent and health care team, the school nurse or the school administrator or the administrator’s designee in the absence of the school nurse, and the school employees.

4. (1) The school nurse assigned to a particular school or the school administrator or the administrator’s designee in the absence of the school nurse shall coordinate the provision of epilepsy and seizure disorder care at that school and ensure that all school employees are trained every two years in the care of students with epilepsy and seizure disorders including, but not limited to, school employees working with school-sponsored programs outside of the regular school day, as provided in the student’s individualized plans.

(2) The training required under subdivision (1) of this subsection shall include an online or in-person course of instruction approved by the department of health and senior services that is provided by a reputable, local, Missouri-based health care or nonprofit organization that supports the welfare of individuals with epilepsy and seizure disorders.

5. The school nurse or the school administrator, or the administrator’s designee in the absence of the school nurse, shall obtain a release from a student’s parent to authorize the sharing of medical information between the student’s physician or advanced practice nurse and other health care providers. The release shall also authorize the school nurse or the school administrator, or the administrator’s designee in the absence of the school nurse, to share medical information with other school employees in the school district as necessary. No sharing of information under this subsection shall be construed to be a violation of the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) (Pub. L. 104-191), as amended, if a student’s parent has provided a release under this subsection.

6. No school employee including, but not limited to, a school nurse, a school bus driver, a school bus aide, or any other officer or agent of a school shall be held liable for any good faith act or omission consistent with the provisions of this section, nor shall an action before the state board of nursing lie against a school nurse for any such action taken by a school employee trained in good faith by the school nurse under this section. “Good faith” shall not be construed to include willful misconduct, gross negligence, or recklessness.

Considerations:

Given that the medication can be dispensed in different formulations and dosages, the school nurse should always review the medication and health care provider’s order upon receiving it at the school.
Given that when a student is having a seizure, it can be a stressful situation, it is highly recommended that you familiarize yourself with that student’s Seizure Action Plan.
- NOTE: The student’s Seizure Action Plan should indicate when 911 should be called (i.e. on immediate onset of a 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 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 should develop a plan to systematically check the expiration date on the medication to ensure the medication has not expired.
A multi-dose midazolam vial that has been opened or accessed (i.e., needle-punctured) should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial.
Be sure to ensure the student’s privacy and confidentiality when calling for assistance.
Do not say the student’s name over the PA system or walkie-talkie.
If possible, have someone assist with removing onlookers and other students to provide the student 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.

Supplies:

Seizure Action Plan/Health care provider’s orders and student’s Individualized Health Care Plan (IHCP) and student’s Individualized Emergency Health Care Plan
Parent/Guardian authorization form
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 to assist in obtaining the student’s emergency medication

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 student onto their side to allow vomit/phlegm to be expelled rather than inhaled
Place something soft under the student’s head to protect them from injury
Ensure the student’s airway is not obstructed
Loosen tight clothing around the student’s neck
Do not restrict the student’s arms or legs
Ensure there is no furniture or objects close to the student that could injure him/her
Review the student’s Seizure Action Plan/IHCP/health care provider’s order
Gather the emergency medication and needed supplies in case seizure lasts longer than designated time frame

Procedure:

Identify that symptoms of a 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
1. Ask that another school staff person call 911 or emergency medical services if indicated in student’s Seizure Action Plan
2. 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 supplies and place on a clean surface
Review the six rights of medication administration to be sure it is:
1. The right student
2. The right medication
3. The right dose
4. Being given at the right time
5. Being given by the right route
6. Being given for the right reason
Check 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/ IHCP and ensure the appropriate 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:
1. For the right student
2. The right medication
3. The right dose
4. Being given at the right time
5. Being given by the right route
6. 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 milliliters (mL) needed for the prescribed 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
1. If there are air bubbles in the liquid in the syringe, tap the side of the syringe to bring the bubbles to the top
2. Push the plunger just enough to push the bubbles back into the vial
3. 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 the medication
Replace cap on needle
Twist off or remove the syringe from the needle
1. Discard needle in sharps container
Attach the atomizer tip to the syringe and twist into place
Look into the student’s nostrils to determine if there is fluid or mucus in the nostrils.
If drainage or mucus is present, use a bulb syringe to remove it
1. 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 tip 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 time of medication administration and document on Seizure Observation Recording Form
If EMS/911 has not been called yet, call 911 or EMS services if indicated in 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 students
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 health care 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
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Acknowledgment of Reviewers:

Angie Bulmahn, MSN, RN, NCSN
School Nurse Specialist
Missouri Department of Health and Senior Services

Marjorie Cole, MSN, RN, FASHA
State School Nurse Consultant
Missouri Department of Health and Senior Services

Renee Falkner, BSN, RN
School Nurse Supervision Specialist | Therapylog

Katherine Park, DNP, RN, NCSN
Nationally Certified School Nurse, Pierremont Elementary
Adjunct Professor, Maryville University School of Nursing
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Page last updated February 20, 2024
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