Community Nursing
Yukon Immunization Program
Section 12
Anaphylaxis
2011 March
Page 1
SECTION 12 – ANAPHYLAXIS
TABLE OF CONTENTS
1.0 Types of Reaction .............................................................................................. 2
1.1 Anaphylaxis ...................................................................................................... 3
2.0 Emergency Supplies .......................................................................................... 4
3.0 Anaphylaxis Management ................................................................................. 5
3.1 Treatment of Anaphylaxis- Health Facilities Non Treatment ........................ 6
3.2 Anaphylaxis Treatment for Non-Treatment Facilities ................................... 7
3.3 Treatment of Anaphylaxis- Health Facilities- Treatment.............................. 9
Community Nursing
Yukon Immunization Program
Section 12
Anaphylaxis
2011 March
Page 2
1.0 Types of Reaction
Local
Swelling or induration, tenderness and inflammation at the
injection site. More severe local reactions i.e. edema
and abscesses can occur
Systemic
May include fever, rash, joint or muscle pains, fainting,
seizures or other central nervous system symptoms
Allergic
Include urticaria, rhinitis, bronchospasm, anaphylaxis are RARE
Most likely due to allergy to specific component of the vaccine
such as antibiotic, egg protein, stabilizers such as gelatin or
preservatives
Severe
Can be local or systemic may indicate that additional doses of
the same vaccine should be avoided
Treatment
Most reactions can be treated with mild analgesics and cool
compresses to the injection site
Fever in infants and children, may be treated with
Acetaminophen
Anaphylaxis will be treated according to the Anaphylaxis
Protocol (rural facilities) and protocols set out in the Canadian
Immunization Guide (non treatment health facilities)
Community Nursing
Yukon Immunization Program
Section 12
Anaphylaxis
2011 March
Page 3
1.1 Anaphylaxis
Every vaccine given carries an associated risk of producing an anaphylaxis reaction.
Anaphylaxis is very rare. The estimated annual reported rate of anaphylaxis ranges from 0.4
to 1.8 reports per 1,000,000 doses of vaccine distributed in Canada.
Anaphylaxis is an allergic reaction to a foreign substance, and potentially can be life
threatening.
Anaphylaxis develops over several minutes and usually involves two body systems.





early anaphylaxis symptoms include itchy urticarial rash (90%) of cases,
and angioedema ( which is progressive and painless swelling). Angioedema may be
preceded by; itchiness, nasal congestion, tearing, coughing, and facial flushing
respiratory symptoms including sneezing, coughing, wheezing, laboured breathing
and upper airway swelling
hypotension usually develops later in the reaction
gastrointestinal symptoms (nausea, vomiting and diarrhea) may occur
unconsciousness occurs late in the anaphylaxis process
Note: swelling an uticarial rash at the injection site can occur but not always caused by
an allergic reaction. This reaction can be managed by observation (see CIG pg 81)
Anaphylaxis must always be distinguished from fainting (vasovagal syncope), anxiety and
breath holding episodes.
Fainting: client becomes pale, loses consciousness and may have brief clonic seizure
activity. May be diaphoretic and mildly hypotensive.
Anxiety: client may become fearful, pale and diaphoretic, complain of lightheadedness,
dizziness and numbness, as well as tingling of face and extremities.
Breath-holding: young children may have breath-holding spells when they become upset.
The child is suddenly silent but obviously agitated. Facial flushing and perioral deepens as
breath holding continues. Some spells end with a brief period of unconsciousness during
which breathing resumes.
Observation Post Immunization


clients should remain in the clinic for 15 minutes post immunization
clients at high risk for reaction should remain in the clinic for 30 minutes post
immunization
Community Nursing
Yukon Immunization Program
Section 12
Anaphylaxis
2011 March
Page 4
2.0 Emergency Supplies
1. Copy of anaphylaxis procedures including dosing for epinephrine and
diphenhydramine
2. 1 cc syringes (2)
3. 3 cc syringes (2)
4. 25 G 5/8” needles (2), 23 or 25 G 1” needles (2)
5. alcohol swabs
6. epinephrine 1:1000 (2)
7. diphenhydramine 50 mg/ml (2)
8. diphenhydramine po (liquid)
9. oxygen tank, regulator, adult and pediatric masks & tubing
All emergency supplies are to be checked prior to every immunization clinic, satellite
visit and home visit.
Community Nursing
Yukon Immunization Program
Section 12
Anaphylaxis
2011 March
Page 5
3.0 Anaphylaxis Management
PRINCIPLES – ADMINISTRATION OF EPINEPHRINE
1. administration of epinephrine is the most important step in
management of an anaphylaxis reaction.
2. administer the initial dose of epinephrine into the opposite limb to which
the immunization was given (i.e. if the immunization was given in the left
leg, administer the epinephrine into right leg)
 if vaccines were given in both arms and both legs, administer the
epinephrine at least 2.5 cm (1 inch) from any immunization site.
3. to ensure maximal absorption of epinephrine, use a different limb for
REPEAT doses and again avoid limb in which immunization was given or
administer the epinephrine at least 2.5 cm (1 inch) from any
immunization site.
PRINCIPLES – ADMINISTRATION OF DIPHENHYDRAMINE (BENADRYL™)
1. administration of diphenhydramine is an adjunct to administration of
epinephrine.
2. administer diphenhydramine preferably at a different site to which the
epinephrine was given.
3. Oral diphenhydramine is preferred for conscious patients who are not
seriously ill as injectable diphenhydramine is painful!
REFERENCE:
1.
National Advisory Committee on Immunization (2006). Canadian
Immunization Guide (7th ed.). Ottawa, ON: Canadian Medical
Association.
Community Nursing
Yukon Immunization Program
Section 12
Anaphylaxis
2011 March
Page 6
3.1 Treatment of Anaphylaxis- Health Facilities Non Treatment
Whitehorse Health Centre, Watson Lake Health Centre, Dawson City Health
Centre Yukon Communicable Disease Control Unit, Kwanlin Dun Health Centre &
Rural Facilities conducting any satellite clinics:
Epinephrine Dosing For Anaphylaxis
The dose for epinephrine is 0.01 ml/kg (maximum 0.5 mL).
When the weight of the client is unknown:
Appropriate Dose of Epinephrine (1:1000)/mL According to Age
Age
Dose
2 to 6 months*
0.07 mL
(0.07mg)
12 months*
0.10 mL
(0.10 mg)
18 months* to 4 years
0.15 mL
(0.15 mg)
5 years
0.20 mL
(0.20 mg)
6-9 years
0.30 mL
(0.30 mg)
10 – 13 years
0.40 mL†
(0.40 mg)
≥ 14
0.50 mL†
(0.50 mg)
* Dose for children between the ages shown should be approximated, the volume
being intermediate between the values shown or increased to the next larger dose,
depending on practicality
† For a mild reaction, a dose of 0.3 mL can be considered.
Diphenhydramine Dosing
Age
< 2 years
2 – 4 years
5 – 11 years
≥ 12 years
Source:
1.
Appropriate Dose of Diphenhydramine
Hydrochloride (50 mg/ ml)
Dose
Oral or Injected
0.25 mL
(12.5 mg)
0.50 mL
(25 mg)
0.50-1. mL
(25-50 mg)
1. mL
(50 mg)
National Advisory Committee on Immunization (2006). Canadian
Immunization Guide (7th ed.). Ottawa, ON: Canadian Medical
Association.
Community Nursing
Yukon Immunization Program
Section 12
Anaphylaxis
2011 March
Page 7
3.2 Anaphylaxis Treatment for Non-Treatment Facilities
1. PROMPTLY administer EPINEPHRINE
2. CALL FOR ASSISTANCE. CALL 911 or local number for an ambulance
3. Place patient in recumbent position, elevating the feet if possible
4. Establish oral airway if required
5. Administer HIGH FLOW OXYGEN VIA MASK for any patient with cynanosis,
dyspnea or any other severe reaction. Monitor with pulse oximetry if available
6. If the vaccine was injected sc, an additional dose of 0.005 mL/kg
(maximum 0.3mL) of aqueous epinephrine 1:1000 can be injected into
the vaccine site to slow absorption. This should be given after the initial
dose of epinephrine in moderate to severe cases. It is generally not
repeated.
Local injection of epinephrine into an intramuscular vaccination site is
contraindicated because it dilates vessels and speeds absorption of the vaccine
7. As an adjunct to epinephrine, a dose of Diphenhydramine hydrochloride
(Benadryl ®can be given)
8. Monitor vital signs and reassess the situation frequently, to guide
medication use
9. Arrange for rapid transport to hospital
When there is an anaphylactic reaction in a non treatment facility the
EMERGENCYTREATMENT OF ANAPHYLAXIS NON TREATMENT
HEALTH CENTRE form will be completed. A copy will be provided to the EMS crew (as
applicable) and the original will be kept on the client file.
Community Nursing
Yukon Immunization Program
Section 12
Anaphylaxis
2011 March
Page 8
EMERGENCY TREATMENT OF ANAPHYLAXIS NON TREATMENT
HEALTH CENTRE
NAME___________________________
VACCINE GIVEN
Birthdate:___________
SITE
ROUTE √
IM
SC
IM
SC
IM
SC
IM
SC
TIME:____ADMINISTRATION OF VACCINES
TIME___ ONSET OF REACTION
REACTION
( √ all applicable symptoms)
swelling urticarial rash Pulse:rapid
weak
irregular
sneezing
coughing
decreased B/P
wheezing
uneasiness restlessness agitation
nausea
vomiting
abdominal pain
laboured breathing
upper airway swelling
unresponsive
TIME
TIME
PULSE
RESPIRATION
DRUG
EPINEPHRINE # 1
EPINEPHRINE # 2
EPINEPHRINE # 3
DIPHENHYDRAMINE
TIME: _________
TIME: _________
BLOOD PRESSURE
DOSE
ROUTE
SP02
SITE
IM/PO
OXYGEN VIA MASK HIGH FLOW
ARRIVAL OF EMS
______
/L
SIGNATURE OF RN: _________________________Date:___________
Revised: 2007 August
Note: Discuss with patient or his/her parent/caregiver reason for reporting and confidentiality of information
Community Nursing
Yukon Immunization Program
Section 12
Anaphylaxis
2011 March
Page 9
3.3 Treatment of Anaphylaxis- Health Facilities- Treatment
Community Health Facilities (Treatment):
PATIENTS PRESENTS WITH SEVERE ALLERGIC REACTION
REMEMBER: alternate presentations i.e. abdominal pain, nausea, vomiting, and paresthia, altered
mental state such as anxiety, agitation, and stupor.
**If reaction is secondary to a vaccination, apply tourniquet above the injection site and release for
1 minute every 3 minutes.
SYSTOLIC BP LESS < 90
NO
Establish IV Normal Saline (wide open)
YES
Administer:
Epinephrine 1:1000 (1 mg/ml)
PEDIATRIC: 0.01 ml/kg SC/IM (max. 0.5 ml)
ADULT:
0.1 - 0.5 ml SC/ IM q 5 min
(based on weight and severity)
High Flow 02 (10 L/min)
High Flow O2 (10L/min)
Contact Medevac Doctor
IV Normal Saline (wide open)
On doctor’s order only:
Epinephrine 1:1000 ( mg/ml)
PEDIATRIC: 0.01 ml/kg SC. (max. 0.3 ml)
ADULT:
0.3 - 0.5 ml SC.
(based on weight and severity)
Diphenhydramine: 1.0 mg/kg IM/IV (max 50 mg)
Diphenhydramine: 1 mg/kg IM/IV (max 50 mg)
Hydrocortisone Sodium Succinate:
PEDIATRIC: 5 mg/kg IV bolus (Max 250 mg)
ADULT:
500 mg IV
Hydrocortisone Sodium Succinate:
PEDIATRIC: 5 mg/kg IV bolus (max 250 mg)
ADULT:
500 mg IV
TRANSFER
(Source: Community Nursing, September 1997)
Consult
Medevac Doctor
TRANSFER