HPTV1.1A AllergyWise anaphylaxis training for schools, early years and community settings 1 Introduce yourself and say where you are from. The aim of the training is to provide you with up-to-date information about managing severe allergies in schools and early years settings. With particular emphasis on allergen avoidance, early recognition of symptoms and crisis management. You currently have <number> of <pupils / children> in the <name of school/or early years setting> who are at risk of a severe allergic reaction, otherwise known as anaphylaxis, and later on we ll talk specifically about their allergies, and how they can be managed. To begin with though, I m going to run through what anaphylaxis is, the symptoms, causes, treatments, everyday management and emergency procedures, and then we re going to have a practical session with the trainer devices. If you have any questions please ask as we go along. <or if you prefer you can say: please can you save any questions until the end > Please note, the devices we will be practicing with do not contain adrenaline or have needles in them. 1
Learning objectives Improved and updated knowledge in managing severe allergies, including early recognition of symptoms, allergen avoidance and crisis management Enhanced skills in the use of adrenaline injectors. 2 After this course you should have: Improved and updated your knowledge in managing severe allergies, including early recognition of symptoms, allergen avoidance and crisis management. And gained enhanced skills in the use of adrenaline injectors. 2
What is anaphylaxis? Anaphylaxis is a severe systemic allergic reaction At the extreme end of the allergic spectrum The whole body is affected usually within minutes of exposure to the allergen It can take seconds or several hours. 3 Read the slide and move on to next one. 3
Definition of anaphylaxis Anaphylaxis involves one or both of two features: Respiratory difficulty (swelling of the airway or asthma) Hypotension (fainting, collapse or unconsciousness). 4 Allergic reactions can produce many unpleasant symptoms, but very few are likely to be described as anaphylaxis. This definition helps to explain the differences. (Ewan 1998). 4
What are the symptoms? Swelling of the mouth or throat Difficulty in swallowing or speaking Alterations in the heart rate Hives anywhere on the body Abdominal cramps and nausea Sudden feeling of weakness Difficulty breathing Collapse and unconsciousness. 5 Often the first symptoms are swelling around the mouth and tongue. This can rapidly lead on to difficulty in swallowing or speaking. Alterations in the heart rate, usually this means a very rapid perhaps thready pulse, which doesn t settle with resting, but there can also be an irregular pulse rate. Urticaria, sometimes known as hives or nettle rash, developing anywhere on the body. We have some examples to show you on the next slide. Abdominal cramps and nausea, also diarrhoea and vomiting. This is a sign of another system of the body becoming affected. Though not potentially life threatening these symptoms may well be seen alongside some of the others. Sudden feeling of weakness, or dizziness, this is caused by the blood pressure dropping, and it s really important to get the patient laying down to preserve their blood pressure. You might also want to raise their legs onto a chair which can also help. (Pumphrey 2003). If you do lay them down, make sure that you turn their head to the side, this helps prevent aspiration if they vomit. If vomiting looks likely they should lay on their side. Some patients report a sense of doom, they get a feeling that something terrible is about to happen. Difficulty breathing which can be caused by severe asthma or throat swelling, and collapse and unconsciousness can follow. Please note -You don t have to have all of these symptoms present before either giving treatment or seeking help. If several of these symptoms are present, get help immediately. 5
Urticarial rashes can be extremely varied. From tiny little spots to great big areas. These rashes are usually intensely itchy. Angioedema can cause severe swelling (seen here on the lips) when this affects the airway it can be very dangerous. 6
What exactly is going on? An anaphylaxis reaction is caused by the sudden release of chemical substances, including histamine, from cells in the blood and tissues where they are stored The release is triggered by the reaction between allergic antibodies (IgE) and the allergen. 7 The patient would have been exposed to the allergen previously (that s the thing they re allergic to) and on that occasion the body wrongly perceived the allergen as a threat and started to make antibodies against it. So the next time the body is exposed, it over reacts and the symptoms we ve just discussed occur. For some people very small amounts can trigger a reaction. This can be from: eating touching inhalation injection - as in a wasp sting The child or their parents / carer will know how careful they have to be, so talk to them about how sensitive they are. 7
Types of reaction Uni-phasic rapidly developing severe reaction involving the airway or circulation Bi-phasic early symptoms as above, then a symptom-free period of 1 hour, then increasing symptoms involving breathing and circulation. 8 Uni-phasic meaning one phase, the reaction comes on rapidly but once treated the symptoms go away and don t return. However a few people experience bi-phasic reactions. Two phases. About 1-20% of children have a bi-phasic reaction. (Lieberman 2005). There could be all the symptoms we ve just discussed immediately and then a rest period when everything appears to have gone away, (this could be after using emergency treatment.) Then the symptoms come back again and they can be very serious. It s for this reason that anyone who has an allergic reaction of this kind must go to hospital and they must be monitored for 6-12 hours to ensure they re not having a bi-phasic reaction (NICE 2011). Children having anaphylaxis are likely to be admitted overnight. It s likely medical staff will give additional medication to prevent any recurrence while the patient is being monitored in hospital. The patient, family member or carer will also need to ensure that they have spare or replacement emergency medicine before leaving the hospital. 8
Common causes Peanuts Tree nuts Milk Egg Sesame Fish Shellfish Wasp Bee Latex Penicillin Drugs Kiwi Lupin 9 Anything which contains protein could cause an allergic reaction however most people react to a fairly small group of things. These are the most common causes. Peanut Allergy is the most common cause of severe allergic reactions in the UK affecting about 1:70 children. (Grundy et al 2003) Reactions to peanut can be unpredictable. Tree nut Allergy such as hazelnuts, Brazil nuts, almonds, walnuts and cashew. About 25-30% of peanut allergic children go on to develop allergies to tree nuts too. Milk Allergy affects up to 3% of infants. About 19% will have outgrown their allergy before starting school, but by 16 years 79% will have outgrown it (Skripak et al 2007). Milk allergy is a difficult allergy to deal with as milk is added to so many different things. Egg Allergy also affects many infants. About 50% will outgrow it. Some children can tolerate well-cooked egg, but not raw or lightly cooked egg. Sesame seed Allergy is another unpredictable allergy like peanut and it s usually life long. Fish and Shellfish Allergy it s possible to be allergic to one type of fish or shellfish and not the others. Kiwi Allergy becoming a common allergy. With severe symptoms more likely to occur in younger children than in those over 16 years of age. Please see the Anaphylaxis Campaign fact sheets for more detailed information about specific allergens. 9
Treatments Adrenaline is the mainstay of treatment: Reverses swelling Relieves asthma Constricts the blood vessels Stimulates the heartbeats Antihistamines and asthma inhalers. 10 As these reactions come on so quickly there is often not enough time for antihistamine tablets or syrup to work. Antihistamines take at least 15 minutes to start working. An injection of adrenaline (otherwise known as epinephrine) works within seconds. It reverses the swelling around the airway so that the child can breathe, and it relieves asthma symptoms too. The allergic reaction causes the blood vessels to leak fluid which causes the blood pressure to drop. The adrenaline constricts the blood vessels which helps to stabilise the blood pressure, and it stimulates the heart beats. Adrenaline is a very safe drug if it is given correctly. It is a hormone normally produced by the body, but in a crisis the body can t produce enough. When we hear stories of people dying from severe allergic reactions it is almost always because adrenaline wasn t given, or there was a delay in giving it. Antihistamines may be useful if the reaction is coming on slowly, and asthma inhalers may also help. Incidentally children with asthma, as well as severe allergies, are far more at risk of a severe reaction than allergic children who do not have asthma. As a preventative measure they should make sure their asthma is VERY well controlled. (Uguz et al 2005). 10
Emerade auto injector: Devices Adult dose 0.5 mgs & 0.3mgs Child dose 0.15mgs 18 month shelf life. 12 The child s dose goes up to 30kgs (4 ½ stone) ACTION: You may wish to demonstrate using the Emerade trainer device here. The Emerade should be administered into the upper outer aspect of the thigh Remove the needle shield Press the device firmly against the upper, outer thigh, at right angles to the leg. Hold in place for 5 seconds. Remove and place in a rigid container. (The ambulance crew will be able to dispose of this for you.) Massage the injection site gently for a few seconds. 11
EpiPen auto injector: Devices Adult dose 0.3mgs Child dose 0.15mgs 18 month shelf life. 12 Again the child s dose goes up to 30kgs (4 ½ stone) ACTION: You may wish to demonstrate using the EpiPen trainer device here. The EpiPen should be administered into the upper outer aspect of the thigh Remove the blue safety cap with orange tip facing down Hold device a few centimetres away from, but at right angles to the leg, and jab firmly Hold in place for 3 seconds. Remove and place in a rigid container. (The ambulance crew will be able to dispose of this for you.) Massage the injection site for a few seconds. Make sure you keep your thumb away from either end of the device. 12
Jext auto injector: Devices Adult dose 0.3mgs Child dose 0.15mgs 18 month shelf life. 12 Please note: Children need to go onto the adult dose when they weigh around 30kgs which is around 4 ½ stone. ACTION: You may wish to demonstrate using the Jext trainer device here. Grasp the Jext in your dominant hand, with the black tip facing down, and thumb tucked in. Remove the yellow safety cap Place the black injector tip against the outer thigh holding the injector at a right angle to the thigh. Push the black tip firmly into the outer thigh You will hear the injector fire Hold in place for 10 seconds. Remove the Jext from the leg, you will not see the needle as a needle shield covers it as you withdraw. Gently massage around the injection site for 10 seconds. The paramedics will be able to dispose of the device for you. 13
Route of administration The correct route of administration for adrenaline auto-injectors is through the anterolateral aspect of the mid thigh. 14
Storage Accessible Avoid extremes of temperature Clearly labelled In date. 13 The auto injector devices should always be accessible, so never stored in a locked cupboard or room. All the staff should know where it is stored so that it can be collected quickly and taken to the child. The devices are designed to be stored at room temperature. They re not meant to be stored in the fridge, or in bright sunlight. If a child carries one in his rucksack this should not be left leaning against a radiator in the winter or left on a window sill in the summer. They should be clearly labelled with the child s name, and should be in date. They have an 18 month to 2-year shelf life so this can be overlooked. We recommend that parents should check the devices each term to make sure they remain in date and that they have not changed in appearance. Sometimes there can be several dates on the device. The expiry date is the date on the device itself and not the one on the dispensers label. 15
Key principles of good management Allergen avoidance Early recognition of symptoms Crisis management. 14 Managing severe allergies in schools and early years settings can be divided into three areas. Allergen avoidance, early recognition of symptoms and crisis management. These are the three important steps to managing severe allergies and ALL staff should know how to prevent exposing these children to their allergen, how to spot the early signs of a reaction, and what to do in an emergency, and also what not to do, as the wrong action could endanger the child s life. 16
Allergen avoidance Know the child, and their allergies Be allergy aware and risk assess Special occasions School trips Cookery lessons, science experiments School pets, bird tables. 15 If you have a child in your care who has a severe allergy, please get to know the child. They should have a healthcare plan outlining their medical needs, so make sure you have seen this. Find out what they re allergic to and what things they need to avoid. This will help you to make informed decisions and avoid unnecessary exposure to the child s allergen. These children are very normal children except for their allergy, so it s important that they join in all aspects of the curriculum. You will need to risk assess activities the child is involved in, particularly trips away, cookery and science experiments and mealtimes. Allergy awareness - Allergens can turn up unexpectedly. For example, trees in the school grounds with walnuts on. Cereal cartons which contained crunchy nut cornflakes. Special occasions like Christmas are often more risky times because different foods may be brought into school or early years settings. School trips can be hazardous when the child is being taken out of the normal environment. Again talk to the parents or carer about this to help identify any risks and conduct a risk assessment. Cookery lessons and science experiments may be hazardous so plan ahead and talk to the pupil or parents / carer well in advance. It s also a good idea to avoid using home economics rooms as form rooms for food allergic pupils. Does the school have a bird table or a furry pet? Birds are often fed on peanuts or nut feeders... and small furry animals are often fed on nut and seed based foods. See Questions and Answers pages and factsheets in your pack for further ideas on avoiding allergens in schools and early years settings. 17
Crisis management Alleviating fear Indemnity insurance Individual protocols / Healthcare management plans. 16 There can be a lot of fear about managing this condition. Children may be frightened because they know how serious it could be. Parents because they worry about someone else caring for their child, and whether they will spot the early signs and act quickly, and staff may well be nervous about whether they will be able to spot early signs too. Many people are worried about giving someone an injection. Hopefully this training will allay any fears you have, but please ask if you have any particular concerns or questions. Indemnity insurance - Most Local Education Authorities (LEA s) are happy to indemnify staff to give emergency treatment as long as the staff have received regular high-quality training. This should be provided at least annually. Each child should have an individual protocol/management plan about how to manage their allergy. This should be developed and agreed by the child s doctor, the parents and the school, and is designed to make management clear and simple. There is also a lower risk of repeated reactions when a protocol or management plan is used (Ewan & Clark 2005). *(Look at specific protocols for children in the school) 18
What to do in an allergic reaction Stay calm Patient positioning Call for help Using management plan, assess the reaction Give emergency treatment Make a note of the time Monitor closely until ambulance arrives. 17 I want you to imagine now that a pupil has approached you and said that they are feeling very ill and that they are having an allergic reaction. What do you do? Talk the staff through an allergic reaction and use a protocol/management plan to guide the treatment. 19
Who s responsible for what? Written consent? Provide school with full information? Ensure medicine is in date? 18 Written consent? - It s the schools or settings responsibility to ensure that written consent has been obtained from the parents to administer emergency treatment should it be needed. Full information - sounds obvious, but the parents have a responsibility to ensure that the school or early years setting have been given full information about their child s condition. There have been cases of parents not informing the school of their child s allergies, instead the child carries an adrenaline injector in their rucksack in secret. The parents also have a responsibility to ensure that any medication is in date. We recommend that parents check the medication at least once each term. 20
A few things to think about! Will a supply teacher know who I am? Kissing can seriously damage your health! Other training needs? For example, breakfast and after school clubs, school discos, sports clubs, school visitors, bus drivers/escorts, midday supervisors, catering staff. 19 Many children worry that supply teachers will not know who they are and will not know what to do. If you have regular supply teachers it s worth asking them to attend your annual training sessions, if not then you should consider how you can ensure that they ll know which child has severe allergies and what to do. Kissing! This can be a huge issue for allergic teenagers. Suddenly instead of just considering what they are eating, the allergic teenager needs to consider what their boyfriend or girlfriend is eating too. There have been a number of nasty reactions after kissing. It may be appropriate to mention here that alcohol and recreational drugs can speed up a reaction and lower inhibitions, they may also impair judgement in realising that they are having an allergic reaction. And consider the other training needs within the school or setting. If the allergic children are attending these other clubs or groups then those staff also need training. 21
Want more information? Contact the Anaphylaxis Campaign Helpline Tel: 01252 542029 Website: www.anaphylaxis.org.uk Anaphylaxis Campaign Membership 20 If you would like more information, this can be obtained by contacting the Anaphylaxis Campaign by phone on 01252 542029 or visiting their website. The Anaphylaxis Campaign provides additional information, support groups and runs a helpline. Membership of the Campaign for individuals provides access to members only sections of the website and regular e-newsletter, and for healthcare professionals & trainers similar targeted information and communication is available to the Professional membership 22