IM Versed at school

allnurses Guide · Jan 9, 2008

We have a new student that started on Monday. This child has an order for IM Versed for use with a seizure that lasts over 3 minutes. I am the only nurse in the district (Illinois) and am housed about 12 minutes from the school that the child is attending. Even if I were housed at her school I would not be comfortable giving IM Versed at school. I spoke with the Neurologist's nurse and she stated that he will not order rectal Diastat for the child.
Does anyone have any experience with this?

Any particular reason you are not comfortable with the order? Is it because it is Versed, IM, or both?

Versed actually seems to be a fairly safe choice being the shortest acting benzo. Although, I have never used Versed for seizure activity.

What do the parents do at home for the child?

missfixit · Jan 10, 2008

I am in South Carolina and a nurse can train non-medical personnel to administer IM medications-- in ER situations. If this is allowed in your state, the first thing I would do is talk with the principal or your supervisor about training at least 2 people, at the child's school, to administer the med.

okschoolnurse · Jan 17, 2008

Holy Cow!!!!! Train unlicensed personnel to give IM versed?????? Do you have reversal???? do you have oxygen????? Can you intubate to support resperations?????

I would NEVER even consider that!!!!

The big topic in our state has been the intranasal versed. We are not even comfortable with that, but IM????

Wow. :bugeyes:

Trauma Columnist · Jan 17, 2008

Would definitely want clarification for the IM Versed. I am a pre-hospital RN in IL and must have a physician order each time I give IM Versed for sz. Think this may be a 911 situation.

missfixit · Jan 17, 2008

I remember reading something that stated, in EMERGENCY situations that nonlicensed personnel can be trained to administer er meds. I'll have to look into it more- when I have time. I'll update you to what I find out. I know that Glucagon can be given. It might not pertain to ALL meds. I'll try to find out.

allnurses Guide · Jan 18, 2008

I have one special needs child and the school is required to provide all needed services while they are in school, so if they need a nurse at that school all day then the school has to provide it. Now if the school has found a loophole and are able to not provide nursing services for them I certainly don't know about it, and so far being military we have lived in 3 states and 4 school districts with my one daughter.

The second thing is this order is for a seizure over 3 minutes. It is fine if you can get an ambulance there in 3 minutes, but if you can't then you are risking brain damage to this child by not giving some kind of antiseizure medication. You could still call EMS, but no one should hold the medication and wait on the EMTs to arrive.

Third, rarely is flumazenil/Romazicon (the reversal for benzos) used outside of ER/EMS if someone is using it regularly outside of that setting then they are doing something wrong. It is much better to support respirations for a short time than to give flumazenil. The half-life for flumazenil is less than 1hr and the half life for Versed is 1-4 hrs. When you give flumazenil the patient needs to admitted to the hospital and watched very carefully for resedation. There are anesthesia providers that go through their whole careers and never give Romazicon. Romazicon is considered very dangerous in the anesthesia community and there have been several cases where patients have died d/t resedation w/o proper monitoring. Romazicon has its' place, but as long as you can support respirations the school isn't one of them. I personally would not even have it around at the school unless EMS has a very long response time.

The last thing diastat is nice choice because of its' delivery method, but diastat/valium has quite a few draw backs. Diastat can cause exactly the same effects as Versed...loss respirations etc. Valium/Diastat has the longest half-life of all the benzos. The active metabolites can last up to 48hrs. What little of information I could find comparing the two is that versed IM was quicker acting and more likely to stop the seizure than diastat (again I wouldn't take that as an absolute because it was only based on a couple of pts.)

Sorry if the post sounds a little harsh...it is not intended that way.

bergren · Jan 21, 2008

This is a policy issues that is not decided by an individual nurse. This is an issue for your Principal, superintendent, school board, school district attorney, state school nurse consultant, and ultimately your state Board of Nursing.

All who have accountability need to weigh in. It may not even be in line with regulations in your state.

You can find your state school nurse Consultant:

http://www.tjcats.net/nassnc/040817/nassnc/nassnc_members.html

Your state's Board of Nursing: https://www.ncsbn.org/index.htm

I did a search of the literature and cannot find any studies or articles that talk about IM Versed outside of an acute setting, nor to children. If this order is accepted, be sure you have a very tight policy on who is to monitor, calling 911, Bag and mask, oxygen etc. What is your EMS response time, distance to hospital?

Good luck - let us know the outcome.

luvschoolnursing, LPN · Jan 23, 2008

Thanks, Martha-I always look forward to your input.

rgroyer1RNBSN, BSN, RN · Jan 26, 2008

All I have to say is Ive been an er nurse for awhile now, and if you do this you better have o2, IM or IV romazicon, Intubation equipment to establish an airway, and a phone to call ems available, I mean its a very good short acting benzo for seizures, I give it in ER all the time, but that is a level 1 trauma center, and its generally in a trauma room thats controlled and the patient already has an airway, now I live in St.Louis which is close to Illinios but Im not sure about that state. Just make sure your prepared to ahndle any emergencies and I would at least have an airway kit available and some O2.

allnurses Guide · Jan 26, 2008

All I have to say is Ive been an er nurse for awhile now, and if you do this you better have o2, IM or IV romazicon, Intubation equipment to establish an airway, and a phone to call ems available, I mean its a very good short acting benzo for seizures, I give it in ER all the time, but that is a level 1 trauma center, and its generally in a trauma room thats controlled and the patient already has an airway, now I live in St.Louis which is close to Illinios but Im not sure about that state. Just make sure your prepared to ahndle any emergencies and I would at least have an airway kit available and some O2.

I still think giving the Versed IM in this circumstance is a good idea. We are talking about a potential (very low probability) of resp. depression vs. probable brain damage for a seizure lasting more than 3 minutes. The research even states that there is a very low to no incidence of resp depression with IM Versed when given by itself, and the incidences where it did were in high volumes (>0.15mg/kg IV) after rapid IV administration. (From Pharmacology & Physiology in Anesthetic Practice...4th edition Stoetling)

Another article: "The incidence of hypoxemia (oxyhemoglobin saturation less than 90%) and apnea (no spontaneous respiratory effort for 15 s) and the ventilatory response to carbon dioxide were evaluated. Midazolam alone produced no significant respiratory effects". Frequent hypoxemia and apnea after sedation with midazolam and fentanyl.

Bailey PL, Pace NL, Ashburn MA, Moll JW, East KA, Stanley TH.

Instead of relying on personal opinions as professionals we should at least research the subject before making an informed decision.

rgroyer1RNBSN, BSN, RN · Jan 26, 2008

Yes I agree with you wtb, but I would think there would need to be alot of training if an unlicensed person is going to have to use it in this situation, and there needs to be one or two specific people trained then they need to be trained continually and trained what to do in the event of an adverse reaction so that if the nurse isnt available they'll know how to handle it, thats all.