Treatment of Severe Allergic Reaction
Protocol for Training
PowerPoint Presentation
January, 2013
1
Credits
• The 2013 training protocol and Power Point
presentation were revised by the Oregon Health
Authority, Emergency Medical Services and
Trauma Systems Office
• Many thanks to Kathleen Mahaffy-Dietrich, RN,
BSN, MPA and Jeanne Fratto, RN, BS, of the
Multnomah Educational Service District for their
assistance with the revisions
2
Background
• The 2013 training protocol and presentation
slides are the responsibility of the Oregon Health
Authority, Public Health Division
• The subject matter contained in this presentation
highlights the information from “Treatment of
Severe Allergic Reaction, A Protocol for
Training” revised January, 2013
3
Topics
• Rules regarding epinephrine administration by
the public
• Recognition of anaphylaxis
• Management of anaphylaxis
• Action of epinephrine
• Use of epinephrine auto-injector devices
• Follow-up
4
State Laws
• Oregon Revised Statute 433.805-830
– Certain individuals may administer epinephrine to
another person who has a severe allergic reaction
when a licensed health care professional is not
immediately available
• Oregon Administrative Rule 333-55
– This law defines the procedures involved to authorize
a person to administer epinephrine
5
State Law
• Procedure
– Individual completes this training
– A statement of completion will be issued by the
instructor
• The authorization to obtain epinephrine is included
• The authorization must be signed by a nurse practitioner or
physician teaching or sponsoring the course
– This document serves as the prescription for epinephrine
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State Law
• The authorization to obtain epinephrine
– The authorization allows for a prescription of a autoinjector(s) for one child and one adult as an emergency
supply
– The authorization will be returned with the medications and
used for prescription refills of epinephrine up to 4 times
– The authorization will automatically expire three years after
the date of the training
– In order to gain a new authorization for epinephrine, the
training must be repeated
• A new statement of completion and authorization will be issued
7
What If the Pharmacist Won’t Honor the
Authorization?
• Call or e-mail the Oregon Health Authority
contact listed on the inside cover of the training
manual
8
State Law
• Who may be trained and subsequently
authorized to administer epinephrine?
– Person must be at least 18 years of age
– Person must have a reasonable expectation to work
in an environment that poses a risk for individuals
with a sensitivity for a severe allergic reaction
• Examples: schools, camps, forestry work, public venues,
etc.
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Allergic Reactions
and Anaphylaxis
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Definitions
• Allergen
– A protein not normally found in the body
– Exposure may cause an exaggerated allergic reponse
• Examples of allergens
–
–
–
–
–
–
Food
Medications
Insect stings
Latex
Other
This will be discussed in more detail later
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Definitions
• Normal reaction to an allergen
– Exposure to the allergen either causes no response
or produce expected, minimal signs
• Expected response to an insect sting
– Reddening of an area surrounding the sting
• Size of the area can grow to the size of a quarter
– Pain, swelling and itching may accompany the
redness
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Definitions
• Localized allergic reaction
– An exaggerated response that occurs when the body
is exposed to an allergen
– The signs are limited to the affected extremity or stays
on one side of the body
• Localized reaction to an insect sting
– Itching, redness and swelling will extend to an area
larger than a quarter
• It may extend over a joint line
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Definitions
• Anaphylaxis
– A life-threatening emergency
– Without treatment, it is fatal!
– Signs will appear on multiple areas of the body
• Or extend past one side of the body
– Signs may appear and progress rapidly
• Onset from minutes-to-hours
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Severity of Allergic Reactions
• Example: sting to the tip of the finger
• Normal reaction
– Swelling contained to the site of the sting
• Localized allergic reaction
– Swelling spreads to the hand (past one joint)
• Anaphylaxis
– Reaction spreads to the entire body
15
Allergic Reactions In Perspective
• For the purposes of this class, the information
will focus primarily on the recognition and
treatment of anaphylaxis
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Signs of Anaphylaxis
• Difficulty breathing
• Abdominal pain, nausea
or vomiting
• Widespread hives or
hives on the torso and
neck
• Flushed skin
• Sweating
• Sense of doom
• Incontinence
– Higher-pitched sounds with
breathing
• Difficulty swallowing or
hoarseness
• Swelling of eyes, lips,
face or tongue
• Rapid or weak pulse
• Dizziness or fainting
• Loss of consciousness
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Why People Die From Anaphylaxis
• Tissue swelling
– The tongue and airway passages
• Airway constriction
– Muscles surrounding the lower airways tighten
• Drop in blood pressure
– Blood vessels dilate
• Immediate injection of epinephrine is the single
factor most likely to save a life during anaphylaxis!
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Anaphylaxis
• The unpredictable nature of anaphylaxis
– It may occur with the first exposure or after repeated
exposures
– Onset may be immediate or delayed
– Reactions will vary from person to person
– There may be several signs or just one
19
Anaphylaxis
• The predictable side of anaphylaxis
– Death will occur if the condition is not treated swiftly with
epinephrine
– If a person has had an anaphylactic attack in the past, they
are very likely to experience it again with future exposures
– A person’s history of allergy or sensitivity may make them
vulnerable to anaphylaxis
– Persons with asthma may have an increased risk for
anaphylaxis as well
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Wisdom With Recognition

The faster the onset of signs from exposure, the
higher risk for severe symptoms and death

One or more signs of anaphylaxis will require
immediate injection of epinephrine

Call 9-1-1
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Epinephrine For Anaphylaxis
• Oregon State law allows you to administer
epinephrine to any person “suffering from a
severe allergic response to an insect sting or
other allergen.”
• “The decision to give epinephrine should be
based upon recognition of the signs of a
systemic allergic reaction…”
Note: The terms “severe allergic response”
and “systemic allergic reaction” are
considered to be functionally the same as
anaphylaxis.
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Causes of Anaphylaxis
23
Insect Venom
• Typical offenders
–
–
–
–
Yellow jackets
Honey bees
Wasps
Hornets
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Food Allergies
• Other food allergens
• Accounts for 35-55% of
all cases of anaphylaxis
–
–
–
–
–
–
–
–
–
–
–
• Most common food
allergens:
– Peanuts
– Tree nuts (walnuts,
hazelnuts, etc.)
– Fish
– Milk
– Eggs
Soy
Shellfish
Apricots
Bananas
Cherries
Kiwis
Papayas
Peaches
Pineapples
Plums
Strawberries
Keep in mind that a person can develop
an allergy to any food
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Other Allergens
• Exercise
• Latex
• Medications
Keep in mind that a person
can develop an allergy to
any medication
– Penicillin
– Aspirin
– Non-steroidal anti-inflammatory drugs
• Ibuprofen, naproxen, etc.
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Review
• Scenarios will be listed on the next few slides
• Read each scenario and determine if the person
is suffering from anaphylaxis
• Debriefing slides will discuss the key points of
recognition and treatment of the respective
reactions
27
Scenario #1
• 15 year-old was stung by a bee on his calf
• An area the size of a nickel is red and swollen on his
calf
– No swelling or redness found anywhere else
• No hives are seen
• He tells you this is the first time he has ever been
stung
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Scenario #1 Debriefing
• Normal reaction
– The signs did not expand beyond the size of a quarter
• What is his risk for developing anaphylaxis?
– Appears to be a low risk at this point
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Treatment for Normal Reactions
• If reaction was from an insect sting
– Cleanse the sting site
– Remove the stinger
• Only honeybees leave their stinger behind
– Reassure and calm the person
– Observe the person for at least 30 minutes
– Notify the parent or guardian
30
Scenario #2
• An 8 year-old has hives on her neck and chest
– She is scratching at them
• She appears to be breathing normally
• She ate a cookie 30 minutes ago
– A friend gave it to her
• She has a history of allergies to peanuts
– She has an EpiPen Jr.
31
Scenario #2 Debriefing
• Anaphylaxis
– The signs involve the entire body
• Hives on her neck and chest
• What is her risk for developing anaphylaxis?
– High risk
– She has a prescription for epinephrine
• This tells you that her peanut allergy is severe
• Should you give her the EpiPen Jr?
32
Scenario #2 Debriefing
• When should a person with a significant history
of allergic reaction be given epinephrine?
– Persons with a history of anaphylaxis have a strong
likelihood of developing it again
– Epinephrine should be given when any sign of
anaphylaxis appears
33
Scenario #3
• A student tells you that another student was
stung in the face after poking at a wasp nest with
a stick
• The child who was stung is screaming “it hurts!”
repetitively.
• He has a swollen upper lip and cheek
34
Scenario #3 Debriefing
• Local allergic reaction
– Swelling correlates with the sting locations
• What is his risk for developing anaphylaxis?
– Low
– Due to the location of the sting, the best action to take is to
seek professional medical attention
– In the meantime, follow the procedures for treating a
normal allergic reaction and monitor him for any change
35
Scenario #4
• A staff member directs you to help another 24 year-old
staff member
• His lips are swollen
• He is struggling to breathe
– You hear wheezing sounds
• He feels dizzy and wants to pass out
• He also feels like he is going to throw up
36
Scenario #4 Debriefing
• This is anaphylaxis
– Wheezing, dizzy, nausea, swollen lips and wanting to
pass out
• Epinephrine needs to be given immediately!
– Do not waste time attempting to find the cause
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Management of Anaphylaxis
38
Anaphylaxis Treatment Protocol
1. Determine if the person is suffering from an
anaphylactic reaction
2. Do not move the person
3. Have the person sit or lie down
4. Select the proper version of the epinephrine
auto-injector
39
Anaphylaxis Treatment Protocol
5. Administer the epinephrine through the device
6. Call or have someone else call 9-1-1. Do not
leave the person unattended.
7. Note the time when the auto-injector was used
8. Remove the stinger if present
40
Anaphylaxis Treatment Protocol
9. Check and maintain the person’s airway and breathing
10. Monitor for changes in the person’s condition
11. If the person’s condition does not change or worsens
after 5 minutes, administer another auto-injector at the
same dose
12. Upon the arrival of EMS, advise them of the person’s
signs before and after the epinephrine was given.
41
Multiple Insect Stings

Potential to cause a toxic reaction


10 or more stings
Elevated levels of venom in the body
• Any type of response may occur as a result
– Localized reaction or an anaphylactic reaction
42
Dealing With Multiple Stings
• Be prepared to give epinephrine
• Call 9-1-1
• Monitor the person closely
43
Epinephrine
• Powerful drug
– Obtained by prescription only
• Corrects all of the life-threatening problems of
anaphylaxis
• Easy to give
– Auto-injector
44
Limits of Epinephrine
• Oregon law only allows the use of the
epinephrine auto-injector for a person suffering
from anaphylaxis
• The law does not allow epinephrine to be used
for an isolated asthma attack
45
Constricts
Blood
Vessels
The Work of
Epinephrine
Epinephrine
Opens
lower
airways
Reduces
Swelling
46
Why Is Epinephrine Effective In the
Treatment of Anaphylaxis?
• The answer is found in the next slide
47
Anaphylaxis
Drops blood
pressure
Raises blood
pressure
Causes
swelling
Reduces
swelling
Constricts
the lower
airways
Opens the
lower
airways
48
Side Effects of Epinephrine
•
•
•
•
•
•
•
Rapid heart rate
Feeling of nervousness
Tremors
Nausea and/or vomiting
Sweating
The effects may last
Headache
between 5 and 20 minutes
Pale skin
49
Epinephrine Auto Injectors
• Pre-measured dose in each
– Pens for adults and children
• Trigger device
– Injects epinephrine directly into the body
50
Storage Of Epinephrine
• Store in a dark place at room temperature
– The medication is very sensitive to light
• Protect the auto-injector from freezing
temperatures
– Do not store this in the refrigerator
• Protect the auto-injector from extreme heat
– Keep it out of the glove box
51
Storage Of Epinephrine
• Periodically check the medication
– Solution should be clear and without particles
– Auto-injectors with tan or brown solution must be
discarded
– Check the expiration date
• Replace as needed
52
Adult and Child
Epinephrine Auto-Injectors
53
Adult and Child Auto-Injectors
Auto-Injector
Name
Dose and Target
Weight range
for this device
Approximate
Age Range for
the device
EpiPen
Auvi-Q 0.3
Twinject
Adult dose for all:
0.3 milligrams
Greater than 66
pounds
9-10 years or
older
EpiPen Jr.
Auvi-Q 0.15
(No child-specific
pen for the
Twinject
Child dose for all:
0.15 milligrams
33-66 pounds
3 – 9 or 10 years
Note: the epinephrine auto-injectors are not typically indicated
for infants and toddlers. However, the risk of death from
anaphylaxis is greater than the risk of administration of the
drug.
54
General Procedures For the
Auto-Injector
1. Remove the auto-injector from its protective
case
2. Remove the safety caps of the injector
3. Hold the injector firmly and keep fingers away
from the tips of the device
55
General Procedures For the
Auto-Injector
4. Position the device at a 90-degree angle
against the thigh
–
–
Push hard enough to cause a click for some devices
Push down on the trigger for other devices
5. Hold the device firmly against the thigh for 510 seconds during administration
–
Consult product directions
56
General Procedures For the
Auto-Injector
6. Remove the device and place it pack into its
protective case (when applicable)
7. Massage the skin at the injection site for 10
seconds
8. Call 9-1-1 if this was not performed already
9. Note the time when the auto-injector was used
57
Instructions For Specific Devices
• Auvi-Q
– https://www.auvi-q.com/
• EpiPen
– http://www.youtube.com/watch?v=tjILFYPE3Uw
• Twinject
– http://www.twinject.com/
– Device no longer available as of March 2012
• Adrenaclik
– http://www.adrenaclick.com/about-adrenaclick/adrenaclicktraining.aspx
– May not be OSHA-approved
• Exposed needle
58
Key Points of Administration
• Choose the correct type of auto-injector for the
general size and weight of the person
• Remove all safety caps prior to placement of the
device on the person
• Place the device against the outside of the thigh
59
Key Points of Administration
• Keep firm contact between the auto-injector and the
thigh during administration
– Maintain contact with the skin
– Remove the device after 5-10 seconds
• Massage the site of administration to encourage
faster absorption of the epinephrine
• Place the used auto-injector back into its case, if
applicable
60
Strategies For the Preparation and
Prevention of Anaphylaxis
61
Prevention
• Specific strategies to avoid insect stings and
reduce the exposure to food allergens are
outlined in detail in Section VII: B-E in the
epinephrine training protocol.
• Discuss how those strategies may be applied in
your situation.
62
Preparation
• Identify those who are at risk of anaphylaxis
– People with a prescribed auto-injector
– People with a history of allergic reactions
– People with a history of asthma
• When possible, educate those at risk for allergic
reactions with prevention strategies
63
Preparation
• Get a signed consent for emergency treatment
for minors
• Know who is trained in first aid and CPR
• Have an emergency response plan in place and
review it on an annual basis as a minimum
64
Preparation
• Know where the epinephrine is kept
• Review the steps of administration
• Know how to get emergency help
– How long does it normally take EMS to respond to
your location?
– Where is the nearest hospital?
65
Summary
• Anaphylaxis is a life-threatening event
• Epinephrine is the life-saving treatment for
anaphylaxis
• DO NOT HESITATE TO GIVE EPINEPHRINE!
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Summary
• Consider ways to minimize or prevent the
exposure to food or insect allergens
• Preparation is everything
– Know the signs of anaphylaxis
– Familiarize yourself with the epinephrine auto-injector
on a regular basis
– Know how to access the medication and professional
emergency medical help in your area
– Take a first aid and CPR class
67