Emergency Treatment of Anaphylactic Reactions

Transcription

1 Emergency Treatment of Anaphylactic Reactions Authorising Officer Signature Of Authorising Officer: Tom Cahill, Deputy Chief Executive Version: V3 Ratified By: HPFT Drugs and Therapeutic Committee Date Ratified: 19 th January 2009 Name of originator/author: Practice Standards Facilitator Name of responsible committee/lead Lead Nurse Strategy Group individual: Date issued: March 2009 Review date: April 2011 Type Clinical Summary: Recognition of and first aid treatment for anaphylactic reactions. Target audience: All medical staff and registered nurses and pharmacists. Hertfordshire Partnership NHS Foundation Trust is committed to providing an environment where all staff, service users and carers enjoy equality of opportunity. The Trust works to eliminate all forms of discrimination and recognise that this requires, not only a commitment to remove discrimination, but also action through positive policies to redress inequalities. Providing equality of opportunity means understanding and appreciating the diversity of our staff, service users & carers and ensuring a supportive environment free from harassment. Because of this Hertfordshire Partnership NHS Foundation Trust actively encourages its staff to challenge discrimination and promote equality of opportunity for all.

2 CONTENTS: Section Page Overview of Procedure for the treatment of anaphylactic reactions 3/4 1 Introduction 5 2 Purpose 5 3 Standards for the Treatment of Anaphylaxis 5 4 Cautions 8 5 Further Treatment and aftercare 8 6 Self Medication 8 7 Storage of adrenaline 8 8 Immunisation 8 9 Triggers and the recording of alerts Adverse Reactions/Incidents/Medication Errors Responsibilities Training Consultation, Approval and Ratification Process Process for monitoring compliance with this document Process for reviewing, approving and archiving this document Dissemination, Implementation and Access to this document References Associated Documentation 11 Equality Impact Assessment Stage One 12 Version Control Version Date Author Status Comment V1 Nov 2003 P Crosby Superseded Archived V2 Nov 2006 P Crosby Superseded Archived V3 March 09 P Crosby Current Agreed by Trust Executive Comments and Feedback on this document were obtained from: Medicine Management Team Drugs and Therapeutic Committee Members of the Lead Nurse Strategy Group Members of the Equality Impact Assessment Scrutiny Group Page 2 of 14 March 2009

3 Initial treatment for an anaphylactic reaction The Emergency Services/Resuscitation Team must be called without delay

4 Treatment for an anaphylactic reaction if skills and equipment are available The Emergency Services/Resuscitation Team must be called without delay NB: Within HPFT Intravenous adrenaline may only be administered by a medical practitioner, it is a hazardous procedure and requires a different strength of injection. Page 4 of 14 March 2009

5 1. Introduction Anaphylaxis is the term used to describe a severe, life-threatening, generalised or systemic hypersensivity reaction (anaphylactic reaction). This is characterised by rapidly developing life-threatening airway and/or breathing and/or circulation problems usually associated with skin and mucosal changes. There is a broad range of triggers but those most commonly identified include, a reaction to a drug anaesthetic agents, antibiotics, vaccines, a reaction to some foods e.g. nuts or following an insect sting. Direct care staff must be aware that anaphylaxis can occur and that in the UK incidents of anaphylactic reactions is rising. This is an emergency situation which can in severe cases causes rapid deterioration and death and first aid treatment must be given without delay. This document is based on the Resuscitation Council (UK) Guidance Emergency treatment of anaphylactic reactions January 2008 and the Joint Committee on Vaccination and Immunisation, January Immunisation Against Infectious Disease (Green Book) HMSO. This procedural document replaces the previous policy titled Responding to Anaphylactic Shock for First Responders. 2. Purpose This procedural document is written for medical and nursing staff to ensure an effective response when providing first aid treatment for an anaphylactic reaction. First aid treatment includes the administration of adrenaline (also known as epinephrine) which requires additional training by the nurse to ensure competency. For further information refer to the Resuscitation Council (UK) Guidance Emergency treatment of anaphylactic reactions January Standards for the Treatment of Anaphylaxis The response outlined below is that recommended by the Resuscitation Council and adapted to meet the circumstances within the Trust. They indicate the course of action by a registered nurse until medical/emergency service assistance is available. Sudden onset and rapid progression of symptoms The service user will feel and look unwell. Most reactions occur over several minutes. Rarely, reactions may be slower in onset. The time of onset of an anaphylactic reaction depends on the type of trigger. An intravenous trigger will cause a more rapid onset of reaction than stings which, in turn, tend to cause a more rapid onset than orally ingested triggers. The service user is usually anxious and can experience a sense of impending doom

6 Treatment of an anaphylactic reaction Reassure the service user. Call for emergency medical assistance depending on the procedure for the unit. For emergencies in the community call the emergency services. All staff must know how to summon emergency assistance. Duty doctor to be informed as soon as possible. Service user positioning All service users should be placed in a comfortable position. The following factors should be considered: Service users with Airway and Breathing problems may prefer to sit up as this will make breathing easier. Lying flat with or without leg elevation is helpful for service users with a low blood pressure (Circulation problem). If the service user feels faint, do not sit stand them up - this can cause cardiac arrest. or Service users who are breathing and unconscious should be placed on their side (recovery position). Pregnant service users should lie on their left side to prevent caval compression. Remove the trigger if possible Removing the trigger for an anaphylactic reaction is not always possible. Stop any drug suspected of causing an anaphylactic reaction. Remove the stinger after a bee sting. Early removal is more important than the method of removal. After food-induced anaphylaxis, attempts to make the service user vomit are not recommended. Do not delay definitive treatment if removing the trigger is not feasible. Treat with Adrenaline. Adrenaline is the most important drug for the treatment of an anaphylactic reaction. If available, give adrenaline injection 500 micrograms IM (0.5 ml 1:1000 solution) by intramuscular injection. (the preferred site is the artero-lacteral aspect of the middle third of the thigh) The following doses are those given by the British National Formulary. Page 6 of 14 March 2009

7 Dose of Adrenaline for Adults and Adolescents (above 12 years) 500 micrograms IM (0.5 ml 1:1000 solution) (For the dose for children 12 years and under refer to the flowchart on page 3 and 4 of this policy.) For Adrenaline auto-injectors, e.g. Minijet or EpiPen, refer to product information on administration. NB: Should mis-diagnosis occur administration of adrenaline intramuscularly is unlikely to have harmful effects. Repeat the IM adrenaline dose if there is no improvement in the service user s condition. Further doses can be given at about 5-minute intervals according to the service user s response. In an emergency, nurses who have been trained in the recognition and treatment of anaphylaxis may give an unprescribed adrenaline injection 500 micrograms IM (0.5 ml 1:1000 solution) by INTRAMUSCULAR INJECTION only, for the emergency treatment of anaphylaxis. This injection may be repeated in 5 minutes if there has been no clinical improvement in the service user s condition. Services should carry out a risk assessment to decide whether a stock of adrenaline should be available for emergency use. Units where treatment is administered by intramuscular injection on a regular basis, should hold a stock of Adrenaline 500 micrograms IM (0.5 ml 1:1000 solution) ampoules with appropriate needles and syringes. NOTE: Adrenaline should not be given subcutaneously as it takes too long to absorb. Intravenous adrenaline is only administered by a medical practitioner, is a hazardous procedure and requires a different strength of injection. Administer Oxygen If available, administer oxygen at a high flow rate using an oxygen mask with an oxygen reservoir. Ensure that the oxygen flow is sufficient (10-12 litres per minute) to prevent collapse of the reservoir during inspiration until emergency assistance arrives. Maintain clinical observations for condition of the skin, pulse rate, blood pressure, respiratory rate and effort. The dose of adrenaline should be repeated in 5 minutes if there is no clinical improvement. Commence cardiopulmonary resuscitation if total collapse occurs. Monitor Monitor the service user as soon as possible (pulse, blood pressure, ECG, pulse oximetry) Page 7 of 14 March 2009

8 Cardiorespiratory arrest following an anaphylactic reaction Start cardiopulmonary resuscitation (CPR) immediately and ensure that help is on its way. The intramuscular route for adrenaline is not recommended after cardiac arrest has occurred. Further interventions The further interventions outlined in the algorithm on page 3 and 4.will require intervention by medical staff 4. CAUTIONS 4.1 Special Populations The Resuscitation Council has set out the following guidance: Previous guidelines recommended adrenaline dose adjustments in certain circumstances (e.g., in patients taking tricyclic antidepressants, the previous recommendation was to give half the dose). The Working Group considered it unhelpful to have caveats such as this in the setting of an acute anaphylactic reaction. There is large inter-individual variability in the response to adrenaline. In clinical practice, it is important to monitor the response; start with a safe dose and give further doses if a greater response is needed, i.e., titrate the dose according to effect. Adrenaline can fail to reverse the clinical manifestation of an anaphylactic reaction, especially when its use is delayed or in patients treated with beta-blockers. The decision to prescribe a beta-blocker to a patient at increased risk of an anaphylactic reaction should be made only after assessment by an allergist and cardiologist. 4.2 Cocaine The Joint Committee on Vaccination and Immunisation, 2006, Chapter 8, "Vaccine Safety, and the Management of Adverse Events Following Immunisation" page 60, gives the following advice. Although cocaine may interact with the actions of adrenaline, anaphylaxis is sufficiently rare to not recommend either withholding immunisation from known users or undertaking routine questioning about recreational drug use in individuals attending for vaccination. In the unlikely event of collapse in someone who is suspected of having recently taken cocaine, adrenaline should be used only with extreme caution and using half the normal adult dose. 5. FURTHER TREATMENT AND AFTERCARE All service users who suffer an anaphylactic reaction should attend an acute hospital following the incident. Page 8 of 14 March 2009

9 5.1 Transfer to acute hospital The emergency services should be given the following information. A written record should accompany the service user which provides the following information: A description of the reaction with circumstances and timings to help identify potential triggers. A list of administered treatments. All actions taken must be recorded in service user's care record. 5.2 Aftercare The service user should be warned of the possibility of recurrence of symptoms and inpatients should be kept under observation for 8-24 hours and the GP notified of the incident on discharge. The Resuscitation Council advises that the service user is referred by the GP for investigation and follow-up by an allergy specialist. 6. SELF MEDICATION Service users who are known to be hypersensitive may carry a pre-filled adrenaline syringe e.g. an EpiPen for adults or an EpiPen Jr for children. They need to be instructed in advance on how to inject it. These devices contain a single dose for use in an emergency. Service users who are prone to attacks should be encouraged to wear a medialert to provide this information to first responders. 7. STORAGE OF ADRENALINE Adrenaline must be stored away from light and replaced before the expiry date. Units which carry a stock of adrenaline injection should check the ampoules regularly for discoloration. If there is any pink or brown colour present, the ampoules should be replaced even if they have not reached the expiry date. As with all drugs, if staff need to carry a stock of adrenaline it must be carried in a locked receptacle in the locked boot of a car for safety reasons. 8. IMMUNISATION 8.1 Immunisation must not be undertaken unless a stock of adrenaline 1 in 1000 for intramuscular injection is available. An anaphylaxis kit, including adrenaline 1 in 1000 for intramuscular injection, needles for intramuscular injection, graduated 1 ml syringes or prefilled syringes and a pocket mask must be available at all immunisation sessions. Packs should be checked regularly to ensure contents are within their expiry dates. 8.2 Nurses who undertake immunisations must know the dosage of adrenaline appropriate for their client group. 8.3 Where an immunisation is to be administered, in addition to the individual prescription of a vaccine, the service user must have a prescription for adrenaline 500 micrograms IM (0.5 ml 1:1000 solution) for intramuscular injection for use in the event of anaphylactic shock. Page 9 of 14 March 2009

10 8.4 In some situations where groups of service users may not be individually identified before presentation for immunisation for example, CDAT clinics, a Patient Group Direction (PGD) may be in force for the administration of adrenaline in an identified clinical situation. For further information refer to the HPFT Patient Group Direction Policy. 9. Triggers and the recording of alerts 9.1 Most anaphylactic reactions occur in individuals who have no known risk factors making it difficult to advise on special precautions. The possibility of sensitivity to injections will have been considered by the prescriber but there is no way of predicting who will react, other than by a previous history of a reaction to this or another, possibly related, preparation. 9.2 Where it is known that an individual may have a hyper-sensitivity reaction to a substance, this must be recorded on the designated Alert section of the care record/electronic patient record and the allergy section on the prescription card, which is always accessible to all clinical staff. This will ensure that in an emergency there is no opportunity for confusion or dependency on other people to provide information. The entry should include other information relevant to all health care professionals and be signed and dated. 10 Adverse Reactions/Incidents/Medication Errors a) The incident to be reported under the Hertfordshire Partnership NHS Trust "Learning from Adverse Events Policy" followed. b) Doctors, pharmacists and nurses should report adverse reactions to drugs to the Medicines and Healthcare Products Regulatory Agency (MHRA) via prepaid yellow cards for reporting at the back of the BNF or electronically on: Also advise the supplying pharmacy and the District Immunisation Coordinator of adverse reactions to vaccines. c) Following a response to an anaphylactic attack, staff should take time to reflect on practice and discuss whether any changes to practice are required. 11. Responsibilities All medical and nursing staff must be aware of their responsibilities within this policy and ensure that they have attended the appropriate training and maintain the competency required for their role. 12. Training 12.1 All Registered nurses who administer vaccines must be familiar with the steps necessary to respond to anaphylactic reaction and have undertaken basic life support training which includes training in the recognition and treatment of anaphylaxis as a minimum and have attended refresher courses to ensure up-to-date practice It is advisable that registered nurses who administer parenteral medication have training in responding to anaphylactic reactions Training in the emergency treatment of anaphylactic reactions is part of the HPFT Immediate Emergency Care and Basic Life Support training. Refer to the Trust Mandatory Training Programme for further details. Anaphylaxis training slides are available on the staff internet. Page 10 of 14 March 2009

11 Members of staff can also access e-learning on (The user name is the name which will appear on the certificate using the correct upper and lower case and the password is anaphylaxis) 13. Consultation, Approval and Ratification Process This policy has been circulated for comments within Trust services. The document will be approved by the Trust Drugs and Therapeutic Committee and accepted as an organisation-wide policy by the Trust Executive Committee Process for monitoring compliance with this document Incidents of anaphylactic reactions are rare and will be monitored via the Learning from Adverse Events Policy procedure and notified to the Head of Medicines Management/Head of Nursing as appropriate. 15. Process for reviewing, approving and archiving this document This document will be reviewed annually or whenever national policy, guideline or changes require to be considered (whichever occurs first), by the author and agreed by the HPFT Drugs and Therapeutic Committee. All procedural documents are retained and achieved as set out in the Trust document, The development and management of procedural documents. 16. Dissemination, Implementation and Access to this document This policy is disseminated throughout the Trust following ratification via the policy guardians. and will be published on the HPFT staff website. Access to this document is open to all via the Trust public website. The Clinical Leads/Ward Managers/Team Leaders must discuss the policy within teams to ensure awareness of this policy and clearly defined responsibilities for its implementation. Any persistent problem areas which need addressing through further development of the protocol to be reported to the author and areas of unmet need discussed with line manager. 17. References The Resuscitation Council (UK), (revised January 2008) The Emergency Treatment of Anaphylactic Reactions, Guidelines for Healthcare Providers, Health Protection Agency, (2005) National Minimum Standards for immunisation training. British National Formulary Joint Committee on Vaccination and Immunisation,. Immunisation Against Infectious Disease (Green Book), (January 2006), Chapter 8 Vaccine Safety, and the Management of Adverse Events Following Immunisation, HMSO NHS Immunisation website Associated Documentation This procedural document should be used in conjunction with the following HPFT policies all of which are available on the HPFT staff website Page 11 of 14 March 2009

12 Learning from Adverse Events Policy Medicines Policy Immunisation Policy Patient Group Directions Policy Management of Care Records Policy Page 12 of 14 March 2009

13 Equality Impact Assessment (EIA) Stage 1 Policy or service being assessed Emergency Treatment of Anaphylactic Reactions Summary of Policy: This document is written for medical and nursing staff when providing first aid treatment for an anaphylactic reaction. Anaphylaxis is the term used to describe a severe, life-threatening, generalised or systemic hypersensivity reaction. This is characterised by rapidly developing life-threatening airway and/or breathing and/or circulation problems usually associated with skin and mucosal changes. Lead Person: Pamela Crosby, Practice Standards Facilitator Date of Assessment: November Is this a new or existing policy or service? 2. What is the expected outcome of the service/policy (e.g. aims, objectives and purpose of the service/policy, standards for practice) New: 3. Does this policy/service link to others? If Yes: X yes please state link below: Medicines Policy, Administration of Oxygen, Immunisation policy. 4. Does the Policy/Service show that the 11 Yes: X principles of mental health recovery have been taken into account? Existing: X An effective response when providing first aid treatment for an anaphylactic reaction. If yes, please give evidence: Links to recovery principle 10 - Recovery is evidence based and effective: We will ensure that the recovery-oriented health, social care and social inclusion services are provided in ways that are helpful, knowledgeable, timely, consistent and informed by evidence from lived experience, formal research and other valid sources. 5. Who is intended to benefit from the policy/service: In what way. 6. How is the policy/service to be put into practice? Who is responsible? 7. How and where is information about the policy/service publicised? 8. What regular consultation do you carry out with different communities and groups re the policy/service? 9. Are there concerns that the policy/service could have an adverse impact* because of: Age Disability Gender Ethnicity Sexual Orientation Religion/Belief 10. If YES to one or more of the above please state evidence. 11. Do the differences amount to discrimination?* 12. If YES could it still be justifiable e.g. on grounds of promoting equality of opportunity for one group? I.e. Indirect discrimination can be justifiable sometimes when a service is being provided for a particular target group E.g. Asian women s breast Page 13 of 14 March 2009 No: No: Service users and carers are assured of an effective response to a reaction. The policy is to be followed by all medical and nursing staff. Available on the staff website and staff training on responding to anaphylactic reactions. The policy discussed at the Lead Nurse and Drugs and Therapeutic committees. Yes: N/A Yes: Yes: No: X No: N/A No: N/A

14 screening, Gay men s sexual health clinic, Mental Health Services for Older People etc. If Yes: Please give reasons below: N/A 13. Do you think this policy/service specifically contributes to promoting equality and diversity in Hertfordshire? If so, in what way? Please note any examples of good practice. 14. What approaches will you take to get feedback on your assessment? 15. How will the assessment link to other mainstream service planning or review processes? 16. Should there now be a Full Impact Assessment and if so what are the reasons? 17. What further data, information or assistance do you need to carry out a full assessment? No specific contribution. Feedback from EIA scrutiny group. The assessment links to emergency care planning. There is no evidence in stage one that a full impact assessment is required. N/A Agreed by the EIA Scrutiny group on Page 14 of 14 March 2009