Emergency use of buccal midazolam
      in dental practice

The RC (UK) has recently received a number of enquiries regarding the use of midazolam for emergency seizure control in dental practice. The following statement should clarify any concerns or queries:

Prolonged seizures are dangerous and may cause severe long lasting cerebral damage to adults and children alike. In the event of a seizure occurring in a dental practice setting the guidance published by the Resuscitation Council (UK) ‘Medical Emergencies and Resuscitation: Standards for clinical practice and training for dental practitioners and dental care professionals in general dental practice’ should be followed. If the patient continues to fit after an ambulance has been called then the RC (UK) guidance suggests the administration of buccal midazolam to assist in terminating the seizure. The dose is 10mg for adults and an appropriately reduced dose for children.

The evidence for using midazolam in this manner and for this indication is strong. Despite this being an ‘unlicensed’ use of the drug, buccal midazolam for prolonged seizure control is recommended in the British National Formulary, by the Advanced Paediatric Life Support course, the Royal College of Paediatrics and Child Health and numerous other high profile institutions throughout the UK, e.g. Great Ormond Street Hospital for Children. Paediatricians throughout the country prescribe this drug for parents of children who may have a seizure at home and all the National Epilepsy organisations recommend its use in this situation.

Preparations of midazolam have changed recently in an effort to standardize and reduce overdose concerns. Current formulations include midazolam solution for injection 1mg/ml, 2mg/ml and 5mg/ml. The 2mg/ml and 5mg/ml solutions are now largely limited to general anaesthesia and intensive care settings. An unlicensed ‘special order’ preparation of midazolam buccal liquid 10mg/ml is available for use in emergency settings for seizure control (‘Epistatus’). Most recently the Scottish Dental Clinical Effectiveness Programme (SDCEP) ‘Drug Prescribing for Dentistry’, November 2009 Update, has removed ‘midazolam buccal liquid’ from its list of available drugs. This is the 10mg/ml ‘special order’ preparation. It has not removed the use of midazolam however, but has replaced the ‘special order’ preparation with ‘midazolam injection solution’ which is 2mg/ml or 5mg/ml. Use of midazolam for uncontrolled seizures is still recommended by the SDCEP.

Other concerns regarding midazolam have centred around the drug’s reclassification as a ‘Schedule 3’ Controlled Drug. Such reclassification requires certain legal processes. This includes written prescription requirements. However, the law for this Schedule 3 drug does NOT require safe custody i.e. locked cupboard, nor the need to keep a midazolam controlled drug register. Some institutions are encouraging such practices as part of their own Health and Safety protocols but there is no legal obligation to do so.

Similarly, concerns have been raised about acquiring stocks of midazolam for use in the emergency setting of seizure control. Those dental practitioners who perform ‘conscious sedation’ using midazolam injection solution will of course have regular stocks of the drug and can use the intravenous preparation via the buccal route (as recommended by the SDCEP above). Those dental practitioners who do not use midazolam regularly are still permitted to requisition the Schedule 3 Drug under the conditions laid out by the Royal Pharmaceutical Society of Great Britain Guidance ‘Medicines, Ethics and Practice: a guide for pharmacists and pharmacy technicians: Section 1.2.14’.
 

January 2010
 
David A Gabbott and Alexander Crighton
Co–Chairmen Project Group:
Resuscitation Council (UK) ‘Medical Emergencies and Resuscitation: Standards for clinical practice and training for dental practitioners and dental care professionals in general dental practice’  
 
 
 
 

 
 

	© Resuscitation Council (UK)  2010   This page last updated: 25 January 2010