10/19/2017 Emergency Preparedness for Anaphylaxis in School Michael Corjulo APRN, CPNP, AE-C ASNC April 20, 2017 Objectives Review a brief overview of anaphylaxis related to the school environment Demonstrate the use of epinephrine autoinjectors currently available Discuss emergency allergy/anaphylaxis plans Discuss the role of Benadryl in the treatment of anaphylaxis 1
Anaphylaxis A serious, generalized allergic or hypersensitivity reaction that is rapid in onset and potentially fatal Acute onset (minutes to several hours) Significant drop in BP, dizziness, syncope +/- any combination of: Skin or Mucosal Involvement: Generalize urticaria Itching (anywhere) Flushing Swollen lips, tongue, uvula Respiratory compromise: Dyspnea Stridor or frequent throat clearing Difficulty swallowing saliva Wheezing Persistent GI symptoms: Significant cramping Nausea/Vomiting Diarrhea 2
Anaphylaxis: Causes & Risk Factors Milk, eggs, tree nuts, peanuts, shellfish, and finned fish are by far the most common food causes in pediatrics Insect stings and various other allergens are important considerations Known allergy with known or suspected ingestion/exposure significantly elevates level of concern raises the anaphylaxis red flag Other allergic conditions Allergic threshold Fatal Anaphylaxis Delay in administration of epinephrine Concomitant asthma, especially if poorly controlled Adolescence Lucky anaphylaxis 3
Epinephrine: Rapid Onset and Short Duration Vasoconstrictor that prevents or decreases Upper airway/laryngeal edema Hypotension Shock Smooth muscle relaxation Bronchodilator GI and GU Cardiac inotropic and chronotropic Adverse effects are the similar to endogenous epinephrine (adrenaline) effects Tremor, anxiety, pallor, and palpitations Anaphylaxis Treatment: Universal Considerations 1. Stay calm 2. Have someone call 911 Stay with student, don t hang up, report allergic reaction and epinephrine being given 3. Administer epinephrine autoinjector Every professional medical organization in the U.S. recognizes epinephrine as the first line treatment for anaphylaxis Developmental and Emotional Considerations Expiration dates 4. Lie down if able, avoid rapid rise to upright position 5. Notify parent/guardian, appropriate school staff, and PCP/Allergist when able 4
Epinephrine Dosage and Administration IM absorbs 10x faster than SC Through clothes (empty pocket) Autoinjectors 0.3mg > 55 lbs Up to 20% need a 2 nd dose Inadequate dose Delay in initial dose Suboptimal injection technique Biphasic reaction Up to 11% More common with insect venom Epinephrine Autoinjectors Originally developed in the 1970s for the military to treat chemical weapon exposure Epipen first approved in 1987 Has a 2017 generic equivalent Twinject first approved in 2003, updated as Adrenaclick in 2012 Has a 2016 generic equivalent Auvi-Q first approved in 2013 Recalled in 2015 Returned February 2017 5
10/19/2017 Epinephrine Autoinjectors: Know your options Device Comparison 0.15mg 0.3mg Needle guard Audio instructions Epipen Adrenaclick Auvi-Q 6
Epipen 7
Emergency Anaphylaxis Plans Components Demographics Life-threatening allergies Related medical history Asthma Oral allergy syndrome Anaphylaxis symptoms Treatment protocol Optional State-specific medication authorization Emergency care plan for lay person 8
10/19/2017 Sample Plans https://www.aaaai.org/aaaai/media/med ialibrary/pdf%20documents/libraries/an aphylaxis-emergency-action-plan.pdf Sample Plans https://www.foodallergy.org /file/emergency-careplan.pdf 9
10/19/2017 Sample Plans https://www.aap.org/enus/documents/aaemergencyplan.pdf FOOD/INSECT EMERGENCY ANAPHYLAXIS CARE PLAN and MEDICATION AUTHORIZATION Connecticut State Law and Regulations 10-212(a) require a written medication order of an authorized prescriber, (physician, dentist, optometrist, advanced practice registered nurse or physician's assistant, and for interscholastic and intramural sports only, a podiatrist) and parent/guardian written authorization, for the nurse, or in the absence of the nurse, a qualified school personnel to administer medication. School: District/Town: STUDENT INFORMATION Student Name DOB: Home/Cell Phone Grade KNOWN LIFE-THREATENING ALLERGIES: MILK SOY BEE STINGS CONFIRMED WITH ALLERGY TESTING YES NO NO TREATMENT PLAN Yes Give epinephrine upon exposure (before the onset of any symptoms) If Yes Provide separate medication authorization if treatment indicated AIRWAY: Difficulty breathing, swallowing, chest tightness, wheeze THROAT: Tight, hoarse, swollen tongue, difficulty swallowing/drooling CARDIAC: Dizzy, faint, confused, pale or blue, hypotension, weak pulse &/OR ANY COMBINATION OF SYMPTOMS FROM DIFFERENT BODY AREAS: Swollen lips, repetitive cough, sneezing, profuse runny nose Hives, itching (anywhere), swelling (e.g., eyes) Nausea, Vomiting, diarrhea, crampy pain Epinephrine Auto-injector, Jr (0.15mg) IM side of thigh No (Increases risk of severe reaction) Yes (list): AFTER EXPOSURE TO KNOWN OR SUSPECTED ALLERGY & ANY OF THESE SYMPTOMS: EPINEPHRINE History of Asthma? TREE NUTS WHEAT SHELLFISH FISH (OTHER) LATEX EGGS: OTHER: KNOWN ORAL ALLERGY SYNDROME: PEANUTS FOLLOW THIS PROTOCOL: 1. INJECT EPINEPHRINE IMMEDIATELY! 2. Call 911 3. Lie down if able, avoid rapid upright positioning & continue monitoring 4. Give Bronchodilator/Albuterol if has asthma 5. Notify Parent/Guardian 6. Notify Prescribing Provider / PCP 7. When indicated, assist student to rise very slowly. Epinephrine Auto-injector (0.3mg) IM side of thigh A second dose of epinephrine can be given 5 minutes or more if symptoms persist or recur. Relevant Side Effects Medication shall be administered during school year: Tachycardia Other: 2016 TO 2017 Medication Allergies NKDA Other: NOTE: IF NURSE IS NOT AVAILABLE, THE EPINEPHRINE AUTO INJECTOR MAY BE GIVEN BY DESIGNATED SCHOOL PERSONNEL WITH EXPOSURE OR FOR ANY ANAPHYLAXIS SYMPTOMS TO BE COMPLETED BY PARENT AND AUTHORIZED HEALTHCARE PROVIDER: REQUIRED Prescriber s Authorization to Self- Administer NO *Yes, Confirms student is capable PRESCRIBER S PRINTED NAME OR STAMP AUTHORIZATION to safely and properly administer medication Prescriber s Signature: Date: I authorize the student to possess and self-administer medication OR I authorize this medication to be administered by school personnel I also authorize communication between the prescribing health care provider and school nurse necessary for allergy management and administration of this medication Parent/Guardian Consent Signature: Date: *TURN OVER FORM FOR INSTRUCTIONS ON ADMINISTERING EPINEPHRINE* 10
EMERGENCY ALLERGY CARE PLAN FOR STUDENT NAME: GRADE/SCHOOL: ALLERGIES: GIVE EPINEPHRINE UPON EXPOSURE TO ABOVE ALLERGY OR GIVE EPINEPHRINE AT THE ONSET OF ANY OF THE BELOW SYMPTOMS IF ALLERGEN LIKELY EATEN (OR STUDENT STUNG) SYMPTOMS OF ANAPHYLAXIS: Chest tightness, shortness of breath, cough, wheezing, profuse runny nose Dizzy, faint, pale, blue, confused Tightness and/or itching in throat, difficulty swallowing, hoarseness, drooling Swelling of lips, tongue, throat Itchy mouth, itchy skin, hives Hives, itching (anywhere), swelling (e.g. face, eyes) Nausea, vomiting, diarrhea, crampy pain Insert Picture if available EPINEPHRINE ADMINISTRATION PROTOCOL: 1. Administer Epinephrine Auto-Injector: circle one: (0.15mg 0.3mg) 2. Have someone call 911 for ambulance, don t hang up, and stay with student 3. Administer other medication: 4. Lie down if able; avoid rapid rise to upright position 5. Notify school and parent/guardian as soon as possible EPI AUTO-INJECTOR DIRECTIONS: For EPIPEN and EPIPEN JR.: 1. Stay Calm 2. Grip in your dominant hand as shown 3. Pull off blue activation cap. 4. Hold orange tip near outer thigh, OK to inject through clothing, but make sure pocket on that leg is empty. 5. Swing and jab firmly into outer thigh until you hear it click so you know it s injecting the medicine. Hold in place and count to 10; remove and massage 10 sec. (orange tip will automatically slide over needle) 6. Auto-injector should be given to EMS to take to E.R. EMERGENCY CONTACTS Name: Relation: Name: Phone: EMERGENCY/PHYSICIAN CONTACTS Phone: The role of Diphenhydramine (Benadryl) in allergy treatment Antihistamine (H1 blocker) Blocks histamine (naturally occurring chemical) released upon exposure to an allergic trigger Histamine release causes: sneezing; itchy, watery eyes; runny nose; hives; and rashes Common Side Effects sleepiness, fatigue, or dizziness; headache; dry mouth; or difficulty urinating 11
Diphenhydramine use in the treatment of anaphylaxis No one ever died from not getting Antihistamines are Too Little, Too Late and Potentially Detrimental. Antihistamines are widely recommended in anaphylaxis for their anti-allergenic properties, which comprise the inhibition of mediator release from mast cells and basophils. [13] However, firstly, Benadryl to treat their anaphylaxis, antihistamines have no proved clinical effect on immediate and life threatening symptoms of anaphylaxis. In conventional doses, antihistamines fail to prevent the massive release of histamine observed in anaphylaxis. [6] They are slower in onset than adrenaline and have little effect on blood pressure. They play a negligible role in relieving bronchospasm or gastrointestinal symptoms, relegating them to second tier treatment. [1,13] As a consequence they may just be useful for relief of mild symptoms, such as allergic reactions limited to the skin or the mucous membranes and flushing, itching, urticaria, and rhinorrhea But children and adults have died from using Benadryl and delaying the use of epinephrine during anaphylaxis Should Antihistamines be Used to Treat Anaphylaxis? (D. A. Andreae; M. H. Andreae). BMJ. 2009;338:b2489 Reasons people die from anaphylaxis Inadequate prevention Accidental exposure Risk-taking Lack of access to (enough) epinephrine Delay in epinephrine administration Benadryl first Fear of injection Unexpected severity Not using expired epinephrine 12
Solution (for schools and beyond) Use Emergency Allergy Plans just to treat Anaphylaxis Model after the AAAI plan and remove the antihistamine option Use separate medication authorizations and care plans to treat other allergic conditions where antihistamine use is safe and appropriate Oral Allergy Syndrome (OAS) Urticaria (chronic or recurring hives) 13