MULTIDISCIPLINARY PROCEDURE PROCEDURE FOR MANAGING AN ANAPHYLACTIC EMERGENCY First Issued June 2011 Issue Version Four Purpose of Issue/Description of Change Planned Review Date To promote safe and consistent practice when managing an anaphylactic emergency 2019 Named Responsible Officer:- Approved by Date Medicines Governance Pharmacist Advanced Practitioner Multi Disciplinary Procedure MMSOP24 Medicines Governance Group May 2016 Target Audience All Clinical Services UNLESS THIS VERSION HAS BEEN TAKEN DIRECTLY FROM TRUST WEB SITE THERE IS NO ASSURANCE THIS IS THE CORRECT VERSION
CONTROL RECORD Title Procedure for Managing an Anaphylactic Emergency Purpose To promote safe and effective practice when managing an anaphylactic emergency Author Quality and Governance Service (QGS) Impact Assessment Completed Yes No Actions Required Yes No Subject Experts Lisa Knight / Tom Meade / A Baker Document Librarian QGS Groups consulted with :- Medicines Management Group Date formally approved by May 2016 Medicines Management Group Infection Control Approved May 2016 Method of distribution Email Intranet Archived Date: Location: Access VERSION CONTROL RECORD Version Number Author Status Changes / Comments Version 1 Medicines Governance Pharmacist R/ TC Procedures now applies to all clinical services across the Trust Version 2 Medicines Governance Pharmacist R To incorporate NICE guidance Version 3 Medicines Governance Pharmacist R To update expired document and clarify storage requirements Version 4 Medicines Governance Pharmacist R To update adrenaline dosing to comply with revised BNF recommendations Status New / Revised / Trust Change 2/8
INTRODUCTION PROCEDURE FOR MANAGING AN ANAPHYLACTIC EMERGENCY Anaphylaxis can be triggered by a very broad range of triggers. Most commonly identified triggers in the UK include food, medicines and venom from insect stings. Trust staff may have to respond to an anaphylactic emergency resulting from any trigger; however it is essential that practitioners anticipate the possibility of an anaphylactic reaction occurring in a patient resulting from medication they may have administered or supplied to the patient. Anaphylaxis is more likely to occur after a number of exposures to a particular antigen, but it can take place when there has been no prior sensitisation. A staff member may only have seconds in which to deal with the situation effectively. Although an anaphylactic reaction can result from medication administered via any route, there is a higher possibility of a rapid onset anaphylactic reaction from an injected medication. All practitioners who administer any medication by injection or the application of topical products must therefore ensure they have access to an anaphylactic shock kit as detailed in this document. PROCEDURE OUTCOME Check allergy status of all patients prior to administration or supply of any medication Distinguish between an anaphylactic reaction, fainting (syncope) and panic attacks Respond appropriately to an anaphylactic emergency in a community setting TARGET GROUP All clinical staff in Trust required to undertake this role TRAINING All staff in the Trust are required to comply with mandatory training, as specified in the Trust s Mandatory Training Matrix and their service specific training matrix. TRUST POLICIES AND PROCEDURES Refer to current Trust Policies and Procedures DEFINITIONS Anaphylaxis Anaphylaxis is a severe, life-threatening, generalised or systemic hypersensitivity reaction. It is characterised by rapidly developing life-threatening airway and/or breathing and/or circulation problems usually associated with skin and mucosal changes 3/8
RECOGNITION OF AN ANAPHYLACTIC REACTION Onset of anaphylaxis is rapid, typically within minutes and its clinical course is unpredictable with variable severity and clinical features this causes diagnostic difficulty. The most serious symptoms of anaphylaxis include cardiovascular collapse, bronchospasm, angioedema (localised oedema of the deeper layers of the skin or subcutaneous tissues), pulmonary oedema, loss of consciousness and urticaria. Asthmatic patients with anaphylaxis often develop bronchospasm. DIFFERENTIAL DIAGNOSIS Practitioners should be able to distinguish between an anaphylactic reaction, fainting (syncope) and panic attacks. Fainting is relatively common in adults and adolescents, but infants and children rarely faint. Sudden loss of consciousness in young children should be presumed to be an anaphylactic reaction, particularly if a strong central pulse is absent. A strong central pulse persists during a faint or seizure. Panic attacks should be distinguished from anaphylaxis. Symptoms include hyperventilation that may lead to paraesthesiae (numbness and tingling) in the arms and legs. There may be an erythematous rash associated with anxiety, although hypotension and pallor or wheezing will not be present. If the diagnosis is unclear, anaphylaxis should be presumed and appropriate management given CLINICAL FEATURES OF FAINTING AND ANAPHYLAXIS Symptoms and/or signs Skin Respiration Cardiovascular Neurological Onset following injected medication such as vaccine administration Fainting Generalised pallor, cold clammy skin Normal respiration- may be shallow, but not laboured Bradycardia, but with strong central pulse, hypotensionusually transient and corrects in supine position. Sense of light-headedness, loss of consciousness improves once supine or head down position, transient jerking of the limbs and eye-rolling which may be confused with seizure, incontinence Before, during or within minutes of vaccine administration Anaphylaxis Skin itchiness, pallor or flushing of skin, red or pale urticaria (weals) or angioedema Cough, wheeze, stridor, or signs of respiratory distress (tachypnoea, cyanosis, rib recession) Tachycardia, with weak/ absent central pulse, hypotension-sustained Sense of severe anxiety and distress, loss of consciousness no improvement once supine or head down position Usually within 5 minutes, but can occur within hours of vaccine administration 4/8
Taken from Chapter 8 Immunisation against infectious disease March 2013 ALLERGY STATUS It is the responsibility of the practitioner administering any treatment - to assess the patient for the risk of development of an anaphylactic reaction e.g. determines any history of relevant allergies. Any allergy must be recorded in the patient s care plan or health record Where there is any previous history of allergy to a particular medication, the medication should not be given and the authorised prescriber should be contacted for advice on alternative treatments There is a risk of an anaphylactic reaction to any medication given by any route If a medication has been prescribed for which there is a documented history of allergy in a particular patient, an incident form must be completed. ANAPHYLACTIC SHOCK KIT Adrenaline may be administered to patients suffering from an anaphylactic emergency, in the absence of a prescription or Patient Group Direction. This is because it is exempt from prescription only status when it is used for the purpose of saving life in an emergency. The anaphylactic shock kit contains:- Adrenaline Injection 1:1000 (1mg in 1ml) for intramuscular use (Minimum of 5 kept in original manufacturer s packaging with information leaflet) Hypodermic Needles (23G) x 5 Hypodermic Syringes (1ml) x 5 Pre printed current laminated card with adrenaline dosage PRACTITIONER RESPONSIBILITIES All health practitioners must identify where adrenaline is stored prior to any preparation for the administration of an injected medication All health practitioners must have adrenaline available in either the clinical room or the patient s home in the event of an anaphylactic reaction All health practitioners who administer any medication by injection must ensure they have access to an anaphylactic shock kit on their daily visits. All bank staff when covering for permanent staff must have access to an adrenaline shock kit Adrenaline should be stored in a container not accessible to patients where it can be accessed rapidly in an emergency. Staff delivering care in community clinics must not draw up adrenaline in advance, adrenaline should only be drawn up for use when required to manage an anaphylactic reaction. It is the responsibility of the practitioner to check that the shock kits are complete and fully equipped and the adrenaline has not expired. Do not split the manufacturer s packaging. Essential product information is contained in the packaging with the medication. 5/8
If the patient lives alone the practitioner can administer the medication unassisted, provided there is access to a phone to summon appropriate help should an emergency occur Adrenaline needs to be checked for discolouration prior to commencing visits/clinic sessions as adrenaline may be affected by extreme temperatures i.e. in a car and protected from direct sunlight. All equipment must be stored safely in all environments. Follow manufacturer s storage instructions. Note: Chlorphenamine (chlorpheniramine) and hydrocortisone are not first-line treatments and therefore are not included in the shock kit MANAGERS RESPONSIBILITY To monitor attendance at Essential Learning Training, via management supervision and annual appraisals To ensure all staff have access to anaphylactic shock kits and have a system in place to monitor compliance Inform new starters of anaphylaxis distance learning resource, if required All service managers must ensure the shock kit is labelled property of Wirral Community NHS Foundation Trust and if found to return box to relevant service MANAGEMENT OF AN ANAPHYLACTIC EMERGENCY Emergency contact number:- All staff must be familiar with the relevant emergency contact number for their base, as this differs across clinical premises on the Wirral. Also there is a need for a coordinated system to guide emergency staff to where the patient is, otherwise there can be a time delay in attending to the patient If bank or agency staff are working with clinical teams they must be advised of procedure how to contact emergency services for that clinical area Staff who are based at Wirral University Teaching Hospital must follow their own service guidance on urgent referral to secondary care ANAPHYLAXIS IS ALWAYS AN EMERGENCY SITUATION REQUIRING IMMEDIATE ACTION If a patient shows signs of anaphylaxis e.g. stridor; wheeze; respiratory distress or clinical signs of shock the following steps must be followed: - 1. Telephone for an ambulance immediately (or if already on Arrowe Park Hospital site, arrange for urgent transfer to secondary care) and state that there is a case of suspected anaphylaxis 6/8
2. If available call for help from other Trust employed staff or responsible adult if needed and:- Assess the patient; check central pulses and respiration Maintain a clear airway Remove trigger where possible, i.e. stop administration of medicine or remove the stinger after a bee sting Lie the patient down, ideally with the legs raised (unless the patient has breathing difficulties or in the case of pregnant patients, lay the patient on their left side to prevent caval compression). Administer oxygen if available, refer to Trust procedure for use of emergency oxygen MMSOP30 for full details If breathing stops, mouth to mouth/mask resuscitation should be performed All patients with clinical signs of shock, airway swelling or definite breathing difficulties should be given adrenaline (epinephrine) 1:1000 1mg in 1ml administered by intramuscular (IM) injection (never subcutaneously). For information on dosing see below. The preferred site is the anterolateral aspect of the middle third of the thigh Stay with the patient at all times Dosages of adrenaline (epinephrine) 1:1000 (1mg in 1ml) to be administered by intramuscular injection (IM) Age Dose of Adrenaline (epinephrine) Volume of 1:1000 (1mg in 1ml) Child 1 month 5 years 150 micrograms 0.15ml 6 11 years 300 micrograms 0.3ml 12 17 years 500 micrograms (or 300 micrograms if child is small or prepubertal) 0.5ml (or 0.3ml if child is small or pre-pubertal) Adults 500 micrograms 0.5ml If there is no improvement in the patient s condition repeat the same dose at 5 minute intervals until the ambulance arrives (or patient has been transferred to secondary care), monitor pulse and respirations and blood pressure, if machine available. Because of the possibility of delayed reactions, all individuals who have had an anaphylactic reaction must be transferred immediately to secondary care, even if they may appear to have made a full recovery. Record all care in the patient s records including if known, the time of onset of the reaction and the circumstances immediately before the onset of symptoms. This information must be transferred with the patient to secondary care to help identify the possible trigger. Complete a Trust incident form and inform line manager or on call duty manager, within at least an hour of the incident or earlier if practicable. Sexual Health Services to inform the doctor on duty at the clinic and the on call manager for the Trust within at least an hour of the incident or earlier if 7/8
practicable. If it is an evening clinic they should inform their line manager the next day. REFERENCES National Institute for Health and Clinical Excellence (2011) CG134 Anaphylaxis: assessment to confirm an anaphylactic episode and the decision to refer after emergency treatment for a suspected anaphylactic episode Immunisation Against Infectious Disease, Chapter 8. Vaccine safety and the management of adverse events following immunisation. Department of Health (2013) March. Emergency Treatment of Anaphylactic Reactions (2008) Resuscitation Council (UK) January. (updated July 2012) Standards for Clinical Practice and Training for Dental Practitioners and Dental Care Professionals in Dental Practice (2006) Resuscitation Council (UK) July. (updated December 2012) Faculty of Sexual and Reproductive Healthcare of the Royal College of Obstetricians and Gynaecologist (2010). Service Standards for Resuscitation in Sexual Health Services. October. 8/8