Administration of Emergency Anti-Seizure

Contents

Introduction | Minimum Standards of Training | Guidelines for School Districts | Training Materials and Seizure Action Plans | Resources | Acknowledgements

I. Introduction

According to the Centers for Disease Control and Prevention, an estimated one in ten people will have at least one seizure over the course of their lifetime.¹ Seizures occur when the brain experiences sudden and temporary bursts of electrical activity that interrupt the normal flow of messages between its cells.² These abrupt electrical discharges can lead to involuntary changes in bodily movements or functions, as well as alterations in perception, behavior, and/or consciousness. Epilepsy is a type of neurological condition that increases the likelihood of a person experiencing repeated seizures. For some individuals, seizures may follow a specific pattern or tend to happen more frequently in certain circumstances, known as a seizure trigger. Some examples of common seizure triggers include time of day, sleep deprivation, illness, flashing lights or patterns, menstrual cycles or other hormonal changes, and missed medications. There are several different types of seizures, and symptoms vary by seizure type.

The Seizure Safe Schools Act (California Education Code (EC) Section 49468-49468.5, as amended by Assembly Bill 1810, effective January 1, 2023), authorizes a local educational agency (LEA) to designate volunteer personnel to receive initial and annual refresher training regarding the emergency use of anti-seizure medication.³ The law requires the State Superintendent of Public Instruction (SSPI) to review and update the minimum training standards for the administration of emergency anti-seizure medication at least every five years,⁴ and requires a school district, county office of education, or charter school to annually distribute a notice to all staff that includes a description of volunteer training and other specified information.⁵

This document provides minimum training standards for the administration of emergency anti-seizure medication in accordance withECSection 49468.2. These training standards were developed in consultation with organizations and providers with expertise in epilepsy and administering emergency anti-seizure medication and administering medication in a school environment, as required by ECSection 49468.2(c)(1).

Local educational agencies may also wish to consult their legal counsel.

II. Minimum Standards of Training

Schools may designate one or more volunteers at a school to receive initial and annual refresher training, based on the standards developed by the SSPI, regarding the emergency use of anti-seizure medication from the school nurse or other qualified person designated by an authorizing physician or surgeon.⁶ Minimum standards of training must include the following:

1. Recognition of the signs and symptoms of seizures and the appropriate steps to be taken in response to those symptoms.
2. Administration, or assisting with the self-administration of, an emergency anti-seizure medication, or a medication or therapy prescribed to treat the symptoms of seizures, seizure disorders, or epilepsy, including manual vagus nerve stimulation, approved by the United States Food and Drug Administration, or any successor agency.
3. Basic emergency follow up procedures
4. Written materials covering the information above ⁷

A. Recognition of the signs and symptoms of seizures and responding to symptoms⁸

Seizures can vary in their presentation and may affect people differently. Some common signs and symptoms of seizures include⁹:

• Loss of consciousness or awareness
• Staring spells or unresponsiveness
• Confusion or disorientation
• Uncontrollable jerking movements or convulsions
• Muscle stiffness or rigidity
• Changes in sensation, such as tingling or numbness
• Sudden changes in mood or emotions
• Temporary cessation of breathing or difficulty breathing
• Loss of bowel or bladder control

It is important to note that not all seizures involve convulsions or loss of consciousness. Some seizures may only involve subtle changes in awareness or behavior, which can make them more difficult to recognize.

In response to seizure symptoms, the following steps should be taken¹⁰:

1. Stay calm and keep the person safe: Move any objects or furniture that could cause harm if the person were to convulse or move uncontrollably during the seizure. Clear the area around the person and make sure they are lying down comfortably, if possible.
2. Time the seizure: If possible, try to time the duration of the seizure. If the seizure lasts longer than 5 minutes, call 911 for emergency medical services.
3. Do not restrain the person: It's important to allow the person to move and convulse as necessary during the seizure. Do not try to hold them down or restrain their movements.
4. Protect their head: If the person is convulsing or jerking, place a cushion or something soft under their head to protect it from injury.
5. Do not give anything by mouth: Do not attempt to force anything into the person's mouth during a seizure, as this could lead to choking or injury.
6. After the seizure has ended, stay with the person and reassure them as they regain consciousness. Allow them to rest until they feel ready to stand up and move around.
7. Seek medical attention: If the person has never had a seizure before, or if the seizure lasts longer than 5 minutes, call 911 for emergency medical services. Additionally, seek medical services immediately if the person has difficulty breathing, appears to be injured, or is experiencing repeated seizures.

B. Administration or assisting with self-administration of emergency anti-seizure medication¹¹

There are several types of emergency anti-seizure medications and therapies, including intranasal, oral, and rectal medications, as well as vagus/vagal nerve stimulation therapy. The instructions below are general references for the administration of different types of emergency anti-seizure medications and therapies. Always follow the student’s seizure action plan, the health care provider’s written orders, and the manufacturer’s instructions for administration of emergency anti-seizure medication.

Steps in the Administration of Intranasal Rescue Medicines¹²:

1. If the medicine is given during or after a seizure with loss of consciousness, turn the person on their side so they are facing you (or the person who will be giving the medication).
2. If the person has had a focal seizure or the medicine is given after or between seizures, the person can be sitting in a comfortable position.
3. If possible, wash your hands.
4. Open the package and check the dose of the medicine with the prescription.
5. Get the nasal spray device out of the blister pack.
6. Hold the medication with your thumb on the bottom of the plunger and your first and middle fingers on either side of the nozzle.
7. Do not press the plunger yet. If you press the plunger too early, you will lose the dose.
8. Place the tip of the nozzle into 1 nostril until your fingers are on either side of the nozzle and touch the bottom of the nose.
9. Press the bottom of the plunger firmly with your thumb to deliver the dose of nasal spray.
• Make sure to firmly press the plunger using 1 motion.
10. Remove the nozzle from the nostril after giving the dose.
11. Throw away the nasal spray unit and the empty blister package in the trash.
12. Check on the person after the seizure and after the medication is given. Watchto make sure the seizure has stopped, and no bothersome side effects occur.
13.  Document the administration of the medication, continue to observe student, and follow seizure action plan next steps.

Steps in the Administration of Oral Rescue Medicines¹³:

1. Follow the healthcare provider’s orders for method of administration:
   • Oral: Oral medicine may include swallowing a pill with water or chewing a medication in tablet form. Oral rescue medication should only be given if the person is awake and alert and not at risk for choking on a pill or water.  The person should only chew the medication if the doctor has directed the person to do so in the prescription.
     
   • Sublingual: Gently slide the medication under the person’s tongue where it will dissolve and be absorbed into the bloodstream. Allow medication to dissolve completely. The person should not chew or swallow the medication during this process.
   • Buccal: Place the medication on the side of the mouth between the cheek and the gum where it will dissolve and be absorbed into the bloodstream. Allow the medication to dissolve completely. The person should not chew or swallow the medication until the medicine is completely dissolved.
     
2. Check on the person after the seizure and after the medication is given. Watchto make sure the seizure has stopped and no bothersome side effects occur.
3.  Document the administration of the medication, continue to observe student, and follow seizure action plan next steps.

Steps in the Administration of Rectal Rescue Medicines¹⁴:

1. Turn the person on their side so they are facing you (or the person who will be giving the medication).
2. Get the medicine out of the package and check the dose of the medicine with the doctor’s order.
3. Remove the cap from the syringe and make sure that the “seal pin” is removed with the cap.
4. Put lubricating jelly on the tip of the syringe.
5. Adjust the person’s clothes and bend the upper leg forward so the rectum can be seen.
6. Spread the cheeks of the buttocks and gently insert the tip of the syringe into the rectum.
7. Push the plunger on the syringe in and slowly count to three. Count to three again before removing the syringe.
8. Then squeeze the buttocks together and count to three to prevent leaking of the medicine.
9. Re-adjust the person’s clothes back to normal.
10. Follow the doctor’s recommendations for observing the person afterwards.
11.  Document the administration of the medication, continue to observe the student after administering the rescue medication, and follow seizure action plan next steps.

Vagus Nerve Stimulation (VNS) Therapy works to decrease the occurrence or intensity of seizures by sending regular, mild pulses of electrical energy to the brain through an implanted device in the left chest area. If a seizure occurs, a magnet, often worn on the wrist or belt, can be swiped over the implanted device to send an extra burst of stimulation to the brain, which may help stop a seizure.

Steps in the Administration of VNS Therapy¹⁵:

1. Always know the location of the magnet. Magnets are often worn on a wristband or belt clip.
2. During a seizure, swipe the magnet over the generator (implanted device) for less than two seconds.
   • If worn on the wrist, the magnet should be on the inside of the wrist. Assist student to move arm so that magnet on wrist swipes over generator in left chest area.
   • If worn on the belt, remove magnet to swipe over left chest area.
3. The magnet can be used more than once during a seizure. Doing so will not harm the generator or student.
4. Document the use of the magnet, continue to observe student, and follow seizure action plan for next steps.

C. Emergency Follow-up Procedures¹⁶

Follow the student’s seizure action plan, health care provider’s instructions, and manufacturer’s instructions for follow-up procedures after administering emergency anti-seizure medication. Notify the school nurse or the nurse assigned to the local educational agency in accordance with EC Section 49468.3(b).

Call 911 for help if¹⁷:

• A seizure lasts 5 minutes or longer
• One seizure happens right after another without the person regaining consciousness (“coming to”) between seizures
• Seizures happen closer together than usual for that person
• The person has trouble breathing and/or their face or lips are turning blue
• The person appears to be choking
• The seizure happens in water, like a swimming pool or bathtub
• The person is injured during the seizure
• You believe this is the first seizure the person has had
• The person asks for medical help

D. Written Materials

An LEA must retain for reference the written materials covering the minimum standards of training (the information described in A through C above).¹⁸

III. Guidelines for School Districts

School districts should consider developing policies and procedures that align with these training standards and address topics including, but not limited to, training protocols, emergency care plans, medication or therapy storage, and documentation.

It is recommended that documentation of all training, including sign-in sheets, training materials, copies of notices describing the volunteer request and training, report of administration emergency anti-seizure medication, and any follow-up documentation be maintained according to the district’s policies and procedures.

IV. Training Materials and Seizure Action Plan

Pursuant to the Seizure Safe Schools Act (EC Section 49468-49468.5) the California Department of Education (CDE) developed this section to provide LEAs with resources related to training LEA staff to recognize the signs and symptoms of seizures and to administer emergency anti-seizure medication. The CDE provides the sample training materials and plans to LEAs as information; it does not endorse or approve the training materials or plans.

Training Materials

The following training materials may be used by LEAs to train LEA staff to recognize the signs and symptoms of seizures and to administer emergency anti-seizure medication.

• Epilepsy Foundation Trainings
  Epilepsy Seizure Training for School Personnel (On Demand) - v2.0

Live trainings can be arranged by contacting your local Epilepsy Foundation:

• Epilepsy Foundation of Northern California
• Epilepsy Foundation Los Angeles
• Epilepsy Foundation of San Diego County
• Epilepsy Foundation Greater Orange County

• California School Nurses Organization Training
  California School Nurses Organization (CSNO): Guidelines for Specialized Health-Care Procedures, Seizure module

• Epilepsy Alliance Training
  Seizure Recognition and First Aid For School Personnel

Training must include written materials covering the minimum standards of training listed above. Sample written materials include:

1. Recognizing seizure symptoms and appropriate steps to take in response:
   • Seizure and Epilepsy Overview (PDF)
   • Seizure First Aid Poster (PDF)
   • Seizure Event Diary (PDF)
2. Medication administration materials:
   • Vagus Nerve Stimulation (VNS) Therapy (PDF)
     
   • Epilepsy Foundation: Rescue Therapies (PDF)
3. Additional seizure related resources:
• Tips for Seizure Observation and Recording (PDF)
• Questionnaire for Parent of a Student with Seizures (PDF). Available in multiple languages on the Epilepsy Foundation website.

Seizure Action Plans

Before administering emergency anti-seizure medication or therapy prescribed to treat seizures in a student diagnosed with seizures, a seizure disorder or epilepsy, the Seizure Safe Schools Act requires LEAs to obtain from the student’s parent or guardian a seizure action plan that includes all of the following:

1. Authorization, in writing, for the medication to be administered to the student at school. Authorization shall be effective for the school year in which it is granted, and shall be renewed each school year, unless needed sooner.
2. A copy of a statement, in writing, from the student’s health care provider that includes all of the following information:
   • The student’s name
   • The name and purpose of the medication
   • The prescribed dosage
   • The method of administration
   • The frequency with which the medication may be administered
   • Detailed seizure symptoms, including frequency, type, or length of seizures that identify when the administration of an emergency anti-seizure medication becomes necessary.
   • The circumstances under which the medication may be administered
   • Any potential adverse responses by the student and recommended mitigation actions, including when to call emergency services, including the emergency 911 telephone number.
   • A protocol for observing the student after a seizure including, but not limited to, whether the pupil should rest in the school office, whether the student may return to class, and the length of time the student should be under direct observation.
     
3. How and where the emergency anti-seizure medication will be stored at the school.
4. A signed notice verifying that the parent or guardian was given information about Section 504 of the federal Rehabilitation Act of 1973 (29 U.S.C. § 794) and the federal Individuals with Disabilities Education Act (IDEA) (20 U.S.C. §§ 1400 et seq.) pursuant to subdivision (e) of Section 49468.2, and that the parent or guardian understands that it is the parent’s or guardian’s right to request a plan pursuant to Section 504 of the federal Rehabilitation Act of 1973 (29 U.S.C. § 794) or an individualized education program (IEP) at any time.
5. A signed notice verifying that a student’s seizure may be responded to, including with the administration of emergency anti-seizure medication prescribed to the student, by a nonmedical professional who has received training pursuant to subdivision (c) of Section 49468.2.

(EC Section 49468.3(a).)

The school nurse assigned to the school or a nurse from the LEA shall collaborate with the parent or guardian of each student diagnosed with seizures, a seizure disorder, or epilepsy to create a seizure action plan pursuant to subdivision (a) of Section 49468.3, if the student does not have an IEP pursuant to the federal IDEA (20 U.S.C. §§ 1400 et seq.), or a plan pursuant to Section 504 of the federal Rehabilitation Act of 1973 (29 U.S.C. § 794). (EC Section 49468.3(c).) If the school obtains written consent from a student’s parent or guardian, in accordance with the Family Educational Rights and Privacy Act (FERPA), the seizure action plan shall be distributed to any school personnel or volunteers responsible for the supervision or care of that student.

LEAs may choose to use one of the sample seizure action plans below, develop their own plan, or use a plan provided by the student’s healthcare provider.

Epilepsy Foundation Seizure Action Plans  Available in English, Spanish, Chinese, Korean, Tagalog, and Vietnamese.

Seizure Action Plan Coalition Available in English, Spanish, Chinese, Korean, Tagalog, Vietnamese, and Ukrainian.

V. Resource

American Academy of Pediatrics

California Department of Public Health

California Medical Association

California School Nurses Organization

Centers for Disease Control and Prevention

National Association of School Nurses

VI. Acknowledgements

In compliance with the authorizing statute¹⁹,the following agencies were consulted in the review of the training standards:

• California Medical Association
• California School Nurses Organization
• Epilepsy Foundation
• Epilepsy Foundation of Northern California
• Epilepsy Foundation Los Angeles

___________________

1. Centers for Disease Control and Prevention: Epilepsy
2. Epilepsy Foundation
3. EC Section 49468.2(a)(1)
4. EC Section 49468.2(c)(1)
5. EC Section 49468.2(d)(1)
6. EC Section 49468.2(a)(1)
7. EC Section 49468.2(c)(2)
8. EC Section 49468.2(c)(2)(A)
9. Epilepsy Foundation
10. Epilepsy Foundation: General First Aid for Seizures
11. EC Section 49468.2(c)(2)(B)
12. Epilepsy Foundation: Nasal Rescue Therapies
13. Epilepsy Foundation: Oral Rescue Medicines
14. Epilepsy Foundation: Rectal Rescue Medicines
15. Epilepsy Foundation: Vagus Nerve Stimulation (VNS) Therapy
16. EC Section 49468.2(c)(2)(C)
17. Epilepsy Foundation: General First Aid for Seizures
18. EC Section 49468.2(c)(2)(D)
19. EC Section 49468.2(c)(1)