treatment of severe allergic reaction

1. 1 TREATMENT OF SEVERE ALLERGIC REACTION Protocol for Training PowerPoint? Presentation Based on “Treatment of Severe Allergic Reaction, A Protocol for Training” revised January 2008 Instructor Overheads And Outline Presentation For Use With The Training Protocol For: “Treatment of Severe Allergic Reaction” Instructor Overheads And Outline Presentation For Use With The Training Protocol For: “Treatment of Severe Allergic Reaction”

2. 2 TREATMENT OF SEVERE ALLERGIC REACTION PROTOCOL FOR TRAINING INSTRUCTOR MANUAL PRODUCED BY: DEPARTMENT OF SCHOOL HEALTH SERVICES PREPARED BY: Jan Sanderson, RN, BSN, MST, CSN Multnomah Education Service District 11611 NE Ainsworth Circle Portland, OR 97220-9017 Dr. Edward L. Schmitt, Superintendent August 1999 A Technical Assistance Manual for School Districts To Plan Implementation of ORS 433.800-830 and OAR 333-55-000 through 035 TREATMENT OF SEVERE ALLERGIC REACTION PROTOCOL FOR TRAINING INSTRUCTOR MANUAL PRODUCED BY: DEPARTMENT OF SCHOOL HEALTH SERVICES PREPARED BY: Jan Sanderson, RN, BSN, MST, CSN Multnomah Education Service District 11611 NE Ainsworth Circle Portland, OR 97220-9017 Dr. Edward L. Schmitt, Superintendent August 1999 A Technical Assistance Manual for School Districts To Plan Implementation of ORS 433.800-830 and OAR 333-55-000 through 035

3. 3 Introduction Anaphylaxis is a sudden severe allergic reaction Sensitive individuals can experience reactions from: Food Medication Insect stings Exercise Other Introduction [page 1] ? In certain sensitive individuals food, medication, inhaled pollens or fumes, even exercise can precipitate a life- threatening allergic episode.Introduction [page 1] ? In certain sensitive individuals food, medication, inhaled pollens or fumes, even exercise can precipitate a life- threatening allergic episode.

4. 4 Introduction, cont’d. In the US each year there are: Approximately 50 deaths due to insect stings Approximately 100 deaths related to food allergies Introduction [page 1] ? In certain sensitive individuals food, medication, inhaled pollens or fumes, even exercise can precipitate a life- threatening allergic episode.Introduction [page 1] ? In certain sensitive individuals food, medication, inhaled pollens or fumes, even exercise can precipitate a life- threatening allergic episode.

5. 5 Introduction, cont’d. Immediate injection of epinephrine is the single factor most likely to save a life during anaphylaxis! Introduction [page 1] ? It is estimated that 8 in every 1,000 people are allergic to insect stings, it is extremely difficult to predict the potential sensitivity of any particular person. ? Stinging insects account for 40 to 100 deaths annually in the United States alone; additional fatalities go unrecognized.Introduction [page 1] ? It is estimated that 8 in every 1,000 people are allergic to insect stings, it is extremely difficult to predict the potential sensitivity of any particular person. ? Stinging insects account for 40 to 100 deaths annually in the United States alone; additional fatalities go unrecognized.

6. 6 Introduction Legislation passed in 1981- authorized trained individuals to administer epinephrine to people suffering severe reactions to insect stings. Legislation expanded in 1989, to include reactions to other allergens. Intended for situations where medical help is not immediately available: schools camps forests recreational areas Introduction [page 1] ? In 1981 legislation was passed by the State of Oregon to provide a means of authorizing certain individuals to administer lifesaving treatment to persons suffering severe insect sting reactions, when a physician is not immediately available. ? In 1989, the Legislature expanded the scope of the original statute by providing for the availability of the same assistance to persons having a severe allergic response to other allergens. ? Both bills were introduced to address situations where medical help often is not immediately available, such as schools, camps, forests, and recreational areas. Introduction [page 1] ? In 1981 legislation was passed by the State of Oregon to provide a means of authorizing certain individuals to administer lifesaving treatment to persons suffering severe insect sting reactions, when a physician is not immediately available. ? In 1989, the Legislature expanded the scope of the original statute by providing for the availability of the same assistance to persons having a severe allergic response to other allergens. ? Both bills were introduced to address situations where medical help often is not immediately available, such as schools, camps, forests, and recreational areas.

7. 7 Explanation of Laws Person must meet qualifications for training Be 21 years of age or older Reasonable expectation to come into contact with sensitive individuals Complete approved training program An Explanation of the Law and Rules [page 1] ? According to the law (O.R.S. 433.805-830) and the related administrative rules (O.A.R. 333-55-00 to 035), a person who meets the prescribed qualifications may obtain a prescription for pre-measured doses of epinephrine or adrenaline, and the necessary paraphernalia for administration. The administration of epinephrine should be “limited to an emergency situation when a physician is not immediately available.” The person to be treated is defined as a “person suffering severe allergic response to an insect sting or other allergens as defined by the Health Division.” ? In order to qualify for this training a person must be: ? Be 21 years of age or older **(please note that training protocol states 18 years of age; however, law was amended in 1998 to increase age) ? Person must have, or reasonably expect to have, responsibility for or contact with sensitive individuals (ie., camp counselors, scout leaders, school teachers, forest ranger, tour guides, or chaperones.) ? Person must complete state approved training according to the law. An Explanation of the Law and Rules [page 1] ? According to the law (O.R.S. 433.805-830) and the related administrative rules (O.A.R. 333-55-00 to 035), a person who meets the prescribed qualifications may obtain a prescription for pre-measured doses of epinephrine or adrenaline, and the necessary paraphernalia for administration. The administration of epinephrine should be “limited to an emergency situation when a physician is not immediately available.” The person to be treated is defined as a “person suffering severe allergic response to an insect sting or other allergens as defined by the Health Division.” ? In order to qualify for this training a person must be: ? Be 21 years of age or older **(please note that training protocol states 18 years of age; however, law was amended in 1998 to increase age) ? Person must have, or reasonably expect to have, responsibility for or contact with sensitive individuals (ie., camp counselors, scout leaders, school teachers, forest ranger, tour guides, or chaperones.) ? Person must complete state approved training according to the law.

8. 8 Who Should Be Trained? Public or private school employees Camp counselors or employees Youth organization staff or volunteers Forest rangers Foremen of forest workers Any person with exposure to risk Who Should Be Trained? [page 2] ? Persons likely to fall under the definition of the law include: ? Public or private school employees ? Camp counselors or camp employees ? Youth organization staff or volunteers ? Forest rangers ? Foremen of forest workers ? Emergency medical technicians ? Any persons with demonstrated exposure to risk of encountering sensitive individuals. Who Should Be Trained? [page 2] ? Persons likely to fall under the definition of the law include: ? Public or private school employees ? Camp counselors or camp employees ? Youth organization staff or volunteers ? Forest rangers ? Foremen of forest workers ? Emergency medical technicians ? Any persons with demonstrated exposure to risk of encountering sensitive individuals.

9. 9 Who Should Be Trained? Additional training These persons are strongly encouraged to obtain and maintain current training in approved First Aid and CPR course Who Should Be Trained? [ page 2] ? Persons participating in the approved training are strongly encouraged to obtain and maintain current training in an approved First Aid CPR course such as Medic First Aid or the American Red Cross Program.Who Should Be Trained? [ page 2] ? Persons participating in the approved training are strongly encouraged to obtain and maintain current training in an approved First Aid CPR course such as Medic First Aid or the American Red Cross Program.

10. 10 Once Training is Complete Qualified individuals receive a signed certificate The certificate can be used as a prescription for pre-measured doses of epinephrine (1 adult dose and 1 child dose) Prescription can be filled up to four times The prescription is issued in the name of the trained person (this is not a personal prescription) Certificates expire 3 years after issuance Use limited to situations where a licensed health care professional is not immediately available Who Should Be Trained? [ page 2] ? Persons participating in the approved training are strongly encouraged to obtain and maintain current training in an approved First Aid CPR course such as Medic First Aid or the American Red Cross Program.Who Should Be Trained? [ page 2] ? Persons participating in the approved training are strongly encouraged to obtain and maintain current training in an approved First Aid CPR course such as Medic First Aid or the American Red Cross Program.

11. 11 Training Overview What can trigger anaphylaxis? Insect stings, food, medication, other For each allergen: Likely culprits Avoidance measures Identifying the sensitive individual; steps to take ahead of time Who Should Be Trained? [ page 2] ? Persons participating in the approved training are strongly encouraged to obtain and maintain current training in an approved First Aid CPR course such as Medic First Aid or the American Red Cross Program.Who Should Be Trained? [ page 2] ? Persons participating in the approved training are strongly encouraged to obtain and maintain current training in an approved First Aid CPR course such as Medic First Aid or the American Red Cross Program.

12. 12 Training Overview, continued Recognizing Anaphylaxis Treatment for Anaphylaxis Basic information about epinephrine How to give epinephrine Sequence of steps for responding to anaphylaxis Quiz Who Should Be Trained? [ page 2] ? Persons participating in the approved training are strongly encouraged to obtain and maintain current training in an approved First Aid CPR course such as Medic First Aid or the American Red Cross Program.Who Should Be Trained? [ page 2] ? Persons participating in the approved training are strongly encouraged to obtain and maintain current training in an approved First Aid CPR course such as Medic First Aid or the American Red Cross Program.

13. 13 What is ANAPHYLAXIS? Anaphylaxis is a generalized, immediate life-threatening reaction to a foreign protein or allergen Insect’s venom Food Medication Pollen Other Life Threatening Reactions To Allergens - Systemic (Generalized) Allergic Reactions - Anaphylaxis [page 8] ? Anaphylaxis is a generalized immediate life-threatening reaction to a foreign protein or allergen {9}. These allergens may include any of the following: ? Insect’s venom ? Food ? Medication ? PollenLife Threatening Reactions To Allergens - Systemic (Generalized) Allergic Reactions - Anaphylaxis [page 8] ? Anaphylaxis is a generalized immediate life-threatening reaction to a foreign protein or allergen {9}. These allergens may include any of the following: ? Insect’s venom ? Food ? Medication ? Pollen

14. 14 What is Anaphylaxis? Severe life-threatening allergic reactions are rare Immediate administration of epinephrine is vital Person may be unable to self-administer Person may have no history of allergic response Overview [ page 2] ? Severe life-threatening allergic response to various allergens occurs in only a small percentage of the general population. ? When they occur, immediate administration of injectable epinephrine is vital {2}. ? Often a person suffering the response is unable to self-administer his/her injection. ? A person may have no previous history of allergic response and would be unequipped for the situation.Overview [ page 2] ? Severe life-threatening allergic response to various allergens occurs in only a small percentage of the general population. ? When they occur, immediate administration of injectable epinephrine is vital {2}. ? Often a person suffering the response is unable to self-administer his/her injection. ? A person may have no previous history of allergic response and would be unequipped for the situation.

15. 15 What is Anaphylaxis? The 2 key steps in saving a life are: Recognition of anaphylaxis when it occurs; and Swift administration of epinephrine Overview [ page 2] ? Severe life-threatening allergic response to various allergens occurs in only a small percentage of the general population. ? When they occur, immediate administration of injectable epinephrine is vital {2}. ? Often a person suffering the response is unable to self-administer his/her injection. ? A person may have no previous history of allergic response and would be unequipped for the situation.Overview [ page 2] ? Severe life-threatening allergic response to various allergens occurs in only a small percentage of the general population. ? When they occur, immediate administration of injectable epinephrine is vital {2}. ? Often a person suffering the response is unable to self-administer his/her injection. ? A person may have no previous history of allergic response and would be unequipped for the situation.

16. 16 Recognizing Anaphylaxis There are many possible symptoms There may be only one symptom, or there may be many! What symptoms has the person experienced before Reactions vary from person to person Systemic (Generalized) Allergic Reactions - Anaphylaxis [page 8] (Review symptoms on slides 29, 30 & 31) ? Sneezing, wheezing, or coughing ? Shortness of breath or difficulty breathing ? Tightness in chest ? Difficulty in swallowing ? Hoarseness ? Swelling of eyes, lips, face, tongue or elsewhere {10}Systemic (Generalized) Allergic Reactions - Anaphylaxis [page 8] (Review symptoms on slides 29, 30 & 31) ? Sneezing, wheezing, or coughing ? Shortness of breath or difficulty breathing ? Tightness in chest ? Difficulty in swallowing ? Hoarseness ? Swelling of eyes, lips, face, tongue or elsewhere {10}

17. 17 Recognizing Anaphylaxis Anaphylaxis usually occurs quickly Reaction can start within seconds Death can occur within minutes Delayed reactions are also possible Systemic (Generalized) Allergic Reactions - Anaphylaxis [page 8] (Review symptoms on slides 29, 30 & 31) ? Sneezing, wheezing, or coughing ? Shortness of breath or difficulty breathing ? Tightness in chest ? Difficulty in swallowing ? Hoarseness ? Swelling of eyes, lips, face, tongue or elsewhere {10}Systemic (Generalized) Allergic Reactions - Anaphylaxis [page 8] (Review symptoms on slides 29, 30 & 31) ? Sneezing, wheezing, or coughing ? Shortness of breath or difficulty breathing ? Tightness in chest ? Difficulty in swallowing ? Hoarseness ? Swelling of eyes, lips, face, tongue or elsewhere {10}

18. 18 Symptoms Of Anaphylaxis (slide 1 of 3) Sneezing, wheezing, or coughing Shortness of breath / Difficulty breathing Tightness in chest Difficulty swallowing Hoarseness Swelling of eyes, lips, face, tongue or elsewhere Systemic (Generalized) Allergic Reactions - Anaphylaxis [page 8] (Review symptoms on slides 29, 30 & 31) ? Sneezing, wheezing, or coughing ? Shortness of breath or difficulty breathing ? Tightness in chest ? Difficulty in swallowing ? Hoarseness ? Swelling of eyes, lips, face, tongue or elsewhere {10}Systemic (Generalized) Allergic Reactions - Anaphylaxis [page 8] (Review symptoms on slides 29, 30 & 31) ? Sneezing, wheezing, or coughing ? Shortness of breath or difficulty breathing ? Tightness in chest ? Difficulty in swallowing ? Hoarseness ? Swelling of eyes, lips, face, tongue or elsewhere {10}

19. 19 Symptoms Of Anaphylaxis (slide 2 of 3) Sweating and anxiety Nausea, abdominal pain, vomiting and diarrhea Dizziness and/or fainting Loss of bowel or bladder control Sense of impending doom or death Rapid or weak pulse Symptoms Of Anaphylaxis (continued) ? Sweating and anxiety ? Nausea, abdominal pain, vomiting and diarrhea ? Dizziness and/or fainting ? Loss of bowel or bladder control ? Sense of impending doom or death ? Rapid or weak pulse {10}Symptoms Of Anaphylaxis (continued) ? Sweating and anxiety ? Nausea, abdominal pain, vomiting and diarrhea ? Dizziness and/or fainting ? Loss of bowel or bladder control ? Sense of impending doom or death ? Rapid or weak pulse {10}

20. 20 Symptoms Of Anaphylaxis (slide 3 of 3) Flushed skin or extreme pallor Itching, with or without hives Raised red rash in any area of the body Burning sensation, especially in face or chest Blueness around lips, inside lips, or eyelids Loss of consciousness Symptoms Of Anaphylaxis (continued) ? Flushed skin or extreme pallor ? Burning sensation, especially in face or chest ? Blueness around lips, inside lips, or eyelids ? Loss of consciousness {10} The presence of only one of these symptoms does not, of itself, mean anaphylaxis is present. However, only one symptom may be present (e.g., very low blood pressure). Although anaphylactic reactions typically result in multiple symptoms (e.g., hives, difficulty breathing, loss of normal blood pressure), reactions may vary substantially from person to person. Previous history of anaphylactic reactions and known exposure to potential allergens should increase the suspicion that these signs and symptoms represent an anaphylactic reaction. Because reactions vary little from time to time in the same individual, a description of previous reactions should be elicited if possible.Symptoms Of Anaphylaxis (continued) ? Flushed skin or extreme pallor ? Burning sensation, especially in face or chest ? Blueness around lips, inside lips, or eyelids ? Loss of consciousness {10} The presence of only one of these symptoms does not, of itself, mean anaphylaxis is present. However, only one symptom may be present (e.g., very low blood pressure). Although anaphylactic reactions typically result in multiple symptoms (e.g., hives, difficulty breathing, loss of normal blood pressure), reactions may vary substantially from person to person. Previous history of anaphylactic reactions and known exposure to potential allergens should increase the suspicion that these signs and symptoms represent an anaphylactic reaction. Because reactions vary little from time to time in the same individual, a description of previous reactions should be elicited if possible.

21. 21 Possible Allergens - Insects It is estimated that 8 in every 1,000 people are allergic to insect stings Stinging insects account for 40 to 100 deaths per year in the U.S. Introduction [page 1] ? It is estimated that 8 in every 1,000 people are allergic to insect stings, it is extremely difficult to predict the potential sensitivity of any particular person. ? Stinging insects account for 40 to 100 deaths annually in the United States alone; additional fatalities go unrecognized.Introduction [page 1] ? It is estimated that 8 in every 1,000 people are allergic to insect stings, it is extremely difficult to predict the potential sensitivity of any particular person. ? Stinging insects account for 40 to 100 deaths annually in the United States alone; additional fatalities go unrecognized.

22. 22 Possible Allergens - Insects Bees, wasps, hornets and yellow jackets cause most fatal reactions Yellow jackets are most common in the Pacific Northwest Insects are more likely to sting during the late summer and fall Bees are more likely to sting on warm, bright days General Information [page 2] ? The venom from insect stings can act as an allergen and cause an allergic response in a person. ? Fatal or serious reactions to stings are confined almost entirely to bees, wasps, hornets and yellow jackets {1}. ? Insects are more likely to sting during late summer and fall when it is dry and few flowers are still in bloom. Venom is more powerful during this time of the year and stinging insects are easier to arouse {3}. ? Bees are more likely to sting on warm bright days, particularly following a rain. ? The yellow jacket is the most frequent cause of a reaction in this part of the country. General Information [page 2] ? The venom from insect stings can act as an allergen and cause an allergic response in a person. ? Fatal or serious reactions to stings are confined almost entirely to bees, wasps, hornets and yellow jackets {1}. ? Insects are more likely to sting during late summer and fall when it is dry and few flowers are still in bloom. Venom is more powerful during this time of the year and stinging insects are easier to arouse {3}. ? Bees are more likely to sting on warm bright days, particularly following a rain. ? The yellow jacket is the most frequent cause of a reaction in this part of the country.

23. 23 Insect Identification If possible, it is important to identify stinging insects, but this should never delay treatment! Only the honey bee leaves a “stinger” Insect Identification [pages 2 & 3] ? Stinging insect identification: Patients, especially children, are seldom able to identify the offending insect. Identification of the stinging insects depends upon color and markings, but the habitat is even more important. Although such identification may be impossible, an attempt should be made so the sensitive person can avoid future exposure and the allergist can be informed. Categories of stinging insects are shown on page 3 of the protocol. ? The honey bee is the only stinging insect to leave a stinger in the flesh. The stinger continues to inject venom until scraped away. Insect Identification [pages 2 & 3] ? Stinging insect identification: Patients, especially children, are seldom able to identify the offending insect. Identification of the stinging insects depends upon color and markings, but the habitat is even more important. Although such identification may be impossible, an attempt should be made so the sensitive person can avoid future exposure and the allergist can be informed. Categories of stinging insects are shown on page 3 of the protocol. ? The honey bee is the only stinging insect to leave a stinger in the flesh. The stinger continues to inject venom until scraped away.

24. 24 How to Avoid Insect Stings Stinging insects are attracted to: Light yellow and blue colors Sweet drinks (soft drinks, juice, beer) Cosmetics, lotions, perfumes, and hair spray Paint fumes Food odors Heat given off by dark colors Stinging Insects [page 3] ? Bees, wasps, hornets and yellow jackets may be attracted to the following: ? Light yellow and blue colors ? Sweet drinks such as soft drinks, juice or beer ? Cosmetics, perfume, suntan lotion, hair spray ? Paint fumes (may attract and act as an alarming agent) ? Food odors ? Heat given off by dark colors Stinging Insects [page 3] ? Bees, wasps, hornets and yellow jackets may be attracted to the following: ? Light yellow and blue colors ? Sweet drinks such as soft drinks, juice or beer ? Cosmetics, perfume, suntan lotion, hair spray ? Paint fumes (may attract and act as an alarming agent) ? Food odors ? Heat given off by dark colors

25. 25 Increased Risk of Insect Stings Associated With: Picnics, cooking / eating outdoors Areas of trash / garbage Areas of insect habitat Flowers Bright colored clothing Fragrant perfumes / cosmetics Exposed skin Becoming excited Insect Avoidance Measures - (continued) [page 4] ? Picnics, cooking or eating outdoors ? Areas of trash or garbage ? Known areas of insect habitat ? Becoming excited, swatting or hitting at the insect {4}Insect Avoidance Measures - (continued) [page 4] ? Picnics, cooking or eating outdoors ? Areas of trash or garbage ? Known areas of insect habitat ? Becoming excited, swatting or hitting at the insect {4}

26. 26 How To Avoid Insect Stings Sensitive or suspected sensitive person should wear: Smooth, hard finish white or tan clothing Hats Long sleeved shirts and slacks Socks and shoes Gently brush insects away - don’t swat How To Avoid Insect Stings [page 4] ? Sensitive or suspected sensitive persons should wear the following as much as possible: ? Smooth, hard finish white or tan clothing ? Hats ? Long sleeved shirts and slacks ? Socks and shoes ? It is best not to become excited, swat or hit at the insect. A gentle brushing may make it leave. {4}How To Avoid Insect Stings [page 4] ? Sensitive or suspected sensitive persons should wear the following as much as possible: ? Smooth, hard finish white or tan clothing ? Hats ? Long sleeved shirts and slacks ? Socks and shoes ? It is best not to become excited, swat or hit at the insect. A gentle brushing may make it leave. {4}

27. 27 What is not an anaphylactic reaction to insect sting? Normal Reactions Produce localized, sharp pain at sting site Redness, heat and swelling occur Swelling about the size of a quarter Usually lasts about 24 hours Medical attention usually not needed Stings around eyes, nose or throat may be more serious Should seek medical care Intervention for Normal Reactions [pages 5 & 6] ? A sting in a normal person produces localized, sharp pain which lasts a variable period of time following the insertion of the stinger. ? Within minutes, a small reddened area appears at the sting site ? Swelling may enlarge to about the size of a quarter {5} with hardening and redness (refer to Figure 1 on page ). Variable amounts of pain and itching may accompany the redness, heat and swelling. ? This response usually last about 24 hours, while a sting on the hand or foot may produce swelling that last for several days. ? This reaction does not generally require medical attention. ? If the sting occurs around the eye, nose or throat the reaction may be more severe. Stings around eyes are particularly serious and should be evaluated by a physician as long term eye damage is a possibility. Stings in the mouth or throat may become life threatening as even minimal swelling may cause obstruction. These types of stings need immediate medical attention {7}. If pain and itching subside or remain minimal, person can return to normal activities. If worsens, follow interventions for more serious reactions. Intervention for Normal Reactions [pages 5 & 6] ? A sting in a normal person produces localized, sharp pain which lasts a variable period of time following the insertion of the stinger. ? Within minutes, a small reddened area appears at the sting site ? Swelling may enlarge to about the size of a quarter {5} with hardening and redness (refer to Figure 1 on page ). Variable amounts of pain and itching may accompany the redness, heat and swelling. ? This response usually last about 24 hours, while a sting on the hand or foot may produce swelling that last for several days. ? This reaction does not generally require medical attention. ? If the sting occurs around the eye, nose or throat the reaction may be more severe. Stings around eyes are particularly serious and should be evaluated by a physician as long term eye damage is a possibility. Stings in the mouth or throat may become life threatening as even minimal swelling may cause obstruction. These types of stings need immediate medical attention {7}. If pain and itching subside or remain minimal, person can return to normal activities. If worsens, follow interventions for more serious reactions.

28. 28 Intervention Steps For Normal Reactions Remove stinger as soon as possible Cleanse sting site Apply ice pack Elevate limb Reassure and calm the person Observe for at least 30 minutes Intervention Steps For Normal Reactions [page 5] ? If stinger is present, it is a good idea to remove it as soon as possible {16}. The traditional teaching is that the stinger should be scraped or flicked off with fingernail rather than pinching or pulling it out. Others believe that the best method to remove the stinger is whatever can be done most quickly. ? Cleanse the area with soap and water or antiseptic solution. ? Apply ice pack (DO NOT apply ice directly to the skin - wrap in cloth covering. ? If sting site is in an extremity, elevate and rest the limb. ? Reassure and calm the person. ? Observe the person for at least 30 minutes. If localized pain and itching subside or remain minimal, person can return to normal activity. If itching and swelling increase locally, then person should seek medical treatment as quickly as possible. If person begins to show signs of systemic reaction, follow instructions for systemic reactions.Intervention Steps For Normal Reactions [page 5] ? If stinger is present, it is a good idea to remove it as soon as possible {16}. The traditional teaching is that the stinger should be scraped or flicked off with fingernail rather than pinching or pulling it out. Others believe that the best method to remove the stinger is whatever can be done most quickly. ? Cleanse the area with soap and water or antiseptic solution. ? Apply ice pack (DO NOT apply ice directly to the skin - wrap in cloth covering. ? If sting site is in an extremity, elevate and rest the limb. ? Reassure and calm the person. ? Observe the person for at least 30 minutes. If localized pain and itching subside or remain minimal, person can return to normal activity. If itching and swelling increase locally, then person should seek medical treatment as quickly as possible. If person begins to show signs of systemic reaction, follow instructions for systemic reactions.

29. 29 What is not an anaphylactic reaction to insect sting? Localized Reactions To Insect Stings Allergic reaction to allergen Involves pain, itching and swelling Larger area of swelling than normal reaction Swelling extends and crosses major joint line Swelling does not involve other areas of body May be delayed Symptoms may last up to one week or more Localized Allergic Reaction To Stings [pages 5 & 6] ? An allergy is a hypersensitivity to a particular substance, called an allergen. This results in an exaggerated reaction when the individual is exposed to the allergen. Allergies may arise quite suddenly with no known history of allergic response. Even a person who has had normal reactions to stings, can develop an allergic response to subsequent stings {8}. ? A localized reaction may involve pain, itching and swelling at the sting site. ? A localized reaction is distinguished from a normal reaction by the amount of swelling at the sting site. There is a larger area of swelling with a localized reaction {5}. ? In a localized reaction, the swelling involves a larger area and crosses a major joint line {5} (refer to Figure 2 on page 6 of the training protocol). ? However, the swelling does not involve other body parts. ? The local response, in some cases, may be delayed. A delayed reaction may occur in a matter of hours following the sting. Symptoms may include prolonged and intensified swelling, pain and redness. Depending on the sting site, the entire arm, leg or head may be involved. ? It is not unusual for these symptoms to persist for up to a week or more. Localized Allergic Reaction To Stings [pages 5 & 6] ? An allergy is a hypersensitivity to a particular substance, called an allergen. This results in an exaggerated reaction when the individual is exposed to the allergen. Allergies may arise quite suddenly with no known history of allergic response. Even a person who has had normal reactions to stings, can develop an allergic response to subsequent stings {8}. ? A localized reaction may involve pain, itching and swelling at the sting site. ? A localized reaction is distinguished from a normal reaction by the amount of swelling at the sting site. There is a larger area of swelling with a localized reaction {5}. ? In a localized reaction, the swelling involves a larger area and crosses a major joint line {5} (refer to Figure 2 on page 6 of the training protocol). ? However, the swelling does not involve other body parts. ? The local response, in some cases, may be delayed. A delayed reaction may occur in a matter of hours following the sting. Symptoms may include prolonged and intensified swelling, pain and redness. Depending on the sting site, the entire arm, leg or head may be involved. ? It is not unusual for these symptoms to persist for up to a week or more.

30. 30 Intervention Steps For Localized Reactions Remove stinger Cleanse sting site Apply ice pack Elevate limb Reassure and calm person Give antihistamine (Follow school policies) Keep person quiet Observe for at least one hour Intervention for Localized Reactions [page 6] The first five steps are the same as normal reactions: ? Remove stinger. ? Cleanse the sting site with soap and water. ? Apply ice pack. ? Elevate and rest the limb, if sting is on an extremity. ? Reassure and calm the person. ? If physician has ordered administration of oral antihistamine (i.e., Cho-amine? or Benadryl?) give at this time. ? Observe person for at least one hour. If swelling continues to increase in size or area the person should seek immediate medical attention. If person begins to show signs of systemic reaction, follow instructions for systemic reaction.Intervention for Localized Reactions [page 6] The first five steps are the same as normal reactions: ? Remove stinger. ? Cleanse the sting site with soap and water. ? Apply ice pack. ? Elevate and rest the limb, if sting is on an extremity. ? Reassure and calm the person. ? If physician has ordered administration of oral antihistamine (i.e., Cho-amine? or Benadryl?) give at this time. ? Observe person for at least one hour. If swelling continues to increase in size or area the person should seek immediate medical attention. If person begins to show signs of systemic reaction, follow instructions for systemic reaction.

31. 31 Toxic Reactions To Stings Systemic reaction results from multiple stings (usually 10 or more) Symptoms may include: Gastrointestinal, diarrhea, vomiting Drowsiness, fainting, or unconsciousness Generalized swelling Headache and fever Muscle spasms or convulsions Toxic Reactions To Stings [page 7] ? Toxic reactions are sometimes difficult to distinguish from allergic reaction. They result from multiple stings - usually ten or more. Although the person may not have a sensitivity to insect stings, a toxic reaction results from the amount of venom injected into the body, which causes systemic (generalized) poisoning. This could lead to death. ? The principal symptoms are gastrointestinal, with diarrhea and vomiting. ? Drowsiness, fainting and unconsciousness may occur. ? There may be generalized swelling over the body. ? A person may experience headache and/or fever. ? Involuntary muscle spasms and convulsions can occur.Toxic Reactions To Stings [page 7] ? Toxic reactions are sometimes difficult to distinguish from allergic reaction. They result from multiple stings - usually ten or more. Although the person may not have a sensitivity to insect stings, a toxic reaction results from the amount of venom injected into the body, which causes systemic (generalized) poisoning. This could lead to death. ? The principal symptoms are gastrointestinal, with diarrhea and vomiting. ? Drowsiness, fainting and unconsciousness may occur. ? There may be generalized swelling over the body. ? A person may experience headache and/or fever. ? Involuntary muscle spasms and convulsions can occur.

32. 32 Intervention Steps For Toxic Reactions Stay with person - delegate call to 9-1-1 Observe for symptoms of anaphylaxis Give epinephrine if necessary Remove stingers promptly Reassure and calm person Have person transported for medical help Intervention Steps For Toxic Reactions [page 7] ? Do not leave the person alone. Have someone call for emergency medical assistance (9-1-1). ? If there is any question if reaction is allergic or toxic, follow instructions for systemic reaction. ? Give epinephrine if necessary. ? Embedded stingers should be removed promptly and the sites thoroughly cleansed. ? Reassure and calm the person. ? Have person transported for medical help.Intervention Steps For Toxic Reactions [page 7] ? Do not leave the person alone. Have someone call for emergency medical assistance (9-1-1). ? If there is any question if reaction is allergic or toxic, follow instructions for systemic reaction. ? Give epinephrine if necessary. ? Embedded stingers should be removed promptly and the sites thoroughly cleansed. ? Reassure and calm the person. ? Have person transported for medical help.

33. 33 Possible Allergens-Foods Nearly any food can trigger an allergic reaction at any age Food allergies are most common in children and appear to be increasing in frequency Approximately 4 percent of US children have a food allergy Possible Allergens - Foods [page 4] ? Foods may be allergens which can be associated with severe allergic reactions. There are 73 known foods which have been associated with severe reactions. Some of the most common foods associated with anaphylaxis are the following: ? Fish and shellfish ? Egg whites ? Nuts ? Legumes ? Milk ? Certain grains (soy, wheat)Possible Allergens - Foods [page 4] ? Foods may be allergens which can be associated with severe allergic reactions. There are 73 known foods which have been associated with severe reactions. Some of the most common foods associated with anaphylaxis are the following: ? Fish and shellfish ? Egg whites ? Nuts ? Legumes ? Milk ? Certain grains (soy, wheat)

34. 34 Possible Allergens - Foods Foods most often associated with anaphylaxis: Peanuts Most common cause of anaphylaxis in children The food most frequently causing fatal reactions Fish and shellfish Shellfish are the food most frequently causing anaphylaxis in adults Tree Nuts Eggs Soy Milk Wheat Possible Allergens - Foods [page 4] ? Foods may be allergens which can be associated with severe allergic reactions. There are 73 known foods which have been associated with severe reactions. Some of the most common foods associated with anaphylaxis are the following: ? Fish and shellfish ? Egg whites ? Nuts ? Legumes ? Milk ? Certain grains (soy, wheat)Possible Allergens - Foods [page 4] ? Foods may be allergens which can be associated with severe allergic reactions. There are 73 known foods which have been associated with severe reactions. Some of the most common foods associated with anaphylaxis are the following: ? Fish and shellfish ? Egg whites ? Nuts ? Legumes ? Milk ? Certain grains (soy, wheat)

35. 35 Food Avoidance Avoid exposure to known allergens Inform food preparation personnel of known allergies Lunch swapping or sharing should be avoided Read labels on food & skin-care products Avoid cross-contamination Food Avoidance [page 4] ? Sensitive persons should avoid exposure to known allergens ? It is essential to inform food preparation personnel of known allergens for sensitive individuals {4}.Food Avoidance [page 4] ? Sensitive persons should avoid exposure to known allergens ? It is essential to inform food preparation personnel of known allergens for sensitive individuals {4}.

36. 36 Possible Allergens - Medications A person may experience reactions to any medication at any time Most common medications to cause reactions: Penicillin Aspirin Allergy injections Possible Allergens - Medications [page 4] ? Persons can experience severe reactions to medications even if they have previously taken the medication without incident. ? Some of the most common medications to cause reactions include: ? Penicillin causes most anaphylactic reactions yearly (100 to 500 deaths and 10% severe reactions) ? Aspirin is another common drug to which many are allergic ? Persons taking allergy injections may experience a severe allergic reactionPossible Allergens - Medications [page 4] ? Persons can experience severe reactions to medications even if they have previously taken the medication without incident. ? Some of the most common medications to cause reactions include: ? Penicillin causes most anaphylactic reactions yearly (100 to 500 deaths and 10% severe reactions) ? Aspirin is another common drug to which many are allergic ? Persons taking allergy injections may experience a severe allergic reaction

37. 37 Other Possible Allergens Pollens Latex Gloves, balloons, rubber bands, ace wraps, first aid tape, erasers, bungee cords, et cetera! Exercise Unknown substances Other Possible Allergens [page 4] ? Pollens and some foods can cause anaphylaxis in certain sensitive individuals who exercise after being exposed to these substances. ? There have been reports of anaphylaxis to rubber and talcum powder. ? An increasing number of patients are also being recognized as having anaphylaxis to unknown substances.Other Possible Allergens [page 4] ? Pollens and some foods can cause anaphylaxis in certain sensitive individuals who exercise after being exposed to these substances. ? There have been reports of anaphylaxis to rubber and talcum powder. ? An increasing number of patients are also being recognized as having anaphylaxis to unknown substances.

38. 38 Identifying the sensitive individual Steps to take BEFOREHAND: Who in your group has a history of severe allergic reactions? Get signed consent for emergency treatment-**Do not delay treatment if not available! Know how to get emergency help Where is the nearest hospital? EMT unit? Determine ahead of time how to call for help Life Threatening Reactions To Allergens - Systemic (Generalized) Allergic Reactions - Anaphylaxis [page 8] ? Anaphylaxis is a generalized immediate life-threatening reaction to a foreign protein or allergen {9}. These allergens may include any of the following: ? Insect’s venom ? Food ? Medication ? PollenLife Threatening Reactions To Allergens - Systemic (Generalized) Allergic Reactions - Anaphylaxis [page 8] ? Anaphylaxis is a generalized immediate life-threatening reaction to a foreign protein or allergen {9}. These allergens may include any of the following: ? Insect’s venom ? Food ? Medication ? Pollen

39. 39 EMERGENCY PLAN Prepare for identified and unidentified individuals Know where the epinephrine is kept Who is trained to give epinephrine Who is 1st aid/CPR trained Review the plan yearly

40. 40 Treatment For Anaphylaxis Administer epinephrine at the first sign of a systemic reaction Timing is essential The sooner that epinephrine is given, the greater the chance for survival Treatment For Anaphylaxis [page 9] ? Epinephrine should be administered promptly at the first sign of systemic reaction. Because of the dangers involved, you should always be ready to treat the person immediately {2, 6}. ? The most important aspect of intervention for severe allergic response is timing {2,6}. ? It is safer to give the epinephrine than to delay treatment for anaphylaxis. The sooner that anaphylaxis is treated, the greater the greater the person’s chance for surviving the reaction {2,6}. Treatment For Anaphylaxis [page 9] ? Epinephrine should be administered promptly at the first sign of systemic reaction. Because of the dangers involved, you should always be ready to treat the person immediately {2, 6}. ? The most important aspect of intervention for severe allergic response is timing {2,6}. ? It is safer to give the epinephrine than to delay treatment for anaphylaxis. The sooner that anaphylaxis is treated, the greater the greater the person’s chance for surviving the reaction {2,6}.

41. 41 Treatment For Anaphylaxis We will first go over detailed information on epinephrine and how to give it; Then we will go over the entire sequence of steps for responding to anaphylaxis. Treatment For Anaphylaxis [page 9] ? Epinephrine should be administered promptly at the first sign of systemic reaction. Because of the dangers involved, you should always be ready to treat the person immediately {2, 6}. ? The most important aspect of intervention for severe allergic response is timing {2,6}. ? It is safer to give the epinephrine than to delay treatment for anaphylaxis. The sooner that anaphylaxis is treated, the greater the greater the person’s chance for surviving the reaction {2,6}. Treatment For Anaphylaxis [page 9] ? Epinephrine should be administered promptly at the first sign of systemic reaction. Because of the dangers involved, you should always be ready to treat the person immediately {2, 6}. ? The most important aspect of intervention for severe allergic response is timing {2,6}. ? It is safer to give the epinephrine than to delay treatment for anaphylaxis. The sooner that anaphylaxis is treated, the greater the greater the person’s chance for surviving the reaction {2,6}.

42. 42 Epinephrine Powerful drug used for treatment of anaphylaxis Must be obtained by prescription Most immediate and effective treatment available Can only be injected into fatty area under the skin, usually the lateral thigh May have side effects Epinephrine [page 9] ? Epinephrine (or adrenaline) is a powerful drug which is used for the treatment of systemic or anaphylactic reactions {12}. ? It may have adverse side effects. ? It is obtained by prescription only. The training card issued after the training program acts as a prescription to obtain doses of epinephrine. ? In the case of life threatening reaction to insect sings or other allergens, epinephrine is the most immediate and effective treatment available. ? Epinephrine must never be injected into a vein or artery. Cerebral hemorrhage (stroke) and / or serious irregular heart rhythms may occur from improper administration technique. Epinephrine [page 9] ? Epinephrine (or adrenaline) is a powerful drug which is used for the treatment of systemic or anaphylactic reactions {12}. ? It may have adverse side effects. ? It is obtained by prescription only. The training card issued after the training program acts as a prescription to obtain doses of epinephrine. ? In the case of life threatening reaction to insect sings or other allergens, epinephrine is the most immediate and effective treatment available. ? Epinephrine must never be injected into a vein or artery. Cerebral hemorrhage (stroke) and / or serious irregular heart rhythms may occur from improper administration technique.

43. 43 How Epinephrine Acts On The Body Constricts blood vessels Raises blood pressure Relaxes bronchial muscles Reduces tissue swelling Epinephrine - How It Acts On The Body [page 9] Epinephrine (or adrenaline) is a powerful drug which is used for the treatment of systemic or anaphylactic reaction and may have adverse side effects {13}. It is obtained by prescription only. However, in the case of life threatening reaction to insect stings or other allergens, it is the most immediate and effective treatment available. Epinephrine acts on the body by the following: ? Constricts the blood vessels ? Raises the blood pressure ? Relaxes bronchial muscles ? Reduces tissue swelling {13} Epinephrine - How It Acts On The Body [page 9] Epinephrine (or adrenaline) is a powerful drug which is used for the treatment of systemic or anaphylactic reaction and may have adverse side effects {13}. It is obtained by prescription only. However, in the case of life threatening reaction to insect stings or other allergens, it is the most immediate and effective treatment available. Epinephrine acts on the body by the following: ? Constricts the blood vessels ? Raises the blood pressure ? Relaxes bronchial muscles ? Reduces tissue swelling {13}

44. 44 Possible Side Effects/Risks Of Epinephrine Rapid heart rate Nervousness or anxiety Nausea Vomiting Sweating Pallor Tremors Headache Side Effects of Epinephrine [page 9] Temporary and minor side effects of epinephrine may include the following: {14} ? Rapid heart rate ? Sweating ? Nervousness or ? Pallor anxiety ? Nausea ? Tremors ? Vomiting ? Headache Some of the possible side effects of epinephrine may resemble symptoms of anaphylactic shock. However, symptoms related to injection of epinephrine are temporary. Reassurance and a calm demeanor by the care giver are important.Side Effects of Epinephrine [page 9] Temporary and minor side effects of epinephrine may include the following: {14} ? Rapid heart rate ? Sweating ? Nervousness or ? Pallor anxiety ? Nausea ? Tremors ? Vomiting ? Headache Some of the possible side effects of epinephrine may resemble symptoms of anaphylactic shock. However, symptoms related to injection of epinephrine are temporary. Reassurance and a calm demeanor by the care giver are important.

45. 45 Storage And Handling Of Epinephrine Store in dark place at room temperature Do not allow syringe to freeze Keep away from sunlight Check medication for discoloration Solution should be clear Check expiration date Storage and Handling of Epinephrine [page 9] ? Epinephrine should be stored in a dark place at room temperature. The syringe must be protected from freezing. ? Exposure to sunlight will hasten deterioration of epinephrine more rapidly than exposure to room temperature. ? The color should be checked periodically. The drug should be replaced if the solution acquires a brownish-pink tint. If the solution is discolored at the time a patient is having a systemic reaction and there is no other kit available, it should still be given and most likely will be effective. ? It is essential to also check expiration dates on epinephrine kits.Storage and Handling of Epinephrine [page 9] ? Epinephrine should be stored in a dark place at room temperature. The syringe must be protected from freezing. ? Exposure to sunlight will hasten deterioration of epinephrine more rapidly than exposure to room temperature. ? The color should be checked periodically. The drug should be replaced if the solution acquires a brownish-pink tint. If the solution is discolored at the time a patient is having a systemic reaction and there is no other kit available, it should still be given and most likely will be effective. ? It is essential to also check expiration dates on epinephrine kits.

46. 46 EpiPen? Advantages Auto-Injector system delivers pre-measured dose of epinephrine No preparation needed Note: No other device may currently be used by persons completing this training. Sources of Epinephrine - EpiPen? [pages 9 & 10] The EpiPen? delivers one pre-measured dose of epinephrine. The following advantages and disadvantages should be considered: ? Advantages ? Disadvantages ? EpiPen? auto-injectors are marketed ? For elementary school setting by Center Laboratories. The EpiPen? two pens (EpiPen® and the (0.3 ml) and the EpiPen JR? (0.15 ml) EpiPen JR?) may need to be are always ready for immediate use. obtained to provide for ? They require no filling, assembly or appropriate dosing for preparation. different age groups. ? Not recommended for use with infants or toddlers. The concealed needle of the EpiPen? device is activated by a simple push when held against the thigh, through clothing if necessary. A safety cap prevents accidental discharge or injection. These units are ideal for individuals who feel uncomfortable about giving a shot with the traditional syringe and needle. Epinephrine should be administered by pre-measured injection in the subcutaneous tissue (fatty area under the skin) in the upper arm or lateral thigh. However, the manufacturer of the EpiPen? recommends that the auto-injector should be delivered intramuscularly into the anterolateral aspect of the thigh. Sources of Epinephrine - EpiPen? [pages 9 & 10] The EpiPen? delivers one pre-measured dose of epinephrine. The following advantages and disadvantages should be considered: ? Advantages ? Disadvantages ? EpiPen? auto-injectors are marketed ? For elementary school setting by Center Laboratories. The EpiPen? two pens (EpiPen® and the (0.3 ml) and the EpiPen JR? (0.15 ml) EpiPen JR?) may need to be are always ready for immediate use. obtained to provide for ? They require no filling, assembly or appropriate dosing for preparation. different age groups. ? Not recommended for use with infants or toddlers. The concealed needle of the EpiPen? device is activated by a simple push when held against the thigh, through clothing if necessary. A safety cap prevents accidental discharge or injection. These units are ideal for individuals who feel uncomfortable about giving a shot with the traditional syringe and needle. Epinephrine should be administered by pre-measured injection in the subcutaneous tissue (fatty area under the skin) in the upper arm or lateral thigh. However, the manufacturer of the EpiPen? recommends that the auto-injector should be delivered intramuscularly into the anterolateral aspect of the thigh.

47. 47 EpiPen? Administration EpiPen? Administration [page 10] EpiPens® are manufactured by Center Laboratories (a division of EM Industries, Inc.) The EpiE-Z Pen® and Epi E-Z Pen JR® are no longer available due to a recall by the manufacturer. The EpiPen® is ready to administer a pre-measured adult dose of 0.3 ml by auto-injection.EpiPen? Administration [page 10] EpiPens® are manufactured by Center Laboratories (a division of EM Industries, Inc.) The EpiE-Z Pen® and Epi E-Z Pen JR® are no longer available due to a recall by the manufacturer. The EpiPen® is ready to administer a pre-measured adult dose of 0.3 ml by auto-injection.

48. 48 EpiPen JR? Administration EpiPen JR? Administration [page 10] The EpiPen JR? is manufactured by Center Laboratories ( a division of EM Industries, Inc.) The EpiPen JR® is ready to administer a pre-measured dose of 0.15 ml by auto-injection.EpiPen JR? Administration [page 10] The EpiPen JR? is manufactured by Center Laboratories ( a division of EM Industries, Inc.) The EpiPen JR® is ready to administer a pre-measured dose of 0.15 ml by auto-injection.

49. 49 Responding to Anaphylaxis: How to Give Epinephrine Given via pre-measured injection Injected into the subcutaneous tissue (fatty area under the skin) Usually given in lateral thigh Auto-injector can be given through clothing Intervention for Generalized or Anaphylactic Reactions - Observation and First Steps [page 11] ? Using the symptoms given on the previous pages of the training protocol, determine if the person is suffering an anaphylactic reaction. Remember, only epinephrine (or adrenaline) works for the true anaphylactic reaction. Local treatment, oral treatment or inhalation treatment may be helpful but should not be relied upon. It is safer to give epinephrine than to delay treatment. This is a life and death decision. ? Do not move person or leave a person who is exhibiting symptoms of a possible serious reaction. Bring equipment and rescue personnel to him/her. ? Have someone call for emergency assistance (9-1-1). ? Bring supplies to person. Intervention for Generalized or Anaphylactic Reactions - Observation and First Steps [page 11] ? Using the symptoms given on the previous pages of the training protocol, determine if the person is suffering an anaphylactic reaction. Remember, only epinephrine (or adrenaline) works for the true anaphylactic reaction. Local treatment, oral treatment or inhalation treatment may be helpful but should not be relied upon. It is safer to give epinephrine than to delay treatment. This is a life and death decision. ? Do not move person or leave a person who is exhibiting symptoms of a possible serious reaction. Bring equipment and rescue personnel to him/her. ? Have someone call for emergency assistance (9-1-1). ? Bring supplies to person.

50. 50 Responding to Anaphylaxis: How to Give Epinephrine, cont’d. Determine proper dosage Unscrew the yellow or green cap off of the EPIPEN® carrying case and remove the auto-injector from its storage tube. Grasp the unit with the black tip pointing downward. With your other hand, pull off the gray safety cap. Intervention for Generalized or Anaphylactic Reactions - Observation and First Steps [page 11] ? Using the symptoms given on the previous pages of the training protocol, determine if the person is suffering an anaphylactic reaction. Remember, only epinephrine (or adrenaline) works for the true anaphylactic reaction. Local treatment, oral treatment or inhalation treatment may be helpful but should not be relied upon. It is safer to give epinephrine than to delay treatment. This is a life and death decision. ? Do not move person or leave a person who is exhibiting symptoms of a possible serious reaction. Bring equipment and rescue personnel to him/her. ? Have someone call for emergency assistance (9-1-1). ? Bring supplies to person. Intervention for Generalized or Anaphylactic Reactions - Observation and First Steps [page 11] ? Using the symptoms given on the previous pages of the training protocol, determine if the person is suffering an anaphylactic reaction. Remember, only epinephrine (or adrenaline) works for the true anaphylactic reaction. Local treatment, oral treatment or inhalation treatment may be helpful but should not be relied upon. It is safer to give epinephrine than to delay treatment. This is a life and death decision. ? Do not move person or leave a person who is exhibiting symptoms of a possible serious reaction. Bring equipment and rescue personnel to him/her. ? Have someone call for emergency assistance (9-1-1). ? Bring supplies to person.

51. 51 Responding to Anaphylaxis: How to Give Epinephrine, cont’d. Place black tip of EPIPEN® near outer thigh, at right angle to leg. If thigh cannot be used, use thickest part of upper arm. The injection can be given through clothing if necessary. Swing and jab firmly at 90 degree angle into outer thigh until the auto-injector clicks. Intervention for Generalized or Anaphylactic Reactions - Observation and First Steps [page 11] ? Using the symptoms given on the previous pages of the training protocol, determine if the person is suffering an anaphylactic reaction. Remember, only epinephrine (or adrenaline) works for the true anaphylactic reaction. Local treatment, oral treatment or inhalation treatment may be helpful but should not be relied upon. It is safer to give epinephrine than to delay treatment. This is a life and death decision. ? Do not move person or leave a person who is exhibiting symptoms of a possible serious reaction. Bring equipment and rescue personnel to him/her. ? Have someone call for emergency assistance (9-1-1). ? Bring supplies to person. Intervention for Generalized or Anaphylactic Reactions - Observation and First Steps [page 11] ? Using the symptoms given on the previous pages of the training protocol, determine if the person is suffering an anaphylactic reaction. Remember, only epinephrine (or adrenaline) works for the true anaphylactic reaction. Local treatment, oral treatment or inhalation treatment may be helpful but should not be relied upon. It is safer to give epinephrine than to delay treatment. This is a life and death decision. ? Do not move person or leave a person who is exhibiting symptoms of a possible serious reaction. Bring equipment and rescue personnel to him/her. ? Have someone call for emergency assistance (9-1-1). ? Bring supplies to person.

52. 52

53. 53 Responding to Anaphylaxis: How to Give Epinephrine, cont’d. Hold the EPIPEN® firmly against the thigh for approximately 10 seconds. (The injection is now complete, and the window on the EPIPEN® will show red.) The EPIPEN® auto-injector may then be removed; massage the injection area for 10 seconds. Intervention for Generalized or Anaphylactic Reactions - Observation and First Steps [page 11] ? Using the symptoms given on the previous pages of the training protocol, determine if the person is suffering an anaphylactic reaction. Remember, only epinephrine (or adrenaline) works for the true anaphylactic reaction. Local treatment, oral treatment or inhalation treatment may be helpful but should not be relied upon. It is safer to give epinephrine than to delay treatment. This is a life and death decision. ? Do not move person or leave a person who is exhibiting symptoms of a possible serious reaction. Bring equipment and rescue personnel to him/her. ? Have someone call for emergency assistance (9-1-1). ? Bring supplies to person. Intervention for Generalized or Anaphylactic Reactions - Observation and First Steps [page 11] ? Using the symptoms given on the previous pages of the training protocol, determine if the person is suffering an anaphylactic reaction. Remember, only epinephrine (or adrenaline) works for the true anaphylactic reaction. Local treatment, oral treatment or inhalation treatment may be helpful but should not be relied upon. It is safer to give epinephrine than to delay treatment. This is a life and death decision. ? Do not move person or leave a person who is exhibiting symptoms of a possible serious reaction. Bring equipment and rescue personnel to him/her. ? Have someone call for emergency assistance (9-1-1). ? Bring supplies to person.

54. 54 Responding to Anaphylaxis: How to Give Epinephrine, cont’d. Carefully place the used EPIPEN®, needle-end first, into the storage tube of the carrying case, using one hand only to avoid a needle stick. Screw the cap of the storage tube back on completely. If possible, write the time that the medication was given on the carrying case; this can be given to the emergency medical personnel when they arrive. Intervention for Generalized or Anaphylactic Reactions - Observation and First Steps [page 11] ? Using the symptoms given on the previous pages of the training protocol, determine if the person is suffering an anaphylactic reaction. Remember, only epinephrine (or adrenaline) works for the true anaphylactic reaction. Local treatment, oral treatment or inhalation treatment may be helpful but should not be relied upon. It is safer to give epinephrine than to delay treatment. This is a life and death decision. ? Do not move person or leave a person who is exhibiting symptoms of a possible serious reaction. Bring equipment and rescue personnel to him/her. ? Have someone call for emergency assistance (9-1-1). ? Bring supplies to person. Intervention for Generalized or Anaphylactic Reactions - Observation and First Steps [page 11] ? Using the symptoms given on the previous pages of the training protocol, determine if the person is suffering an anaphylactic reaction. Remember, only epinephrine (or adrenaline) works for the true anaphylactic reaction. Local treatment, oral treatment or inhalation treatment may be helpful but should not be relied upon. It is safer to give epinephrine than to delay treatment. This is a life and death decision. ? Do not move person or leave a person who is exhibiting symptoms of a possible serious reaction. Bring equipment and rescue personnel to him/her. ? Have someone call for emergency assistance (9-1-1). ? Bring supplies to person.

55. 55 Intervention Steps For Anaphylaxis Determine if the person is suffering an anaphylactic reaction. It is safer to give the epinephrine than to delay treatment. This is a life-and-death decision. Do not move the person, unless the location poses a safety threat. Have the person sit or lie down. Intervention for Generalized or Anaphylactic Reactions - Observation and First Steps [page 11] ? Using the symptoms given on the previous pages of the training protocol, determine if the person is suffering an anaphylactic reaction. Remember, only epinephrine (or adrenaline) works for the true anaphylactic reaction. Local treatment, oral treatment or inhalation treatment may be helpful but should not be relied upon. It is safer to give epinephrine than to delay treatment. This is a life and death decision. ? Do not move person or leave a person who is exhibiting symptoms of a possible serious reaction. Bring equipment and rescue personnel to him/her. ? Have someone call for emergency assistance (9-1-1). ? Bring supplies to person. Intervention for Generalized or Anaphylactic Reactions - Observation and First Steps [page 11] ? Using the symptoms given on the previous pages of the training protocol, determine if the person is suffering an anaphylactic reaction. Remember, only epinephrine (or adrenaline) works for the true anaphylactic reaction. Local treatment, oral treatment or inhalation treatment may be helpful but should not be relied upon. It is safer to give epinephrine than to delay treatment. This is a life and death decision. ? Do not move person or leave a person who is exhibiting symptoms of a possible serious reaction. Bring equipment and rescue personnel to him/her. ? Have someone call for emergency assistance (9-1-1). ? Bring supplies to person.

56. 56 Intervention Steps For Anaphylaxis, cont’d. Determine proper dosage and administer epinephrine from pre-measured syringe. Have someone call for emergency medical assistance (9-1-1). Remove stinger if one is present Reassure and calm person if possible. Intervention for Generalized or Anaphylactic Reactions - Observation and First Steps [page 11] ? Using the symptoms given on the previous pages of the training protocol, determine if the person is suffering an anaphylactic reaction. Remember, only epinephrine (or adrenaline) works for the true anaphylactic reaction. Local treatment, oral treatment or inhalation treatment may be helpful but should not be relied upon. It is safer to give epinephrine than to delay treatment. This is a life and death decision. ? Do not move person or leave a person who is exhibiting symptoms of a possible serious reaction. Bring equipment and rescue personnel to him/her. ? Have someone call for emergency assistance (9-1-1). ? Bring supplies to person. Intervention for Generalized or Anaphylactic Reactions - Observation and First Steps [page 11] ? Using the symptoms given on the previous pages of the training protocol, determine if the person is suffering an anaphylactic reaction. Remember, only epinephrine (or adrenaline) works for the true anaphylactic reaction. Local treatment, oral treatment or inhalation treatment may be helpful but should not be relied upon. It is safer to give epinephrine than to delay treatment. This is a life and death decision. ? Do not move person or leave a person who is exhibiting symptoms of a possible serious reaction. Bring equipment and rescue personnel to him/her. ? Have someone call for emergency assistance (9-1-1). ? Bring supplies to person.

57. 57 Intervention Steps For Anaphylaxis, cont’d. Check for and maintain open airway by listening and observing person’s breathing. Administer CPR if needed. If the person experiencing an anaphylactic reaction is also asthmatic, you can assist the person in the use of his or her own inhaler if desired, after epinephrine is given. Intervention for Generalized or Anaphylactic Reactions - Observation and First Steps [page 11] ? Using the symptoms given on the previous pages of the training protocol, determine if the person is suffering an anaphylactic reaction. Remember, only epinephrine (or adrenaline) works for the true anaphylactic reaction. Local treatment, oral treatment or inhalation treatment may be helpful but should not be relied upon. It is safer to give epinephrine than to delay treatment. This is a life and death decision. ? Do not move person or leave a person who is exhibiting symptoms of a possible serious reaction. Bring equipment and rescue personnel to him/her. ? Have someone call for emergency assistance (9-1-1). ? Bring supplies to person. Intervention for Generalized or Anaphylactic Reactions - Observation and First Steps [page 11] ? Using the symptoms given on the previous pages of the training protocol, determine if the person is suffering an anaphylactic reaction. Remember, only epinephrine (or adrenaline) works for the true anaphylactic reaction. Local treatment, oral treatment or inhalation treatment may be helpful but should not be relied upon. It is safer to give epinephrine than to delay treatment. This is a life and death decision. ? Do not move person or leave a person who is exhibiting symptoms of a possible serious reaction. Bring equipment and rescue personnel to him/her. ? Have someone call for emergency assistance (9-1-1). ? Bring supplies to person.

58. 58 Intervention Steps For Anaphylaxis, cont’d. Always relinquish care to EMS/911 when they arrive on scene. A person who has been given treatment for a severe allergic reaction must receive immediate and continuing medical attention Follow-Up [page 12] ? The person who has recovered from a severe allergic reaction must receive immediate and continuing medical attention. Additionally, he/she should be made aware of the previously mentioned avoidance measures, as prevention is assuredly preferable treatment.Follow-Up [page 12] ? The person who has recovered from a severe allergic reaction must receive immediate and continuing medical attention. Additionally, he/she should be made aware of the previously mentioned avoidance measures, as prevention is assuredly preferable treatment.

59. 59 ?