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Information and Guidance for using the Oromucosal (Buccal) Midazolam Protocol


Prolonged Acute Convulsive Seizures and Oromucosal Midazolam Treatment

Most seizures resolve spontaneously without intervention, but some people with epilepsy have a frequent occurrence of prolonged seizures. In such cases, carers of people with recurrent prolonged or serial seizure episodes in the community may be able to: terminate the seizure episode, prevent the development of status epilepticus and avoid unnecessary hospital admission by the administration of 10mg Oromucosal (buccal) midazolam, a "rescue medication" [1].

Generalised tonic-clonic status epilepticus is a medical emergency with significant morbidity and a mortality rate of between 16% and 39% [1]. Both morbidity and mortality can be exacerbated by inadequate or delayed treatment, which is why it is so important to be prepared for the situation of status epilepticus, with clear steps and parameters laid out.

Why is a Protocol for Oromucosal Midazolam Treatment Needed?

Oromucosal (buccal) midazolam in the form of pre-filled syringes has been designed specifically for speed of administration and ease of use in an emergency situation. It should be administered by trained caregivers with a clear set of instructions which include when to give it, how much to give and when to call for emergency help [2].

This set of instructions is commonly called a “protocol”, because there should be no variation from the instructions and the steps must be followed exactly as written [1]. It is particularly important that the protocol has this level of detail to always ensure correct administration and that the steps are standardised and always followed in the same way if a person has one or more caregivers. This is because the person with epilepsy will either be unconscious or have impaired consciousness when requiring rescue medication. The protocol may be used in conjunction with a care plan which outlines other aspects of an individual’s epilepsy care and treatment. Additionally, the protocol benefits the prescriber by helping them to organise the prescription instructions.

Training for Caregivers

In addition to using the protocol caregivers should always have undertaken training in epilepsy and the treatment of prolonged and serial seizures with a reputable training provider. Advice about training and choosing a good quality training provider can be found within the Epilepsy Specialist Nursing Association (ESNA) Best practice guidelines for training professional carers in the administration of Buccal (Oromucosal) Midazolam for the treatment of prolonged and / or clusters of epileptic seizures in the community.

Protocol for the Administration of Oromucosal (Buccal) Midazolam: Prescriber-Led

This Oromucosal midazolam protocol supplied by Veriton Pharma can be used with any Oromucosal midazolam 10mg pre-filled syringe and has been designed by epilepsy specialist nurse consultants in conjunction with national clinical guidelines from SIGN and NICE [1][2]. This protocol has also been reviewed by numerous representative epilepsy groups and societies including the Epilepsy Specialist Nursing Association Executive committee.

The Epilepsy Specialist Nursing Association (ESNA) Executive committee supports the use of this document as an emergency interim measure during the situation of Covid-19 to assist in the prescribing of rescue medications; this will be kept under review

The protocol allows the prescriber to organise the prescription instructions for buccal midazolam into a format which can be clearly followed by the caregiver. The protocol contains the essential information for caregivers to be able to safely administer prescribed buccal midazolam to a person with prolonged or serial epileptic seizures in the community.

How to Use This Protocol for the Management of Prolonged Acute Convulsive Seizures

The protocol is a template to be filled-in with or on behalf of the person with epilepsy and should include the specific information relating to them e.g. what to give midazolam for, when to give it, the dosage to be administered, the maximum daily dose and when to call for emergency help.

A brief description of the seizure(s) experienced by the individual to be treated should be provided; this can be achieved by collaborating with carers using evidence available such as a witness description, written seizure recordings or video.

Keep a copy of the protocol for your file as evidence of the original prescription that you have written. The protocol can then be disseminated in the way you choose whether digitally or as a paper version.

Examples of completed protocols are provided here

The protocol is available in the following formats

Generic Protocol for any Buccal Midazolam

Format 1: Editable PDF to complete on your system

Format 2: PDF for printing and completion by hand,
e.g. if the editable version is not compatible with your system

Specific Protocol for Epistatus®

Format 1: Editable PDF to complete on your system

Format 2: PDF for printing and completion by hand,
e.g. if the editable version is not compatible with your system

Additional Resource: A tear-off pad (format number 2) –
order from

If you would like to retain or print a copy of the information given on this page, please click here to download this as a PDF


  1. SIGN 143, Diagnosis and management of epilepsy in adults, A national clinical guideline, (May 2015, Last update- 2018). Chapter 4.11, p.26.
  2. NICE, Epilepsies: diagnosis and management, Clinical guidelines [CG137], (January 2020, Last update- February 2020). Chapter 1.14.

Date of Preparation: April 2020

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Item code number EDM-1022-2019. Date of preparation: March 2019.

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