Protocol for Management of Suspected …

1 Anaphylactic ShockAnaphylactic (Allergic) Shock This type of reactionis usually of a violent nature, often occurring withvery little warning within a few seconds to minutesfollowing administration of drugs such as vaccines,toxoids, immune globulins, antitoxins, diagnosticsolution (tuberculin skin test), antibiotic (such aspenicillin), pollen or other allergic extract, or afterstinging by venomous insects. The following signsand symptoms may develop rapidly anddramatically: apprehension, itchiness, flushing of theface, substernal itchiness, stridorous or wheezybreathing, cyanosis, a drop in blood pressure, andloss of consciousness. Death may ensue immediatelyafter the first sign of difficulty, or the patient mayrecover from the initial signs and symptoms anddevelop, within the next 30-60 minutes, generalizedurticaria, angioedema, acute coryza, bronchial spasm,intestinal and uterine colic and shock should be distinguished from asyncopal episode which is characterized by pallor,slow pulse, salivation, nausea, vomiting andsweating.

2 These syncopal signs and symptomsrespond to measures taken to improve circulation tothe brain: lowering of the head and/or raising thefeet. For an incipient episode, having the patient takea few deep breaths may of AnaphylaxisTreatment is directed at limiting the absorption ofnoxious material and by countering the adversereactions. The ABCD s of resuscitation should befollowed while simultaneously calling ABCD s refer to:A airwayB breathingC circulation D drug treatmentThe principles and Protocol of the ABC s are coveredin CPR of the ProtocolThe emphasis of this Protocol is the Management ofsuspected anaphylactic shock by public health nursesin non-hospitals settings such as immunizationclinics in schools and in the community. Specifically,this document focuses on the drug Management ofsevere allergic reactions following the administrationof vaccines and other immunizing agents, such astoxoids, immune globulins, antitoxins and diagnostictest solutions such as tuberculin skin DISEASE CONTROLP rotocol for Management of Suspected Anaphylactic ShockSummary of First Steps for Suspected AnaphylaxisSigns and Symptoms:Within minutes signs/symptoms can develop and do not resolve quickly with reassurance and/or re-positioning.

3 These consist of sneezing, coughing, itchiness, pins and needles sensation, flushing, facial edema, hives, anxiety, respiratory difficulties, hypotension, shock or : Call 911 ABCD s of resuscitation Drugs (see Drug Administration Record)Revised November 2007 Drug Management Guidelines forManagement of Suspected AnaphylacticShock in Children and AdultsIn order to carry out appropriate Management , ananaphylaxis kit should be complete and available atthe site and time that immunizing agents are ) If you have not called 911, do it now! ii) Place the patient in supine position with feetelevated as toleratediii) Epinephrine* (adrenaline) 1:1000 aqueoussolution lifesaving: first and most importantdrug to give! Administer mL/kg (maximum mLper injection) intramuscularly (IM) into anun-immunized limb. Injecting epinephrineclose or into the same site as theimmunizating agent is contraindicated as itdilates the blood vessels and may speedabsorption of the vaccine (agent Suspected ofcausing the severe allergic reaction).

4 Administering the epinephrine into a largemuscle, such as the vastus lateralis (thigh)muscle, achieves a more rapid and higherconcentration of epinephrine into the bloodstream compared to other sites. If accessing the thigh muscle is problematic,and the person is older than 12 months ofage, epinephrine can be administered in thedeltoid muscle. If all limbs have been used forimmunizations, epinephrine muststill beadministered to the patient can be administered into amuscle close to the site where theimmunization agent was administered. Aminimum distance of cm (or 1 inch)must be maintained betweenthe injectionsites of the immunization agent and theepinephrine drug. Epinephrine,*at the same dose as the initial one,can be repeatedtwice at 10-15 minute intervalsto a maximum of 3 doses. iv)Diphenhydramine (benadryl) (50 mg/mL) Secondary drug to administer in addition toepinephrine to treat symptoms such as pruritus,erythema, urticaria.

5 Remember: never givediphenhydramine alone or before epinephrine. Administer diphenhydramine once(maximum of 50 mg) intramuscularly (IM).It should be given at a site other than theinoculation. Diphenhydramine should notbe repeated. After administration of the drugs, oxygenshould be administered and an intravenousshould be established, where available. After administration of epinephrine anddiphenhydramine, monitor and documentvital signs (pulse, respiration and bloodpressure if sphygmomanometer available)and reassess the patient frequently untiltransport to the hospital. Note: Although the current literature suggests theadministration of antihistamines, includingH1( , Benadryl) and/or H2( ,ranitidine, cimetidine) as an adjunct therapyto treat anaphylaxis , research is still requiredabout the appropriate dose, timing, routeand frequency of these drugs. Prompt transport is essentialas the onset ofangioedema may result in completeobstruction of the patient s airway.

6 In almostall cases, transport will be done ) Follow-up of a Suspected anaphylactic shockIf and when an anaphylaxis kit is used (trueanaphylaxis or false alarm ), the following stepsare recommended as soon as possible aftermanaging the incident:1. Notify the Public Health Supervisor andMedical Officer of Health by phone foradministrative and medical guidance. Fornon-public health settings, notify theimmediate supervisor and medical Complete the Drug Administration Recordon the lid of the anaphylaxis In the case of vaccine-associated anaphylaxis ,(including other immunizing agentsmentioned in the previous sections of thisprotocol) complete a detailed incident reportfollowing existing policies and procedures setout by the immunization provider semployer/regional health authority; andcomplete the Public Health Agency ofCanada (PHAC) form for Adverse EventFollowing Immunization (AEFI) (unlessincident was a simple faint).

7 4. Ensure anaphylaxis kit is refurbished beforereturning to storage site. The one-way valvebarrier device (used for artificial respiration)should be discarded and Ensure that the patient s current and futurerecord(s) are clearly marked with a history ofa Suspected anaphylactic shock followingimmunization(s).While immunization is rarely associated withanaphylaxis, the appropriate routine pre-immunization screening about predisposing factors(ex: allergy to eggs, drugs such as antibiotics orvaccine ingredients, adverse reactions to previousimmunizations) should minimize you have any questions or comments aboutanaphylaxis Management , please contact your PublicHealth Supervisor or your local Medical Officer ofHealth. Note:Keep the contact information of theseindividual(s) accessible and up to Administration RecordName of Patient: _____ Age: _____ Date: _____Name and location of Clinic: (Adrenalin) 1:1000 aqueous solution:Administer mL/kg (maximum mL perinjection) intramuscularly (IM).

8 Epinephrine, at the same dose as the initial one, can be repeatedat 10-15minute intervals to a maximum of 3 following approximate dosages ( mL/kg)may be used:2 to 6 mL6 to 12 mL12 to 18 mL18 months to 4 mL5 mL6 to 9 mL10 to 13 mL 14 mLEpinephrine (Adrenalin) administered:1st doseAmount:_____ mL(if given)Time: _____Site: _____2nd doseAmount: _____ mL(if given)Time: _____Site: _____3rd doseAmount:_____ mL(if given)Time: _____Site: (Benadryl) (50 mg/mL).Administer intramuscularly (IM). A maximumdose of 50 mg(or mL) at site other than inoculation. See pediatric dosages below. Do Not following approximate dosages may be used:Under age 2 mLAge 2 to 4 mLAge 5 to 11 to mL 12 mLDiphenhydramine (Benadryl) administered:Only One Dose Amount: _____Time: _____Site: _____ 1 Page of Drug Management Guidelines forManagement of Suspected AnaphylacticShock in Children and Adults (taped to theinside of the box lid) 3 x 1 mL ampoules of epinephrine (1:1000aqueous solution) 1 x 1 mL vials of diphenhydramine (50 mg/mL) 3 x 1 mL syringes with safety engineeredneedles* (various lenghts with 25G) 1 pocket mask 5 alcohol swabs Sphygmomanometer (optional) Stethoscope (optional) Up to date contact information for the PublicHealth Supervisor and Medical Officer(s) above Drug Administration Record is to be reproduced and included in each anaphylaxis Kit Each kit should contain the following items.

9 *Length of needle to be selected appropriate to patient size and body mass. Suggest: Needle gauge: 25G, needlelenghts: 3 x 1 ; 3 x 5/8 ; 3 x The kits can be stored at room temperature and should be closed with an elastic to ensure the drugs are notexposed to lightwhich can cause them to deteriorate. Additionally, the kits require regular verification toreplace drugs before the expiry Guide and RecordName of patient: _____ Age: _____ Date: _____Name and location of clinic: _____Immediate Measures for Treatment: Call 911 ABCD s of resuscitation Airway Breathing Circulation DrugsRecording Chart GuideCalled 911 at: _____ (time am/pm)Signs and symptoms(circle pertinent findings) Respiratory:Dyspnea, chest tighness, wheezing, cough, stridor Skin:Urticaria, angioedema, generalized itch, flushing Eye/Nasal:runny nose, red eyes, congestion, sneezing Vascular:Hypotension, chest discomfort, dizziness, syncope, headache Other:Difficulty swallowing, abdominal pain, nausea, emesis, diarrhea, diaphoresis, apprehension Other signs and symptoms: _____Vital SignsRespiration Pulse Blood PressureComments(rate/min.)

10 (rate/min.)The use of the Assessment Guide and Recordis optional since it is expected a detailed incident report as per theexisting policies and procedures set out by the immunization provider s employer/regional health authority; andthe Public Health Agency of Canada (PHAC) form for Adverse Event Following Immunization (AEFI) are tobe completed in the event of a suspect or actual anaphylaxis . References:Amercican Academy of Pediatrics. (2006). RedBook. 2006 Report of the Committee on InfectiousDiseases. (27th ed.). Elk Grove Village, IL: Columbia Communicable Disease ControlImmunization Manual. anaphylaxis Pharmacists Association. (2007).Compendium of Pharmaceuticals and Canadian Drug Reference for HealthProfessionals. for Disease Control and Prevention. (2006).General recommendations on of the Advisory Committee onImmunization Practices. Morbidity and MortalityWeekly Report, 55 (RR-15), , A.