Managing Anaphylaxis at School

1. Managing Anaphylaxisat School

2. Sabrina’s Law – Bill 3 • It came into effect January 1, 2006 • Sabrina Shannon had a severe allergy to peanuts, dairy & soy products • Sabrina was 13 when she died after eating french fries at school that had been cross-contaminated with cheese (was thought to be an asthma attack at first) • Sabrina’s Law - (the first of its kind in the world) is intended to protect students at school with life-threatening allergies

3. Sabrina’s Law – Bill 3Click here to view The law states that school boards must establish and maintain a policy on anaphylaxis with: • ways to reduce risk of exposure • a communication plan • regular training • an individual plan for each student with anaphylaxis • a file for each anaphylactic student with: • details on the type of allergy • monitoring and avoidance strategies and appropriate treatment • a readily accessible emergency procedure for the student • storage for epinephrine auto-injectors

4. What is Anaphylaxis? • a sudden & severe allergic reaction involving one or more body systems with multiple symptoms possible • a condition that requires immediate attention and treatment • effects 2% of Canadians, may be higher in children • a growing problem • estimated that ~5% of adult population has experienced it and is on the rise (U.S. data) • has drastically increased in children in the last decade • deaths in Ontario from anaphylaxis are not increasing however (Anaphylaxis Canada)

5. Common Triggers • Foods - 33-55% (peanuts, tree nuts, shellfish, milk, eggs, fish, soy, sesame seed, wheat) • Highest in younger children (6-8% infants have a food allergy) and is increasing • Insect stings (bees, wasps, yellow jackets, other biting insects) • Medications (75% Penicillin, non-steroidal anti-inflammatory [Aspirin], vaccines, + many others) • Latex (balloons, elastics, bandages etc…) • Exercise

6. What to Look for While Eating: • Itching in and around the mouth is often the first symptom observed in people experiencing food-induced anaphylaxis • Commonly & quickly progresses into cramps, nausea, vomiting and diarrhea and/or breathing problems • Students with asthma are at greater risk • ~10% of children with asthma have food allergy • ~10% of children in Canada have asthma • very likely there are students with unidentified anaphylaxis in most schools

7. What Anaphylaxis Looks Like:Sourcehttp://www.anaphylaxis.com/ Signs / symptoms Incidence (%) Hives and swelling of skin 88 Upper airway swelling (throat tightening) 56 Difficulty breathing + wheezing 47 Flush 46 Dizziness, fainting, low BP (weak pulse) 33 Nausea, vomiting, cramps 30 Sneezing, runny nose, watery eyes 16 Headache 15 Pain below the ribcage 6 Itch without rash 4.5 Seizure 1.5 Others (metallic taste, sense of impending ? doom / anxiety / panic)

8. Common Myths vs. FactsSourcehttp://www.anaphylaxis.com/ Reality Anaphylaxis is underreported Cause is usually unexplainable 10-20% of cases show no sign of hives or other skin indications 80% of food-induced, fatal anaphylaxis cases were not associated with skin related signs or symptoms There is no predictable pattern – depends on dose of allergen and individual sensitivity Benefits far outweigh the risks Most people don’t report it Most cases are due to accidental exposure Myth Anaphylaxis is rare Cause is always known It will always show on the skin Previous reactions will predict subsequent ones Epinephrine is dangerous Anaphylaxis is reported It is easy to avoid if you know what you are allergic to

9. Preventing Anaphylaxis Awareness • identify causes and triggers • emergency plan • promoting awareness in the entire school community • e.g. medic-alert bracelets • labeling practices • can be much less stringent outside North America • e.g. chocolate from eastern Europe with undeclared peanut protein • interpreting labels can be tricky • e.g. ovalbumin for egg derivatives, whey or casein for milk ingredients • some allergens are still exempt from declaration • e.g. sulphites

10. Preventing Anaphylaxis Avoidance • avoid contact with allergen • create an allergen safe environment: • avoid using outdoor garbage cans, ensure proper footwear, use latex-free products • avoid sharing of lunches, snacks, and utensils • avoid bulk foods • avoid cross-contamination (sanitation & hand washing)

11. Treating Anaphylaxis Action • administer epinephrine immediately (even if only suspected) • access emergency medical treatment – call ASAP • position student so breathing is comfortable • always send student to hospital even if symptoms resolve, as more acute symptoms can recur several hours after treatment

12. Epinephrine • Epinephrine by injection is the treatment of choice for anaphylactic reactions • Epinephrine works quickly to: • improve breathing & open airways • stimulate the heart • constrict blood vessels (maintains blood pressure & directs blood flow to major organs) • reverse hives and swelling around the face & lips • There are no identified contraindications to the use of epinephrine in life-threatening allergic reactions in an otherwise healthy child

13. Epinephrine Auto-Injectors • Auto-injectors are disposable, prefilled devices that automatically administer a single dose of epinephrine for the emergency treatment of anaphylaxis • Twinject® and EpiPen® are the two brands available in Canada

14. Different Doses • Epinephrine dosing is based on body weight • There are 2 dosage strengths: • EpiPen® Jr. (green) / Twinject® • 0.15 mg for individuals weighing 15-30 kg (33-66 lbs) • EpiPen® (yellow) / Twinject® • 0.30 mg for individuals weighing 30 kg+ (66 lbs+)

15. EpiPen® • Grasp the auto-injector with the ORANGEtip pointing down • Remove the blue safety release • Swing and push ORANGE tip firmly into mid-outer until you hear a click and hold for several seconds • Remove EpiPen® and massage injected area • When the EpiPen® Auto-injector is removed, the ORANGE needle cover automatically extends to cover the injection needle • Call 911 if not already done • On-line demo: http://www.epipen.ca/HCP/English/videos.cfm

16. Twinject® Click here for online video instructions • Contains 2 separate doses of epinephrine • First dose delivered by auto-injector • Second dose delivered manually by syringe

17. Twinject® - First Dose • Remove Injector from case • Grasp needle with one hand • Pull off GREEN Caps 1 & 2 • Jab RED tip of syringe firmly against outer mid-thigh and hold for 10 seconds • remove Twinject® and massage injected area • If needle is showing – dose was delivered • Call 911 if not already initiated • Return syringe to case

18. Second Dose • An extra dose of epinephrine should always be available (World Health Organization) • Schools are being directed to use a second EpiPen® for the second dose • Give if symptoms do not subside within 5-10 minutes or reoccur. A second severe reaction can occur up to 24 hrs after the first. • More than 1/3 will require a second dose of epinephrine

19. Tips For Using Auto-Injectors • Never put fingers over the tip when removing the safety cap, or after the safety cap has been removed • Keep auto-injectors at room temperature and readily available • Occasionally inspect the solution through the viewing window, if it looks brown, cloudy or containing sediment - have it replaced (should be mostly clear & colourless) • Check expiry dates • Auto-injectors can be used directly through clothing • Bend the needle on a hard surface after removing and return to case • Send used injectors with patient (in case provided)

20. References & Resources • Anaphylaxis Canada www.anaphylaxis.org "Back to School: how to manage allergies safely“ - online podcast available on website starting on August 26th, 2009 • Action Steps for Anaphylaxis Management http://www.allergysafecommunities.ca/assets/appendix_b_eng.pdf • MOE Self-Learning Module for Teachers www.eworkshop.on.ca/allergies • Allergy/Asthma Information Association www.aaia.ca • Canadian Society of Allergy and Clinical Immunology www.csaci.ca

21. For More Information • EpiPen®-To Order Training Material / Resources http://www.epipen.ca/ • Twinject® -To Order Training Material / Resources http://www.twinject.ca/ • Health Canada – Allergen Labeling http://www.hc-sc.gc.ca/fn-an/label-etiquet/allergen/index-eng.php