In a nursing home patient with drooling and an active seizure who has a PRN Valtoco (diazepam) intranasal spray, what steps should be taken?

Immediate Management of Active Seizure with Valtoco in Nursing Home Setting

Administer the Valtoco (diazepam) intranasal spray immediately while simultaneously ensuring basic seizure safety measures and preparing for emergency transport if the seizure continues beyond 5 minutes. 1

Step-by-Step Protocol

1. Immediate Safety Measures (Simultaneous with medication preparation)

• Position patient on their side if possible to prevent aspiration of drool/secretions
• Clear area of hard objects to prevent injury
• Do NOT attempt to restrain the patient or place anything in their mouth
• Note the time the seizure started (or estimate when patient was last seen normal)
• Ensure airway is patent; suction may be needed for excessive secretions

2. Administer Valtoco Intranasal Spray

Critical points from FDA labeling 1:

• Do NOT test or prime the device - each device sprays only once
• The patient does NOT need to breathe deeply or inhale during administration
• Dosing depends on prescribed strength:
  • 5 mg or 10 mg dose: Use 1 device in 1 nostril
  • 15 mg or 20 mg dose: Use 2 devices (1 spray in each nostril)

Administration technique:

• Hold device with thumb on plunger bottom, first and middle fingers on either side of nozzle
• Insert nozzle tip into nostril until fingers touch bottom of nose
• Press plunger firmly with thumb
• For higher doses, repeat immediately in opposite nostril with second device
• Discard devices after use

3. Post-Administration Monitoring

Document timing 1:

• Record exact time of Valtoco administration
• Continue observing patient closely
• Monitor respiratory status (benzodiazepines can cause respiratory depression) 2

Call 911 immediately if 1:

• Seizure continues beyond 5 minutes after Valtoco administration
• Seizure behavior differs from patient's typical pattern
• Patient develops concerning respiratory changes or color changes
• You are alarmed by seizure severity or duration

4. Second Dose Considerations

A second dose may be given at least 4 hours after the first dose if prescribed 1. However, in the nursing home setting with an active, ongoing seizure:

• If seizure continues 5 minutes after first Valtoco dose, this represents status epilepticus requiring emergency transport 3
• Do NOT wait 4 hours for a second dose in ongoing seizure - call 911 immediately
• The 4-hour interval applies to recurrent seizure episodes, not ongoing status epilepticus

Critical Pitfalls to Avoid

Regarding drooling: The presence of drooling does NOT contraindicate intranasal administration. The FDA labeling specifically states the patient does not need to breathe deeply or inhale 1. Intranasal benzodiazepines are absorbed through nasal mucosa, not requiring inhalation.

Timing is critical: Current guidelines define status epilepticus as seizures lasting ≥5 minutes 3, 4. In nursing homes, delays in recognition and treatment are common 5. The median time to seizure termination with diazepam nasal spray is approximately 7 minutes when given 5-15 minutes after seizure onset 6, but earlier administration (within 5 minutes) produces faster termination 7, 8.

Do not delay for IV access: Intranasal administration is specifically designed for non-medical settings and is faster than attempting IV access 9, 10. Studies show 67.3% of seizure clusters are treated within 5 minutes using intranasal diazepam 7.

Respiratory monitoring: While benzodiazepines carry risk of respiratory depression, especially when combined with other sedatives 2, this risk must be balanced against the mortality and morbidity of untreated status epilepticus 3. Be prepared to support ventilation if needed, but do not withhold treatment.

After Seizure Terminates

• Continue monitoring for at least 30 minutes
• Assess for need for emergency transport based on patient's baseline seizure pattern
• Document episode details for healthcare provider follow-up
• Ensure adequate supervision as patient may be postictal and at fall risk

The evidence strongly supports immediate use of available rescue benzodiazepines in nursing home settings 5, with intranasal formulations offering ease of use and rapid administration that can prevent progression to refractory status epilepticus 7, 9, 8.