How physicians can guide seizure management in schools

March 17, 2016

Seizures can be serious and scary in schools, but AAP guidelines say action plans outlining rescue medications and interventions can help.

Seizures can be scary and dangerous, particularly in a school setting where medical help may not be immediately available. This is why every school district should have a plan in place to care for students with epilepsy, says the American Academy of Pediatrics (AAP).

To help schools accomplish that task, AAP has released a recent set of guidelines covering everything from prescribing guidelines, rescue medications, and training.

“Children with epilepsy warrant advance planning for medical emergencies in a school setting,” says Cindy Devore, MD, FAAP, chair of the AAP Council on School Health. “Collaboration among prescribing providers, families, and schools may be useful in developing individualized action plans for the use of seizure rescue medications in school.”

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Nearly 1% of US children have epilepsy, and many of them attend traditional school programs. While some of these students’ may have their epilepsy well-controlled through medication, others are never able to fully control their condition. It is therefore important that school personnel know what types of interventions they can and should perform to end the seizure, or at least manage its duration to prevent prolonged recovery periods or additional injury, Devore says.

Seizures that are prolonged may evolve into status epilepticus-a much more serious condition, says Devore. Rescue medications can halt the seizure and prevent the need for more extensive medical care, she says, but inconsistent laws across the country may limit what school staff is able to do in terms of first responder care. Physicians must be aware of their local laws and practices before prescribing a medication regimen for use in schools.

Ideally, a school nurse is available to carry out medical orders from the child’s physician to manage seizures that take place in school, Devore says, but that is not always possible. School nurses may be able to create action plans based on the physician’s order for the school’s unlicensed assistive personnel (UAP) to use in the nurse’s absence. The UAPs can be trained by the nurse to carry out a series of steps depending on what is happening with the child.

In some areas where the schools have no school nurse at all, it may be up to the physician to create an action plan and train staff members. In such cases, physicians have the option of creating a plan specific to the student, or modifying a generic plan from a template.

NEXT: What else should action plans contain?

 

The action plans should also include steps to inform student’s family and/or physician about the frequency of rescue medication use in case standing medications need to be reevaluated. Generally, Devore says rescue medications should be given once a seizure has lasted 5 minutes to prevent progression to status epilepticus. In some cases, rescue medications must be used earlier than 5 minutes, and physicians may give orders to start rescue medications at an earlier interval or as soon as the seizure begins if the student is prone to progressing to status epilepticus early.

It is important to remember, however, that rescue medications are not one-size-fits-all, says Devore.

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“There are significant variations in prescribing practices for seizure rescue medications, as well as school staffing for health services,” she says. “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, before prescribing seizure rescue medications, especially to know whether a school nurse is available to administer the medicine or if that task will fall to unlicensed staff. For example, an individualized action plan will be most effective if it takes into consideration the possible options for prescribing the least restrictive medication choice (ie, buccal or nasal route, rather than per rectum) for the child in his or her specific school environment while ensuring the child’s safety.”

In areas where school nurses are not available and school personnel are not permitted to administer medications, a private nurse may have to be hired for the student-but this is not ideal because it is expensive as well as restrictive for the child.

NEXT: A look at common rescue medications

 

Commonly used rescue medications include:

• Rectal diazepam gel - This commonly used formulation is particularly useful because it can be administered as a rescue medication when it is not possible to give oral medications. Considerations for use, however, are that the student must be partially undressed for administration, especially in cases where there are other students around and it’s not possible to ensure privacy. School personnel may be uncomfortable administering this medication when a school nurse is not available, so families should be consulted about the use of this medication in the school setting before it is added to a school action plan.

• Midazolam - This medication is available in an oral syrup that can be administered in the cheek for students are lying on the their sides, as well as intranasally through an atomizer. School personnel are generally more comfortable administering this over the rectal diazepam, but administration by school staff is usually limited to when the drug is dispensed in a premeasured syringe. Additionally training may be required when this medical is used intranasally by school staff, as it’s a fairly new route of administration, Devore says.

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• Lorazepam - Another oral liquid, lorazepam is not always practical in the school setting because it must be refrigerated. Premeasured syringes can improve the safety of administration in schools, and school personnel generally do not administer the medication if it is not premeasured.

• Clonazepam orally disintegrating tablet - Available in a variety of doses, use of this dissolving tablet may require additional instructions for school staff about positioning the child in a manner to drain secretions, as well as how to place the medication properly into the buccal mucosa to avoid injury to the student’s teeth.

Action plans should also indicate whether that particular student is safe to stay at school after the seizure, and what situations warrant further assessment by a medical professional.

Physicians should also be offering school personnel guidance about monitoring the effects of seizure rescue medications including decreased respirations, oversedation, and cardiopulmonary effects.

“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,” the report notes. “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.”

Action plans must also take into account that seizures may not only occur on school grounds, but during athletic events, on field trips, or during transportation.

“Aspects of the individual action plan that include transportation to and from school activities can be included in the Individualized Education Plan to optimize student safety,” the report notes.

When creating action plans, physicians should be familiar with local and state regulations, and how much care school personnel can provide. The plan should also be spelled out clearly, and specifically for each child in terms of what actions should be taken in the event of a seizure, and when and how rescue medications should be administered, according to AAP. Plans are most beneficial to the child when the least restrictive medications are considered, such as nasal over rectal routes. Physicians should also work collaboratively with the school district, train personnel, and include directions for when additional medical care outside the school should be sought for the student.