Treatment of Severe Allergic Reaction

Protocol for Training

PowerPoint Presentation

January, 2013

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• The 2013 training protocol and Power Point presentation were revised by the Oregon Health Authority, Emergency Medical Services and Trauma Systems Office

• Many thanks to Kathleen Mahaffy-Dietrich, RN, BSN, MPA and Jeanne Fratto, RN, BS, of the Multnomah Educational Service District for their assistance with the revisions

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Credits

• The 2013 training protocol and presentation slides are the responsibility of the Oregon Health Authority, Public Health Division

• The subject matter contained in this presentation highlights the information from “Treatment of Severe Allergic Reaction, A Protocol for Training” revised January, 2013

Background

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• Rules regarding epinephrine administration by the public

• Recognition of anaphylaxis• Management of anaphylaxis• Action of epinephrine• Use of epinephrine auto-injector devices• Follow-up

Topics

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• Oregon Revised Statute 433.805-830– Certain individuals may administer epinephrine to

another person who has a severe allergic reaction when a licensed health care professional is not immediately available

• Oregon Administrative Rule 333-55– This law defines the procedures involved to authorize

a person to administer epinephrine

State Laws

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• Procedure – Individual completes this training

– A statement of completion will be issued by the instructor

• The authorization to obtain epinephrine is included

• The authorization must be signed by a nurse practitioner or physician teaching or sponsoring the course

– This document serves as the prescription for epinephrine

State Law

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• The authorization to obtain epinephrine

– The authorization allows for a prescription of a auto-injector(s) for one child and one adult as an emergency supply

– The authorization will be returned with the medications and used for prescription refills of epinephrine up to 4 times

– The authorization will automatically expire three years after the date of the training

– In order to gain a new authorization for epinephrine, the training must be repeated

• A new statement of completion and authorization will be issued

State Law

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• Call or e-mail the Oregon Health Authority contact listed on the inside cover of the training manual

What If the Pharmacist Won’t Honor the Authorization?

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• Who may be trained and subsequently authorized to administer epinephrine?

– Person must be at least 18 years of age

– Person must have a reasonable expectation to work in an environment that poses a risk for individuals with a sensitivity for a severe allergic reaction

• Examples: schools, camps, forestry work, public venues, etc.

State Law

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Allergic Reactions and Anaphylaxis

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• Allergen– A protein not normally found in the body – Exposure may cause an exaggerated allergic reponse

• Examples of allergens– Food– Medications– Insect stings– Latex – Other– This will be discussed in more detail later

Definitions

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• Normal reaction to an allergen– Exposure to the allergen either causes no response

or produce expected, minimal signs

• Expected response to an insect sting– Reddening of an area surrounding the sting

• Size of the area can grow to the size of a quarter

– Pain, swelling and itching may accompany the redness

Definitions

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• Localized allergic reaction– An exaggerated response that occurs when the body

is exposed to an allergen

– The signs are limited to the affected extremity or stays on one side of the body

• Localized reaction to an insect sting– Itching, redness and swelling will extend to an area

larger than a quarter• It may extend over a joint line

Definitions

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• Anaphylaxis– A life-threatening emergency

– Without treatment, it is fatal!

– Signs will appear on multiple areas of the body• Or extend past one side of the body

– Signs may appear and progress rapidly• Onset from minutes-to-hours

Definitions

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• Example: sting to the tip of the finger

• Normal reaction– Swelling contained to the site of the sting

• Localized allergic reaction– Swelling spreads to the hand (past one joint)

• Anaphylaxis– Reaction spreads to the entire body

Severity of Allergic Reactions

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• For the purposes of this class, the information will focus primarily on the recognition and treatment of anaphylaxis

Allergic Reactions In Perspective

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Signs of Anaphylaxis

• Difficulty breathing– Higher-pitched sounds with

breathing

• Difficulty swallowing or hoarseness

• Swelling of eyes, lips, face or tongue

• Rapid or weak pulse• Dizziness or fainting• Loss of consciousness

• Abdominal pain, nausea or vomiting

• Widespread hives or hives on the torso and neck

• Flushed skin• Sweating• Sense of doom • Incontinence

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• Tissue swelling– The tongue and airway passages

• Airway constriction– Muscles surrounding the lower airways tighten

• Drop in blood pressure– Blood vessels dilate

• Immediate injection of epinephrine is the single factor most likely to save a life during anaphylaxis!

Why People Die From Anaphylaxis

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• The unpredictable nature of anaphylaxis

– It may occur with the first exposure or after repeated exposures

– Onset may be immediate or delayed

– Reactions will vary from person to person

– There may be several signs or just one

Anaphylaxis

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• The predictable side of anaphylaxis

– Death will occur if the condition is not treated swiftly with epinephrine

– If a person has had an anaphylactic attack in the past, they are very likely to experience it again with future exposures

– A person’s history of allergy or sensitivity may make them vulnerable to anaphylaxis

– Persons with asthma may have an increased risk for anaphylaxis as well

Anaphylaxis

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The faster the onset of signs from exposure, the higher risk for severe symptoms and death

One or more signs of anaphylaxis will require immediate injection of epinephrine

Call 9-1-1

Wisdom With Recognition

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• Oregon State law allows you to administer epinephrine to any person “suffering from a severe allergic response to an insect sting or other allergen.”

• “The decision to give epinephrine should be based upon recognition of the signs of a systemic allergic reaction…”

Epinephrine For Anaphylaxis

Note: The terms “severe allergic response” and “systemic allergic reaction” are considered to be

functionally the same as anaphylaxis.

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Causes of Anaphylaxis

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• Typical offenders– Yellow jackets– Honey bees– Wasps– Hornets

Insect Venom

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Food Allergies

• Accounts for 35-55% of all cases of anaphylaxis

• Most common food allergens:– Peanuts– Tree nuts (walnuts,

hazelnuts, etc.)– Fish– Milk– Eggs

• Other food allergens– Soy – Shellfish– Apricots– Bananas– Cherries– Kiwis – Papayas– Peaches– Pineapples– Plums– Strawberries

Keep in mind that a person can develop an allergy to any food

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• Exercise

• Latex

• Medications– Penicillin– Aspirin– Non-steroidal anti-inflammatory drugs

• Ibuprofen, naproxen, etc.

Other Allergens

Keep in mind that a person can develop an allergy to

any medication

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• Scenarios will be listed on the next few slides

• Read each scenario and determine if the person is suffering from anaphylaxis

• Debriefing slides will discuss the key points of recognition and treatment of the respective reactions

Review

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• 15 year-old was stung by a bee on his calf

• An area the size of a nickel is red and swollen on his calf– No swelling or redness found anywhere else

• No hives are seen

• He tells you this is the first time he has ever been stung

Scenario #1

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• Normal reaction– The signs did not expand beyond the size of a quarter

• What is his risk for developing anaphylaxis?– Appears to be a low risk at this point

Scenario #1 Debriefing

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• If reaction was from an insect sting– Cleanse the sting site– Remove the stinger

• Only honeybees leave their stinger behind

– Reassure and calm the person– Observe the person for at least 30 minutes– Notify the parent or guardian

Treatment for Normal Reactions

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• An 8 year-old has hives on her neck and chest– She is scratching at them

• She appears to be breathing normally

• She ate a cookie 30 minutes ago– A friend gave it to her

• She has a history of allergies to peanuts– She has an EpiPen Jr.

Scenario #2

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• Anaphylaxis– The signs involve the entire body

• Hives on her neck and chest

• What is her risk for developing anaphylaxis?– High risk– She has a prescription for epinephrine

• This tells you that her peanut allergy is severe

• Should you give her the EpiPen Jr?

Scenario #2 Debriefing

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• When should a person with a significant history of allergic reaction be given epinephrine?

– Persons with a history of anaphylaxis have a strong likelihood of developing it again

– Epinephrine should be given when any sign of anaphylaxis appears

Scenario #2 Debriefing

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• A student tells you that another student was stung in the face after poking at a wasp nest with a stick

• The child who was stung is screaming “it hurts!” repetitively.

• He has a swollen upper lip and cheek

Scenario #3

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• Local allergic reaction– Swelling correlates with the sting locations

• What is his risk for developing anaphylaxis?– Low

– Due to the location of the sting, the best action to take is to seek professional medical attention

– In the meantime, follow the procedures for treating a normal allergic reaction and monitor him for any change

Scenario #3 Debriefing

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• A staff member directs you to help another 24 year-old staff member

• His lips are swollen

• He is struggling to breathe– You hear wheezing sounds

• He feels dizzy and wants to pass out

• He also feels like he is going to throw up

Scenario #4

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• This is anaphylaxis– Wheezing, dizzy, nausea, swollen lips and wanting to

pass out

• Epinephrine needs to be given immediately!– Do not waste time attempting to find the cause

Scenario #4 Debriefing

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Management of Anaphylaxis

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1. Determine if the person is suffering from an anaphylactic reaction

2. Do not move the person

3. Have the person sit or lie down

4. Select the proper version of the epinephrine auto-injector

Anaphylaxis Treatment Protocol

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5. Administer the epinephrine through the device

6. Call or have someone else call 9-1-1. Do not leave the person unattended.

7. Note the time when the auto-injector was used

8. Remove the stinger if present

Anaphylaxis Treatment Protocol

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9. Check and maintain the person’s airway and breathing

10. Monitor for changes in the person’s condition

11. If the person’s condition does not change or worsens after 5 minutes, administer another auto-injector at the same dose

12. Upon the arrival of EMS, advise them of the person’s signs before and after the epinephrine was given.

Anaphylaxis Treatment Protocol

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Potential to cause a toxic reaction 10 or more stings

Elevated levels of venom in the body

• Any type of response may occur as a result– Localized reaction or an anaphylactic reaction

Multiple Insect Stings

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• Be prepared to give epinephrine

• Call 9-1-1

• Monitor the person closely

Dealing With Multiple Stings

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• Powerful drug– Obtained by prescription only

• Corrects all of the life-threatening problems of anaphylaxis

• Easy to give– Auto-injector

Epinephrine

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• Oregon law only allows the use of the epinephrine auto-injector for a person suffering from anaphylaxis

• The law does not allow epinephrine to be used for an isolated asthma attack

Limits of Epinephrine

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The Work of Epinephrine

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• The answer is found in the next slide

Why Is Epinephrine Effective In the Treatment of Anaphylaxis?

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Anaphylaxis

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• Rapid heart rate• Feeling of nervousness • Tremors• Nausea and/or vomiting• Sweating• Headache• Pale skin

Side Effects of Epinephrine

The effects may last between 5 and 20

minutes

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• Pre-measured dose in each– Pens for adults and children

• Trigger device– Injects epinephrine directly into the body

Epinephrine Auto Injectors

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• Store in a dark place at room temperature– The medication is very sensitive to light

• Protect the auto-injector from freezing temperatures– Do not store this in the refrigerator

• Protect the auto-injector from extreme heat– Keep it out of the glove box

Storage Of Epinephrine

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• Periodically check the medication– Solution should be clear and without particles

– Auto-injectors with tan or brown solution must be discarded

– Check the expiration date• Replace as needed

Storage Of Epinephrine

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Adult and Child Epinephrine Auto-Injectors

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Auto-Injector Name

Dose and Target Weight range for this device

Approximate Age Range for

the device

EpiPenAuvi-Q 0.3Twinject

Adult dose for all: 0.3 milligrams

Greater than 66 pounds

9-10 years or older

EpiPen Jr.Auvi-Q 0.15(No child-specific pen for the Twinject

Child dose for all: 0.15 milligrams

33-66 pounds 3 – 9 or 10 years

Adult and Child Auto-Injectors

Note: the epinephrine auto-injectors are not typically indicated for infants and toddlers. However, the risk of death from

anaphylaxis is greater than the risk of administration of the drug.

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1. Remove the auto-injector from its protective case

2. Remove the safety caps of the injector

3. Hold the injector firmly and keep fingers away from the tips of the device

General Procedures For the Auto-Injector

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4. Position the device at a 90-degree angle against the thigh

– Push hard enough to cause a click for some devices– Push down on the trigger for other devices

5. Hold the device firmly against the thigh for 5-10 seconds during administration

– Consult product directions

General Procedures For the Auto-Injector

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6. Remove the device and place it pack into its protective case (when applicable)

7. Massage the skin at the injection site for 10 seconds

8. Call 9-1-1 if this was not performed already

9. Note the time when the auto-injector was used

General Procedures For the Auto-Injector

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• Auvi-Q– https://www.auvi-q.com/

• EpiPen– http://www.youtube.com/watch?v=tjILFYPE3Uw

• Twinject– http://www.twinject.com/– Device no longer available as of March 2012

• Adrenaclik– http://www.adrenaclick.com/about-adrenaclick/adrenaclick-

training.aspx– May not be OSHA-approved

• Exposed needle

Instructions For Specific Devices

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• Choose the correct type of auto-injector for the general size and weight of the person

• Remove all safety caps prior to placement of the device on the person

• Place the device against the outside of the thigh

Key Points of Administration

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• Keep firm contact between the auto-injector and the thigh during administration– Maintain contact with the skin– Remove the device after 5-10 seconds

• Massage the site of administration to encourage faster absorption of the epinephrine

• Place the used auto-injector back into its case, if applicable

Key Points of Administration

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Strategies For the Preparation and Prevention of Anaphylaxis

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• Specific strategies to avoid insect stings and reduce the exposure to food allergens are outlined in detail in Section VII: B-E in the epinephrine training protocol.

• Discuss how those strategies may be applied in your situation.

Prevention

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• Identify those who are at risk of anaphylaxis– People with a prescribed auto-injector

– People with a history of allergic reactions

– People with a history of asthma

• When possible, educate those at risk for allergic reactions with prevention strategies

Preparation

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• Get a signed consent for emergency treatment for minors

• Know who is trained in first aid and CPR

• Have an emergency response plan in place and review it on an annual basis as a minimum

Preparation

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• Know where the epinephrine is kept

• Review the steps of administration

• Know how to get emergency help– How long does it normally take EMS to respond to

your location?

– Where is the nearest hospital?

Preparation

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• Anaphylaxis is a life-threatening event

• Epinephrine is the life-saving treatment for anaphylaxis

• DO NOT HESITATE TO GIVE EPINEPHRINE!

Summary

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• Consider ways to minimize or prevent the exposure to food or insect allergens

• Preparation is everything– Know the signs of anaphylaxis– Familiarize yourself with the epinephrine auto-injector on

a regular basis– Know how to access the medication and professional

emergency medical help in your area– Take a first aid and CPR class

Summary

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