Anaphylaxis Awareness and Management Guide

1. Allergy and Anaphylaxis

2. Type 1 Allergic Reactions • Mechanism: • Antigen injected, ingested, inhaled, or absorbed • Antibody produced by the immune system marking the antigen for destruction by white blood cells • Histamine released by white blood cells during the process

3. Local Reaction • Signs and Symptoms: • Rash, swelling, itching limited to site of exposure * Low Risk High Risk

4. Mild Allergic Reaction • Signs and Symptoms: • Generalized hives and itching • Normal mental status • No facial swelling • No tight or scratchy throat • No respiratory distress • No signs of shock ANTICIPATE ANAPHYLAXIS! * Low Risk ! High Risk

5. Anaphylaxis • Signs and Symptoms: • Itching, hives, or facial swelling • Tight or scratchy throat • Vascular and volume shock • Respiratory distress • Nausea, vomiting, diarrhea • Altered mental status * Low Risk High Risk

6. Shock Common Mechanisms: Dehydration Anaphylaxis Heart Attack Volume Shock Vascular/Volume Shock Cardiogenic Shock

7. Upper Airway Obstruction nasopharynx tongue epiglottis thyroid cartilage vocal cord cricoid cartilage larynx esophagus trachea *

8. Lower Airway Constriction Bronchial Tubes cartilage muscle mucous membrane larynx trachea bronchi swelling and spasm *

9. Anaphylaxis • A critical systems problem! • Onset may be immediate or delayed • Generally, rapid onset is more severe • May get better, then worse • May reoccur (biphasic) • May involve multiple organ systems *

10. Patient Assessment System SCENE SIZE-UP Stabilize the Scene Stabilize the Patient PRIMARY ASSESSMENT SECONDARY ASSESSMENT Complete then Treat

11. Scene Size-Up Stabilize the Scene Personal Partner Public Patient Safety M.O.I. Number Trauma Medical Environmental SCENE SIZE-UP Patients Rescuers Resources * “The scene size-upwill keep you alive and functioning.”

12. Scene Size-Up Personal Safety Body Substance Isolation: • Eye protection • Gloves • Protective clothing *

13. Primary Assessment Stabilize the Patient Circulatory Respiratory Nervous Pulse Bleeding Airway Breathing Primary Assessment * AVPU Spine “The initial assessment is your quick-check on the status of the patient's three critical body systems.”

14. CPR • CPR 2015 Update: • Begin compressions if unresponsive and in respiratory arrest. • 30:2 ratio on adults and children (100 -120 per minute) • 15:2 ratio for two rescuer CPR on infants and children • Breaths given over 1 second, blow until chest rises • One shock followed by 2 minutes of CPR before next attempt. * AHA Guidelines

15. Circulatory Failure • Automatic External Defibrillator: • Effective only with intact critical systems • Lightning Injury • Submersion Injury • Reversible Cardiac Arrhythmias • Best applied within 5 minutes • Must be followed by immediate ALS • Ineffective in trauma arrest

16. Secondary Assessment 5 Complete Then Treat Physical Exam SAMPLE History Vital Signs Secondary Assessment * “Get the whole picture, complete your list, then return to treat each problem in order of priority.”

17. SOAP Note • Subjective: • Story • • SAMPLE history, if relevant • Objective: • Exam findings • • Vital signs • Assessment: • Problem list (A) • Anticipated problems (A’) • Plan: • Treatment for each existing problem • Evacuation and/or monitoring for anticipated problems *

18. Generic Treatment P – position for best respiration R – reassurance, breathing slow and deep is better than fast and shallow O – supplemental oxygen if available P - positive pressure ventilations to assist respiratory effort * “Respiratory distress that you cannot fix in the field is a life-threatening emergency. The progression to failure may be rapid or slow.”

19. Anaphylaxis Treatment LAY RESCUER • Epinephrine: • 0.01 mg/kg up to 0.3mg intramuscular injection • 0.15 mg for children (<20 kg = 44 lbs) • Injection to the mid lateral thigh • Action: bronchodilation, vasoconstriction *

20. Epinephrine Auto-injectors epinephrine

21. Anaphylaxis Treatment at presentation 10 minutes after epinephrine

22. You Should Know… Indications Contraindications Precautions Dosage Route Side Effects Interactions Storage Disposal

23. Presenter Notes Indication - anaphylaxis; treat bronchoconstriction, upper airway swelling, and vascular dilation all while stabilizing mast cells Contraindications - no absolute; hx of angina, aneurysm, hyperthyroid, use of sympathomimetic; – get the dx correct • Precautions – correct patient, correct dose, location of administration, expiration date, clarity and color of medication Dosage – 0.01 mg/kg to a maximum dose of 0.3 mg; may use the 0.3 mg dose down to 20 kg (44 lbs) Route – lateral mid-thigh Side effect - temporary tachycardia, tremor, headache, anxiety, restlessness, palpitations Interactions - MAO, pure β(?), sympathomimetic drugs Storage – out of direct light and sealed. Temp: ideally = 20° C – 25° C (68° F – 77° F); up to 15° C - 30° F (59° F – 86° F); research suggests freezing and short exposures to temps to 40° C (104° F) or sustained for 38 C (100 F) is okay. Disposal – place in original container and then to a rigid biohazard container (e.g., hospital, EMS, medical provider office)

24. Recognize signs and symptoms • Standards and procedures for acquisition, storage administration and disposal of an epinephrine auto-injector • Emergency follow-up procedures

25. Entity Legislation Entities …in connection with or at which allergens capable of causing anaphylaxis may be present, including: Public Schools Recreation Camps Colleges and Universities Day Care Facilities Youth Sports Leagues Amusement Parks Restaurants Sports Arenas Certification Good for 2 two years

26. ALABAMA

27. https://www.adph.org/Extranet/Forms/Form.asp?ss=s&formID=5763https://www.adph.org/Extranet/Forms/Form.asp?ss=s&formID=5763

28. CALIFORNIA

29. Anaphylaxis Treatment CALIFORNIA LAY RESCUER • Post-injection: • Call 9-1-1 • Monitor critical systems • Position of comfort *

30. Lay Rescuer Responsibilities CALIFORNIA LAY RESCUER • Training • Certification • Obtaining Auto-injector • Storage • Disposal • Record Keeping (keep for 5 years) • purchase, expiration, use, destruction • name of patient • record of expiration date • Date circumstances of disposal

31. LAY RESCUER EPINEPHRINE AUTO-INJECTOR USE LOG (sample)

32. Certification CALIFORNIA LAY RESCUER • Successful completion of approved training program* • Current CPR and AED for adults, children and infants • Fifteen ($15) USD application fee • Complete and mail application form: • http://www.emsa.ca.gov/Epinephrine_Auto_Injector • Good for 2 years from issuance Waived for certain currently licensed California health care professionals*

33. COLORADO

34. https://fs9.formsite.com/ColoradoIMMprogram/form160/index.htmlhttps://fs9.formsite.com/ColoradoIMMprogram/form160/index.html

35. MAINE

36. School District/school: ___________________________________________ Date/Time of Occurrence: _____________________________ Age of Staff (optional): __________ Gender: M F Diagnosis/history of Asthma ¨ Yes o No Knownallergen(s):___________________________________________________________ Trigger that precipitated this allergic episode:____________________________________ Symptoms:_________________________________________________________________ Location of staff when symptoms developed:____________________________________ Location of staff when epinephrine administered:_________________________________ Location of epinephrine storage:_______________________________________________________ Dose give: o 0.15 mg. o 0.30 mg. 2nd doses given: o Yes o No Exp. Date: _______________ Epinephrine administered by: o RN o Other If other, please specify: ___________________ If other than an RN, was this personally formally trained? o Yes ¨ No Date of training _____ If epinephrine was self-administered by a staff at school or a school-sponsored function, did the staff follow school protocols to notify school personnel and activate EMS? o Yes ¨ No o NA Approximate amount of time between onset of symptoms and administration of epinephrine_________________________________ Emergency Plan in place? ¨ Yes o No Written school district policy on management of life-threatening allergies in place? o Yes ¨ No School building emergency response team activated? oYes ¨ No o NA Emergency Medical System: Epinephrine available: ¨ Yes oNo Other emergency measures performed:__________________________________________ Disposition:/Outcome: Debriefing: Recommendations for changes/improvements to current policy or procedures: Form completed by: __________________________________ Date: ________________ Title: ____________________________Phone: __________________________________

37. ATTACHMENT A Certificate of Training in the use of Use of Epinephrine Auto-injectors I am a healthcare practitioner (MD, DO, ARNP, PA, RN, LPN or EMT) licensed in the State of Maine. I certify that _____________________________ has completed anaphylaxis training and the use of epinephrine auto-injectors. The training included, at a minimum: A. How to recognize signs and symptoms of severe allergic reactions, including anaphylaxis; B. Standards and procedures for the storage and administration of an epinephrine auto-injector; and C. Emergency follow-up procedures. This certificate of training allows the individual identified above to utilize epinephrine auto-injectors to treat severe allergic reactions, in accordance with the training provided, for the period of time covered by this certificate. Certification start date: _______________ Certification expiration date (not more than 24 months from certification start date):____________ ___________________________________________ ______________ Signature of healthcare practitioner providing training Date

38. MICHIGAN

39. http://www.michigan.gov/documents/lara/Report_on_the_Use_of_Auto-Injectable_Epinephrine_517141_7.pdfhttp://www.michigan.gov/documents/lara/Report_on_the_Use_of_Auto-Injectable_Epinephrine_517141_7.pdf