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Canberra Hospital and Health ServicesClinical GuidelineManagement of Anaphylaxis in Adults and Children Contents

Contents....................................................................................................................................1

Introduction..............................................................................................................................2

Scope........................................................................................................................................ 2

Background............................................................................................................................... 3

Key Objectives...........................................................................................................................3

Section 1 – Reducing the risk of anaphylaxis............................................................................3

Section 2 – Symptoms and signs of an acute allergic reaction..................................................3

Section 3 – Emergency management of allergy and anaphylaxis at Canberra Hospital............4

Section 4 – Differential Diagnosis..............................................................................................5

Section 5 – Podiatry Services....................................................................................................6

Section 6 – Justice Health..........................................................................................................7

Section 7 – Immunisations........................................................................................................7

Section 8 – Community Nurses (Community Care Program)....................................................9

Implementation...................................................................................................................... 10

Related Policies, Procedures, Guidelines and Legislation.......................................................10

References.............................................................................................................................. 12

Definition of Terms................................................................................................................. 12

Search Terms.......................................................................................................................... 12

Attachments............................................................................................................................13

Attachment A: How to Use an Epipen or Anapen:..............................................................14

Attachment B: Anaphylaxis Emergency Treatment Plan for Schools and Preschools.........17

Attachment C: Adverse Event Following Immunisation (AEFI) Form...................................19

Attachment D: Basic Life Support Chart..............................................................................21

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Introduction

This guideline outlines the emergency management of anaphylaxis in children and adults.

Anaphylaxis is a form of immune-mediated hypersensitivity reaction, which means it is an abnormally vigorous immune response. In most cases, but not always, anaphylaxis is triggered by exposure to an exogenous antigen such as venom, food or drug. Sometimes the cause is not obvious.

Anaphylaxis is a specific immune response mediated by IgE antibodies, which bind to mast cells and basophils to cause degranulation and release of vasoactive mediators. When liberated in large quantities, these mediators cause many physiological changes including bronchospasm, haemodynamic instability, vascular leak, rash and itchiness.

Please note the following online training resources: For clinicians: http://www.allergy.org.au/health-professionals/health-professionals-e-

training https://alm.ascia.org.au/ For childcare and schools: www.allergy.org.au/patients/anaphylaxis-e-training-schools-

andchildcare

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Scope

Management of anaphylaxis in children and adults within inpatient, outpatient and community jurisdictions of ACT Health.

This clinical guideline applies to: Medical Officers Registered nurses and midwives working within their scope of practice Podiatrists Other authorised prescribers

Podiatry Services: this pertains to podiatrists who administer local anaesthetic agents. The podiatrist must have current training in CPR and anaphylaxis management as per the Podiatry Board of Australia requirements.

Justice Health Service: this pertains to all anaphylactic events at the Alexander Maconochie Centre (AMC), Periodic Detention Centre (PDC), and Bimberi Youth Justice Centre (BYJC) while Justice Health Service registered nurses are on site.

Community Nursing: this pertains to community nurses who administer intravenous (IV) and intramuscular (IM) antibiotics in patients’ homes and health centre clinics.

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Background

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Alert: Anaphylaxis is a severe allergic reaction with manifestations in more than one organ system. Anaphylaxis is a medical emergency and therefore requires immediate medical management

Within the hospital setting, common allergenic triggers of anaphylaxis are drugs (especially after parenteral administration), latex, chlorhexidine, a known allergen administered for allergy desensitisation procedures or allergy testing, or a meal containing a food allergen.

Not all drug reactions are anaphylaxis or even allergic in origin. In addition, some features of anaphylaxis can result from other mechanisms. Important examples are: Vancomycin can cause erythema ACE inhibitors such as ramipril can cause angioedema Monoclonal antibodies can cause immune activation and cardiovascular collapse

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Key Objectives

Identification of the patient with anaphylaxis Safe and effective management of the patient with anaphylaxis

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Section 1 – Reducing the risk of anaphylaxis

Before commencing a new treatment, ask the patient if they have any allergies. Consult medical records and drug charts for documented history of drug and other allergies.

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Section 2 – Symptoms and signs of an acute allergic reaction

Mild to moderate allergiesSigns or symptoms that might be observed with any form of allergic reaction: swelling of lips or eyelids (angioedema) hives or welts (urticaria) tingling in the mouth cough or wheeze.

Severe acute allergic reaction and anaphylaxisSymptoms of mild allergy can occur in patients with severe allergic reactions. Symptoms that might indicate anaphylaxis: shortness of breath tightness in the throat sensation of swollen tongue light headedness

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generalised itchiness sweatiness nausea severe anxiety.

Signs of anaphylaxis: swelling of the tongue, pharynx, larynx widespread wheeze reduced air entry tachypnoea severe generalised urticaria hypotension tachycardia loss of consciousness.

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Section 3 – Emergency management of allergy and anaphylaxis at CHHS Facilities

Mild to moderate allergy:1. Stop any intravenous treatment currently underway2. Administer an oral antihistamine

Adults: (Loratidine 10mg) Children: (Loratidine, according to age and weight)

3. Monitor for improvement or progression to signs and symptoms of anaphylaxis.

Anaphylaxis:1. Stop any intravenous treatment currently underway2. Administer adrenaline by intramuscular injection according to standing orders (see

below). Adrenaline dose can be repeated after five minutes if no response to the first dose

3. Administer oxygen by mask4. Establish intravenous access5. Call Medical Emergency Team (dial 8 within the hospital)6. Call on-call Immunologist or immunology trainee via the Canberra Hospital switchboard.

Adrenaline treatment according to standing orders for the emergency management of anaphylaxis:

Adrenaline 1:1000 (1mg/mL)Age (years) Weight (kg) Adrenaline volume (mL)<1 5-10 0.05 – 0.1 mL1-2 10 0.1 mL2-3 15 0.15 mL4-6 20 0.2 mL

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7-10 30 0.3 mL10-12 40 0.4 mL>12 and adult >50 0.5 mL

Alert: Treatment can be repeated after five minutes if there is no response to the first dose

Adrenaline via Epipen or Anapen*Age Which pen? Dose (micrograms)ADULT: Epipen or Anapen 300 300 micrograms IMCHILD 10 - 20 kg: Epipen Junior or Anapen 150 150 micrograms IMCHILD > 20kg: Epipen or Anapen 300 300 micrograms IM

Alert: Epipen Junior should be used for patients weighing <20kg. For children weighing >20kg, use adult dose Epipen.

See Attachment A for instructions on how to use an Epipen or Anapen.

Reporting and documentation should be completed as per the requirements in the Medication Handling Policy.

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Section 4 – Differential Diagnosis

In cases where the patient does not respond to adrenaline, anaphylaxis might not be the correct diagnosis, or the patient might be on another treatment that prevents adrenaline from working.

Examples include: ACE inhibitors such as ramipril can cause angioedema Monoclonal antibodies can cause immune activation that result in cardiovascular

collapse Beta blockers inhibit some actions of adrenaline.

In these cases, seek urgent medical advice from Immunology via the Canberra Hospital switchboard about patient management.

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Section 5 – Podiatry Services

Podiatrists administering local anaesthetic agents must ensure adequate dosages of adrenaline (via autoinjector such as Epipen or Anapen) will be readily available at the time of, and directly after administration. The Podiatry Manager needs to be notified at least 2 weeks prior to administering local anaesthetic to persons between 10-20kg, so that the appropriate adrenaline (Epipen Junior or Anapen 150) can be ordered. Patients

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who weigh <10 kg would not be deemed suitable for local anaesthetic administration by podiatrists.

The podiatrists who administer local anaesthetic agents must be able to recognise and effectively manage anaphylaxis.

Prior to administering a local anaesthetic the podiatrist will check the Podiatry Nail Surgery Pre-surgical Assessment Form and confirm with the patient their allergies or previous reactions to antigens.

Prior to administering local anaesthetics, podiatrists should ensure there is a duress alarm facility in the health centre clinic.

Podiatrists must report to the Podiatry Manager, any incidents of anaphylaxis, or other adverse reactions related to administration of local anaesthetic agent within 24 hours of the event.

Management of mild signs and symptoms (Section 2):1. Cease administration of local anaesthetic2. Place patient in a supine position whilst remaining in the Podiatry chair3. Never leave the patient alone4. Monitor patient for at least 20 minutes for improvement or progression of signs and

symptoms.5. Contact patient’s General Practitioner and arrange same day patient review6. Document all interventions in the patient’s clinical record7. Complete Riskman report8. Add to ACTPAS alerts9. Report to the Podiatry Manager within 24 hours.

Management of anaphylaxis (Section 2):1. Assess airway, breathing, circulation and commence Basic Life Support (BLS) protocols

(See Attachment D).2. Administer adrenaline via Epipen or Anapen3. Never leave patient alone4. Call for additional assistance – press duress alarm.5. Call for ACT Ambulance Service or advise others to request an ambulance

o Dial 0 to obtain a dial tone, then 000o Or 112 for a mobile phone as this is the GSM international standard emergency

access number6. Continue emergency care until ambulance arrives7. Document all interventions in the patient’s clinical record8. Complete Riskman report9. Add to ACTPAS alerts10. Report to the Podiatry Manager within 24 hours.

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Section 6 – Justice Health

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In addition to emergency management (see Section 3), the following should be performed:1. When Justice Health Service staff is notified, the RN will attend the specified area2. Initially, the RN will attempt to determine the cause of anaphylaxis by taking a history

from the patient (if possible)3. If the patient is conscious, they should administer an Epipen or Anapen to themselves 4. If the patient is unable to administer the Epipen or Anapen themselves, the attending

RN will administer the Epipen or Anapen into the patient’s lateral thigh (see Attachment A for how to administer an Epipen or Anapen)

5. If the patient is having difficulty breathing or is unconscious, assess airway, breathing and circulation and commence emergency procedures as appropriate

6. The RN should stay with the patient7. If Ambulance attendance is deemed necessary, the RN should seek assistance from

another staff member present and request for them to call 0-000 for ACT Ambulance Service

8. Prepare patient and any relevant information for transport to the Canberra Hospital.9. This event must be documented in the patient’s medical record in accordance with the

clinical record documentation policy10. Riskman should also be completed.

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Section 7 – Immunisations

To minimise the risk of an adverse event following immunisation all persons prior to vaccination are screened using the pre-vaccination checklist.

A protocol for the management of anaphylaxis and adrenaline must always be immediately at hand where ever vaccines are given. For management of anaphylaxis in an emergency, see Section 3.

Ensure that emergency equipment is available as follows: Telephone Laerdal resuscitator age appropriate and pocket face mask Adrenaline 1:1000 (2 vials and 1mL syringes, 23g needles)

Note:Pocket face masks are not used in community health centres

Alert: Recipients of vaccines must remain under direct observation by a nurse for at least 15 minutes following immunisation.

Clinical features which may assist differentiation between a vasovagal episode and anaphylaxis:

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Vasovagal episode AnaphylaxisOnset Immediate, usually

within minutes of or during vaccine administration.

Usually within 15 minutes, but can occur within hours, of vaccine administration.

Skin Generalised pallor, cool, clammy skin.

Skin itchiness, generalised skin erythema (redness), urticaria (wheals) or angioedema (localised oedema of the deeper layers of the skin or subcutaneous tissues).

Respiratory Normal respiration; may be shallow, but not laboured.

Cough, wheeze, stridor, or signs of respiratory distress (tachypnoea, cyanosis, rib recession).

Cardiovascular Bradycardia, weak/ absent peripheral pulse, strong carotid pulse. Hypotension – usually transient and corrects in supine position.

Tachycardia, weak/absent peripheral and carotid pulse.Hypotension – sustained and no improvement without specific treatment.

Neurological Feels faint, light-headed.Loss of consciousness – improves once supine or head down position.

Sense of severe anxiety and distress.Loss of consciousness – no improvement once supine or head down position.

Documentation All adverse events are reported on Report of Adverse Event Following Immunisation

(AEFI) form, which can be found on the ACT Health Immunisation page (http://health.act.gov.au/our-services/immunisation). This is faxed within 48 hours to Health Protection Service on 6205 1738. (example at Attachment C)

A Riskman report is also made via the Health Intranet (https://acthrisk/) or by phone via the helpsek when computer access is not available, phone: 6205 4000.

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Section 8 – Community Nurses (Community Care Program)

This section applies to community nurses who administer IV or IM antibiotics in patients’ homes or in health centre clinics.

Community nurses do not carry or supply adrenaline. Prior to administering IV or IM antibiotics the community nurse will: Ensure that the patient has received an initial dose of the antibiotic

Note: Community nurses do not administer the first dose of any parenteral medication Ensure a medical order for the administration of Adrenaline is documented on the

‘Medical Officers Orders for Medication Administration’ form Ensure that the following is available in the patient’s home or health centre clinic:Doc Number Version Issued Review Date Area Responsible PageCHHS15/122 1.2 8/5/2015 1/9/2019 Pathology 8 of 20

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o Two vials of Adrenaline 1:1000 (supplied by the patient)o 1 mL syringes, drawing up needles and 23 gauge needles (supplied by the

Community Care Program)

Management of mild to moderate signs and symptoms (Section 2):1. Cease administration of IV or IM antibiotic2. Monitor patient for at least 20 minutes for improvement or progression of signs and

symptoms3. Report to the patient’s General Practitioner and arrange same day patient review.

Advise the patient to call an ambulance if symptoms worsen 4. Document all interventions in the patient’s clinical record5. Complete Riskman report6. Add to ACTPAS alerts

Management of severe signs and symptoms (Section 2):1. Cease administration of IV or IM antibiotic2. Lay patient flat, do not stand or walk; and if breathing is difficult, allow the patient to sit.3. If unconscious, lie the patient on the left side and position to keep the airway clear.4. Call for ACT Ambulance Service, Ph 000 (112 is the mobile phone number for the GSM

international standard emergency access number)5. Assess airway, breathing, circulation and commence basic life support if required 6. Administer adrenaline (as per doctor’s order), by IM injection into the mid-lateral thigh.

If there is no improvement in the patient’s condition the dose can be repeated after 5 minutes

7. Never leave the patient alone8. Continue emergency care until ambulance arrives9. Document all interventions in the patient’s clinical record10. Complete Riskman report11. Add to ACTPAS alerts.

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Implementation

This is an update of a pre-existing guideline, rather than a change in practice. The new guideline will be uploaded onto Sharepoint, with advertisement of the update on the Hub.

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Related Policies, Procedures, Guidelines and Legislation

Adrenaline standing order

Legislation Health Practitioner Regulation National Law (ACT) Act 2010

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Medicines, Poisons and Therapeutic Goods Act 2008 and Regulations 2008 Corrections Management Act 2007 Health Records (Privacy and Access) Act 1997 Health Act 1993 Human Rights Act 2004 Health Practitioner Regulation National Law (ACT) Act 2010 Health Practitioner Regulation National Law Act 2009 Health Practitioner Regulation National Law Regulation Privacy Act 1988 Public Health Act 1997 Public Sector Management Act 1994 Work Health and Safety Act 2011

Policies ACT Health Wide, Occupation Health and Safety Policy. http://inhealth/PPR/Policy

%20and%20Plans%20Register/Work%20Safety%20Policy.pdf ACT Health Framework for Quality Use of Medicines. ACT Health Medication Management Policy. Nursing & Midwifery Continuing Competence Policy. Work Health and Safety Policy. Adult Corrections Health Service Plan 2008-2012 Children and Young Peoples Justice Health Services Plan 2008-2012

Canberra Hospital and Health Services. Operational Procedure, Immunisation Service Delivery in Schools and Child Health Clinics 2016 - 2021

ACT Health Nutrition Department Procedure: Open Food Challenges, August 2009

Standards National Safety & Quality Health Services Standards - Standard 4: Medication Safety. The Australian Council on Healthcare Standards Evaluation and Quality Improvement

Program5 (EQuIP5):1.4.1 Care and services are planned, developed and delivered based on the best available evidence and in the most effective way.1.5.1 Medications are managed to ensure safe and effective practice.

Standard Operating Procedures Alcohol and Drug Services The Management of Adverse Events following Immunisation

within the Alcohol and Drug Services (ADS). Community Care Medication Management. Community Care Anaphylaxis Management in Podiatry Services. Capital Region Cancer Service Hypersensitivity Reaction Management – Immunological

Procedures. Community Care Nursing Management of a Patient Receiving Antibiotics via a Central

Venous Access Device or Intramuscular Route in the Community - Adults.

Standards Code of conduct for registered health practitioners, Podiatry Board of Australia

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Australasian Podiatry Council Competency standards The Australian Council of Healthcare Standards (ACHS) Evaluation and Quality

Improvement Program (EQuIP) ACHS EQuIP 5 - 1.4 - The organisation provides care and services that achieve expected

outcomes

Competency Registration with the Podiatry Board of Australia Current First Aid Certificate as per the Podiatry Board of Australia requirements

Related Policies Community Care: Podiatric Nail Surgery policy Nail Surgery Competency Assessment – Continuing Care Podiatry ACT Health Directorate Podiatry Pre-Surgical Assessment Form Community Care: Nursing Management of patient experiencing an anaphylactic reaction

as result of medication administration in the Community continuing care program Community Health: Medication Manual (revised 2010) ACT Health: 5 Step Correct Patient, Correct Site, Correct Procedure Policy

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References

1. Ellis AK and Day JH. Diagnosis and management of anaphylaxis. CMAJ 2003;169(4):307-312. www.cmaj.ca/cgi/content/full/169/4/307

2. http://www.nps.org.au/health_professionals/publications/nps_radar/2006/ august_2006/epipen

3. Australian Prescriber 34(4), August 20114. Australasian Society of Clinical Immunology and Allergy national guidelines

(www.allergy.org.au)5. The Australian Immunisation Handbook 10th Edition p 85-97. 6. http://www.allergy.org.au/images/stories/anaphylaxis/multinew/

ENG.How_to_give_EpiPen_2011.pdf 7. http://www.allergy.org.au/images/stories/anaphylaxis/2015/

ASCIA_Action_Plan_Anaphylaxis_EpiPen_Personal_2015.pdf

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Definition of Terms

DET: Department of Education AMC: Alexander Maconochie CentrePDC: Periodic Detention Centre BYJC: Bimberi Youth Justice Centre

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Search Terms

Acute, Adrenaline, Adverse, Allergy, Anapen, Anaphylaxis, Epipen, Hypersensitivty, Immunisation, Podiatry, Reaction, Vaccine, Vasovagal

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Attachments

Attachment A: How to Use an Epipen or AnapenAttachment B: Anaphylaxis Emergency Treatment Plan for Schools and PreschoolsAttachment C: Adverse Event Following Immunisation (AEFI) FormAttachment D: Basic Life Support Chart

Disclaimer: This document has been developed by Health Directorate, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Date Amended Section Amended Approved By01/02/2016 RACC and School

Immunisation information added

CHHS Policy Committee

11/07/2017 Title changed and removal of Special schools section

CHHS Policy Committee

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Attachment A: How to Use an Epipen or Anapen:

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Attachment B: Anaphylaxis Emergency Treatment Plan for Schools and Preschools

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Attachment C: Adverse Event Following Immunisation (AEFI) Form

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Attachment D: Basic Life Support Chart

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