Treatment of Severe Allergic Reaction Protocol for Training - - PowerPoint PPT Presentation

Treatment of Severe Allergic Reaction

Protocol for Training

PowerPoint Presentation April, 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 April, 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

• r 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

• n 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
• r 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

• ther 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
• f 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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Epinephrine Constricts Blood Vessels Reduces Swelling Opens lower airways

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

Opens the lower airways Constricts the lower airways

Reduces swelling Causes swelling

Raises blood pressure Drops blood pressure

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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 EpiPen Auvi-Q 0.3 Twinject Adult dose for all: 0.3 milligrams Greater than 66 pounds 9-10 years or

• lder

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

• utlined 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

• n 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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