Treatment of Severe Allergic Reaction

1. Treatment of Severe Allergic Reaction Protocol for Training PowerPoint Presentation January, 2013

2. Credits • 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

3. Background • 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

4. Topics • Rules regarding epinephrine administration by the public • Recognition of anaphylaxis • Management of anaphylaxis • Action of epinephrine • Use of epinephrine auto-injector devices • Follow-up

5. State Laws • 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

6. State Law • 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

7. State Law • 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

8. What If the Pharmacist Won’t Honor the Authorization? • Call or e-mail the Oregon Health Authority contact listed on the inside cover of the training manual

9. State Law • 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.

10. Allergic Reactions and Anaphylaxis

11. Definitions • 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

12. Definitions • 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

13. Definitions • 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

14. Definitions • 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

15. Severity of Allergic Reactions • 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

16. Allergic Reactions In Perspective • For the purposes of this class, the information will focus primarily on the recognition and treatment of anaphylaxis

17. 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

18. Why People Die From Anaphylaxis • 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!

19. Anaphylaxis • 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

20. Anaphylaxis • 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

21. Wisdom With Recognition • 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

22. Epinephrine For Anaphylaxis • 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…” Note: The terms “severe allergic response” and “systemic allergic reaction” are considered to be functionally the same as anaphylaxis.

23. Causes of Anaphylaxis

24. Insect Venom • Typical offenders • Yellow jackets • Honey bees • Wasps • Hornets

25. 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

26. Other Allergens • Exercise • Latex • Medications • Penicillin • Aspirin • Non-steroidal anti-inflammatory drugs • Ibuprofen, naproxen, etc. Keep in mind that a person can develop an allergy to any medication

27. Review • 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

28. Scenario #1 • 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

29. Scenario #1 Debriefing • 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

30. Treatment for Normal Reactions • 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

31. Scenario #2 • 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.

32. Scenario #2 Debriefing • 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 EpiPenJr?

33. Scenario #2 Debriefing • 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

34. Scenario #3 • 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

35. Scenario #3 Debriefing • 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

36. Scenario #4 • 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

37. Scenario #4 Debriefing • 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

38. Management of Anaphylaxis

39. Anaphylaxis Treatment Protocol • Determine if the person is suffering from an anaphylactic reaction • Do not move the person • Have the person sit or lie down • Select the proper version of the epinephrine auto-injector

40. Anaphylaxis Treatment Protocol • Administer the epinephrine through the device • Call or have someone else call 9-1-1. Do not leave the person unattended. • Note the time when the auto-injector was used • Remove the stinger if present

41. Anaphylaxis Treatment Protocol • Check and maintain the person’s airway and breathing • Monitor for changes in the person’s condition • If the person’s condition does not change or worsens after 5 minutes, administer another auto-injector at the same dose • Upon the arrival of EMS, advise them of the person’s signs before and after the epinephrine was given.

42. Multiple Insect Stings • 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

43. Dealing With Multiple Stings • Be prepared to give epinephrine • Call 9-1-1 • Monitor the person closely

44. Epinephrine • Powerful drug • Obtained by prescription only • Corrects all of the life-threatening problems of anaphylaxis • Easy to give • Auto-injector

45. Limits of Epinephrine • 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

46. The Work of Epinephrine

47. Why Is Epinephrine Effective In the Treatment of Anaphylaxis? • The answer is found in the next slide

48. Epinephrine Anaphylaxis

49. Side Effects of Epinephrine • Rapid heart rate • Feeling of nervousness • Tremors • Nausea and/or vomiting • Sweating • Headache • Pale skin The effects may last between 5 and 20 minutes

50. Epinephrine Auto Injectors • Pre-measured dose in each • Pens for adults and children • Trigger device • Injects epinephrine directly into the body