Issued: July 2013 Review date:July 2014
Medicine Standing Order Title: Adrenaline
Rationale: In a rural GP clinic there are times when an authorised prescriber is not
available and in order for patients to access care a registered nurse using standing
orders is the best option.
Organisation/clinic: Church Street Surgery Opotiki.
Scope: To enable registered nurse working in the clinic to treat patients with proven or
suspected anaphylaxis.
Medicine/s: Adrenaline.
Dosage instructions for each medicine: Adrenaline 1:1000 (1mg/ml) 0.5mg or 0.5 ml
intramuscular injection, a further injection every 5 minutes if no improvement in hypotension,
airway swelling, bronchospasm (maximum of 3 doses).
Adverse effects: include hypertension, tachycardia, fear, anxiety, tenseness, restlessness,
disorientation, impaired memory, confusion, irritability, hallucinations and psychotic states.
Headache, weakness, dizziness, anorexia, nausea and vomiting and difficulty in micturition
with urinary retention may also occur.
Muscle tremor and hypokalaemia, psychomotor agitation, pallor, respiratory difficulty,
hyperglycaemia, sweating, hyper-salivation, cold extremities and insomnia have also been
reported. Palpitations, tachycardia (sometimes with anginal pain) and cardiac arrhythmias
may also occur along with hypertension which in some instances may induce reflex
bradycardia as can vasodilation with flushing and hypotension. Ventricular fibrillation may
occur and severe hypertension may lead to cerebral haemorrhage and pulmonary oedema.
Route of administration: IM injection
Indication/circumstances for activating the standing order:
To treat patients with proven or probable anaphylaxis in a school clinic setting – has been
exposed to a known or suspected trigger and is displaying all or any of the following:
Pruritus, urticarial, flushing, dizziness, headache, rhinitis, conjunctivitis; rapid, weak pulse;
wheezing; pain or tightness in the chest; skin flushing especially perioral/facial; abdominal
pain; vomiting; oedema face/neck/general; circulatory collapse; cardiac dysrhythmia,
severe asthma attack; loss of consciousness/convulsions.
Precautions and exclusions that apply to this standing order:
Contraindications: injection into fingers, toes, ears, nose, genitalia, IV administration.
Persons authorised to administer the standing order:
Registered nurses.
Competency/training requirements for the person(s) authorised to administer:
Prior to administering medication under this standing order the registered nurse is required
to undergo the in-house training on the policy, procedure and documentation requirements
for this standing order. In addition the registered nurse may undertake immunisation
administration training. A record of this training will be kept.
Countersigning and audit:
Countersigning by the issuer is required within 7 days of use of this standing order
Definition of terms used in standing order:
Additional information: Follow protocol as attached.
Signed by issuer:
Name:
Title: Medical Practitioner
Signed by Management:
Date:
Name:
Title:
Signed by Nurses working with Standing
Order:
Date:
Name/s :
Date:
This Medicine Standing Order is not valid after the review date.
Nurse Protocol for the Treatment of Anaphylaxis
Registered Nurses may give Adrenaline 1:1000 IM to clients that have symptoms of
anaphylaxis according to the following protocol:
1. ASSESS THE PATIENT





USUALLY HAVE 3 OF THE FOLLOWING
Red, raised and itchy rash, generalised rash
Swollen face, swollen eyes
Difficulty breathing – noisy breathing from airway obstruction (wheeze or
stridor), difficulty swallowing, respiratory arrest
Hypotension; tachycardia; dysrhythmias, circulatory arrest
Abdominal cramps +/ diarrhoea
2. CALL FOR HELP - CALL AMBULANCE
AIRWAY PATENCY: insert airway if necessary
BREATHING: assist with oxygen, mouth to mouth, ambubag
CIRCULATION: – CPR (Cardio Pulmonary Resuscitation)
3. ADMINISTER ADRENALINE
Dosage: 1: 1000 Adrenaline 0.5ml deep IM (try deltoid first)
You can expect to see some response to the adrenaline within 1 – 2 minutes.
If necessary, adrenaline can be repeated at 5 – 15 minute intervals to a maximum of three
doses, alternating sites/ limbs for additional doses

4. Administer OXYGEN @ 8 - 10L if there is respiratory distress (stridor, wheeze)

5. LIE FLAT
Check BP and pulse
- if hypotensive - elevate legs/feet
If stridor present -elevate head/chest

Record vital signs every 5 – 10 minutes and document fully all symptoms and treatment
given. All cases of moderate to severe anaphylaxis should be admitted to hospital for
observation as rebound anaphylaxis can occur 12 – 24 hours after the initial episode.
Flow Chart Summary
Anaphylaxis Suspected
Assess Symptoms
Airway
Breathing
Circulation
Severe Symptoms:
Mild / Moderate Symptoms
Hypotension with collapse, bronchospasm,
airway oedema + urticarial rash
Rash, Urticaria
Stop Medication.
Stop Medication
(if IV, withdraw blood from line and flush)
Administer Adrenaline 0.5mg IM
Assess Patient
Position Supine - If available, administer high
flow oxygen
Report to appropriate Medical Officer
(GP, Emergency Department, consulting
doctor) and arrange patient review
Dial 111
If in Cardiac arrest

Monitor Patient: Commence CPR as indicated


Perform CPR until ambulance
arrives
Elevate legs
Administer adrenaline
Persistent hypotension, bronchospasm or
airway swelling 5 minutes after adrenaline:
Repeat Adrenaline 0.5mg IM (maximum 3
doses)
AMBULANCE HOSPITAL
TRANSFER ASAP