Anaphylaxis Protocol Presented by: Dave Prescott Resuscitation Training Officer Date: 23 September 2011

1. Anaphylaxis Protocol Presented by: Dave Prescott Resuscitation Training Officer Date: 23 September 2011

2. Anaphylaxis Protocol

3. What causes anaphylaxis? UK 1992-2001 Suspected triggers for fatal reactions from Pumphrey R.S.

5. Anaphylaxis definition • The body's acute allergic reaction to some form of allergen • Wasp or bee sting, nut or seafood allergy, drug injection, pollen, latex gloves etc. • Two or more main body systems malfunction • The patient goes into complete collapse

6. Anaphylaxis recognition • It is important that any individual who is carrying out any invasive procedure on a patient is able to distinguish between anaphylaxis, seizures and fainting – any of which may occur within all age groups • Main concern – absence of strong central pulse – suspect anaphylaxis.

7. Anaphylaxis signs & symptoms Anxiety Apnoea Hypotension Sinus tachycardia Angiodema Limpness Weak pulse Hoarseness/stridor Retrosternal tightness Pallor Bronchospasm Urticarial lesions Dyspnoea Wheezing Peripheral oedema Collapse

8. Anaphylaxis precautions • Any Health Care Professional who administers medication or performs any invasive procedure MUST receive training in anaphylaxis management and basic resuscitation annually • They must also sign the Patient Group Direction for the administration of adrenaline following each update

9. Precautions continued • Every Health Care Professional who has patient contact MUST carry a basic resuscitation kit with them at all times • This is for use only in the case of a sudden collapse which follows the administration of medication or the carrying out of a procedure on a patient

10. Precautions continued • When administering immunisations the staff member should ensure that they have a means of summoning help, either by use of a second person (staff, carers, relative) or a mobile phone • Once administered, the patient must be observed for a period of time until YOU are satisfied that they are not having an immediate reaction

11. Resuscitation equipment • Several pairs of protective gloves • One pocket mask • Tissues • Clinical waste bag

12. Adult anaphylaxis equipment • 3 ampoules adrenaline 1:1000 (1mg/1ml) • 3 x 1ml syringe marked in 0.01 mls. • 3 blue needles 23 gauge x 1” • 3 green needles 21 gauge x 1.5” • 1 mask • 1 ampoule opener • Or IMS pre-filled syringe adrenaline 1:1000 (1mg/1ml) with 21G needle

13. Paediatric equipment • 3 ampoules adrenaline 1:1000 (1mg/1ml) • 3 x 1ml syringe marked in 0.01 mls • 3 orange needles 25 gauge x 5/8” (<5) • 3 blue needles 23 gauge x 1” (5-16 yr) • 3 green needles 21 gauge x 1.5” (>16) • 1 mask • 1 ampoule opener

14. Anaphylaxis warning • Consider diagnosis of anaphylaxis when compatible history of severe allergic type reaction with respiratory difficulty and/or hypotension especially if skin changes are present • Be aware that each subsequent reaction may be worse than the previous one • If in doubt treat as anaphylaxis

15. Management procedure • AIRWAY • BREATHING • CIRCULATION • DISABILITY • EXPOSURE

16. Diagnosis • Look for: • Acute onset of illness • Life-threatening Airway and/or Breathing and/or Circulation problems • And usually skin changes • Main clue- weak or absent CENTRAL pulse

17. Faint – onset Before, during or within minutes of vaccine administration Anaphylaxis – onset Usually within 5 minutes but can occur within hours of vaccine administration Fainting or Anaphylaxis?

18. Faint Generalised pallor Cold, clammy skin Anaphylaxis Skin itchiness Pallor or flushing of skin Red or pale urticaria (weals) Angiodema Signs and Symptoms

19. Faint Normal respirations May be shallow but not laboured Anaphylaxis Cough, wheeze or stridor Signs of respiratory distress Tachypnoea Cyanosis Rib recession Use of accessory muscles Respiratory

20. Faint Bradycardia, but with a strong central pulse Hypotension-usually transient and corrects in supine position Anaphylaxis Tachycardia with weak/absent central pulse Hypotension sustained Cardiovascular

21. Faint Sense of lightheadedness Loss of consciousness Improves once supine or head down position Transient jerking of limbs or eye rolling which may be confused with seizure Incontinence Anaphylaxis Sense of severe anxiety and distress Loss of consciousness-no improvement with supine or head down position Neurological

22. Life threatening problems • AIRWAY – swelling, hoarseness, stridor • BREATHING –rapid breathing, wheeze, fatigue, cyanosis, SpO2 < 92%, confusion • CIRCULATION – pale, clammy, low blood pressure, faintness, drowsy/coma Weak or absent central pulse • DISABILITY – AVPU scale, any paralysis, weakness etc. • EXPOSURE – check patient for rashes, skin changes, swellings etc.

23. Procedure • Call for help – request paramedic assistance. • Lie patient flat unless breathing is compromised then sit patient up; if unconscious then recovery position, left side for pregnant females • All patients will benefit from oxygen – non rebreather mask @ 15 litres per minute • Give Intra-muscular Adrenaline as per the protocol • All patients should be transferred by paramedic services to hospital

24. Adult protocol • 500 micrograms (0.5 mls) adrenaline 1:1000 given Intra-muscular to the outer thigh • THERE ARE NO CONTRA-INDICATIONS FOR PATIENT MEDICATION OR minijet pre filled syringe adrenaline 1:1000 given Intra-muscular to the outer thigh OR may have epipen or anapen CAN REPEAT ANY AT FIVE MINUTE INTERVALS IF NO IMPROVEMENT IN PATIENTS CONDITION

25. Adverse reactions Anxiety, Nausea, Tremor, Vomiting, Tachycardia, Sweating, Cold Extremities, Dizziness, Arrhythmias, Headache, Dyspnoea, Local Ischaemic Necrosis, Weakness, Restlessness, Palpitations, Hypertension – Cerebral Haemorrhage, Pulmonary Oedema, Hyperglycaemia, Gluconeogenesis, Glycolisis, Lipolysis, Ketogenesis

26. Adverse reactions continued • Gluconeogenesis is the synthenisation of glucose from non carbo-hydrate sources. • Glycolisis is the breakdown of glucose to pyruvic acid • Lipolysis is the breakdown of fat stored in cells • Ketogenesis is the formation of ketone bodies.

27. Allergic reaction – severe • 999/112

28. Paediatric protocol

29. Paediatric protocol cont. • Child/Infant may have epipen or anapen which they may wish to use as an alternative • CAN REPEAT DOSE AFTER 5 MINUTES IF NO IMPROVEMENT IN PATIENTS CONDITION

30. Use of epipen/anapen • Epipen available in two strengths – 0.3 mg for adults and 0.15 mg for children • Jab firmly into outer thigh, hold in place for 10 seconds, remove and massage area • Anapen available in three strengths – 0.5 mg for adults over 65 kg, 0.3 mg for adults under 65 kg or large children, and 0.15 mg for children • With anapen hold against outer thigh at 90 degrees and press trigger button, hold in place for 10 seconds, remove and massage area • Do not worry about exact measurements of adrenaline – it is a substance produced naturally by the body

31. Incident reporting • The incident should be reported to the Committee on Safety of Medicines, using the yellow card system • Also it must be reported via the Trust to the appropriate G.P.; the health and safety officer and the resuscitation officer • Make sure that you record the batch number of the vaccine

32. Important notes • Make sure that you check the expiry date of your adrenaline regularly • Be aware that adrenaline is available in two formats: 1:1000 and 1:10000 • We (the K.I.P.S.) only use the 1:1000 administered I.M. • The 1:10000 is for use I.V. but only by a SPECIALIST PRACTITIONER USING CARDIAC MONITORING EQUIPMENT

33. Recap • Assess patient – ABCDE • Call for help • Position patient • Adrenaline I.M. • Oxygen if available • Reassure and monitor • Ambulance to Hospital • Documentation

34. Statistics from M.H.R.A. • Between 1997 and 2003 there were 130 reported incidents of anaphylaxis or a similar reaction following immunisation • There were NO deaths • This is of 117 million doses of vaccines supplied to Hospitals, and Integrated Service Providers. • This rate equates to 1 reaction per million vaccine doses

35. Finally…. • My details are: Dave Prescott Resuscitation Training Officer Knowsley Integrated Provider Services 5 Boroughs Partnership NHS Foundation Trust Centre for Independent Living (CIL) Unit 11 Brickfields Huyton Business Park L36 6HY Mobile number: 07768475851 Email: Dave.Prescott@5bp.nhs.uk