Emergency Treatment of an Anaphylactic Reaction in the Community Protocol

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1 Emergency Treatment of an Anaphylactic Reaction in the Community Protocol Reference Number: NHSCT/09/216 Responsible Directorate: Children s Services Replaces (if appropriate): Northern Trust Departmental Protocol for the Management and Treatment of Anaphylaxis in the Community NHSCT/08/24 Policy Author/Team: Type of document: Maeve McGuigan, Lead Public Health Nurse Ashley Ramsay, Assistant Community General Manager Marion Bryson, Health Protection Nursing Service Lorraine Calvert, School Nursing Team Leader Lorna Murphy, School Immunisation Co-ordinator Lorraine Henry and Ann Maybin, Health Visiting Managers Joan Duncan, Community Children s Nurse Approved by: Policy, Standards and Guidelines Committee Corporate Protocol Date Policy disseminated by Equality Unit: 20 October 2009 Date Approved: 10 September 2009 NHSCT MISSION STATEMENT To provide for all the quality of services we would expect for our families and ourselves 1

2 Emergency treatment of an anaphylactic reaction in the Community Protocol 2

3 INTRODUCTION Episodes of anaphylactic reaction appear to be increasingly common and have been strongly associated with the increasing prevalence of allergy type illnesses over the last two or three decades (Resuscitation Council (UK), 2008 It is recognized that the treatment of anaphylaxis continues to be variable and there is a need for a consistent approach which draws together relevant and appropriate expertise as provided by the Resuscitation Council (UK), PURPOSE OF PROTOCOL This protocol outlines procedures and practices within the Northern Health & Social Care Trust (NHSCT) for registered nursing staff (see nursing staff groups below) who are expected to deal with anaphylactic reactions during their usual clinical role, working in community hospitals/settings,gp practices and schools. Nursing Staff Groups included are: Community Adult Nursing Public Health Nursing-School Nursing, Health Visiting and Health Protection Nursing Services Community Paediatrics DEFINITION OF ANAPHYLAXIS Anaphylaxis is a severe, life threatening, generalised or systematic hypersensitivity reaction characterised by rapidly developing life threatening airway and/or breathing and/or circulation problems usually associated with skin and mucosal changes. Resuscitation Council (UK) 2008 MANAGEMENT OF ANAPHYLACTIC REACTIONS The minimal level of care that any patient with an anaphylactic reaction should expect to receive includes: Recognition that they are seriously unwell Early call for emergency help Initial assessment and treatments based on ABCDE approach Adrenaline (Epinephrine) therapy if indicated Investigation and follow up by an allergy specialist When dealing with an anaphylactic reaction within the community it is vital to call for a Paramedic ambulance immediately by dialling do not leave the patient alone unless absolutely necessary. Patients should be positioned according to their presenting condition. If they have respiratory difficulty then they may prefer to sit upright. If they have low blood 3

4 pressure lay down with their legs elevated. If they are unconscious and breathing they should be placed on their left side to prevent caval compression. If possible the trigger should be removed, but this is not always possible. NB Where a patient /child is found to be unresponsive, not breathing or has no pulse present, cardio pulmonary resuscitation (CPR) must be commenced. The algorithm for the management of anaphylactic reactions produced by the Resuscitation Council (UK) is contained within Appendix 1 and details regarding the emergency adrenaline pack is contained within Appendix 2. In an anaphylactic emergency situation, which requires life saving measures, consent, by the patient, to the administration of IM Adrenaline (Epinephrine) is not required. IM Adrenaline (Epinephrine) can be administered without a doctor s prescription in such an emergency situation in accordance with a Patient Group Direction (Appendix 3). Adrenaline (Epinephrine) auto-injectors (Epipen,Anapen) Auto-injectors are often given to patients at risk of anaphylaxis for their own use. At the time of writing, there are only two doses of Adrenaline (Epinephrine) auto-injector commonly available: 0.15 and 0.3 mg. Allergy specialists should prescribe the most appropriate dose of an auto-injector for individual patients. Staff should be familiar with the use of the most commonly available auto-injector devices. The dose recommendations for Adrenaline (Epinephrine) in this protocol are intended for staff treating an anaphylactic reaction. If an Adrenaline (Epinephrine) auto-injector is the only available Adrenaline (Epinephrine) preparation when treating anaphylaxis, staff should use it. Resuscitation Council (UK) 2008 Emergency Adrenaline (Epinephrine) Pack Emergency pack will be available to all staff that is administering any drug. These staff must have completed a training course on anaphylaxis, and have annual update. These staff must have signed a copy of the relevant Patient Group Direction. Emergency pack contents are detailed within Appendix 2. Each staff member is accountable and responsible for ensuring that his or her individual Adrenaline (Epinephrine) pack is fully equipped, stored securely at all times and that drugs are in date. Adrenaline (Epinephrine) packs should not be left with individual patients but taken by the staff member on all visits if required. Adrenaline (Epinephrine) must not be stored for long periods in places of extremes temperature such as the car and should be protected from the light. 4

5 Age Dose of Adrenaline (Epinephrine) 1:1000 BP Under 6 months 0.15ml (150 micrograms) 6 months 6 years 0.15ml (150 micrograms) 6-12 years 0.3ml (300 micrograms) Child more than 12 Years 0.5ml (500 micrograms) (use 0.3ml (300micrograms) if child small or prepubertal) Adult 0.5ml (500 micrograms The best site for IM injection is the anterolateral aspect of the middle third of the thigh.for IM injections, the needle needs to be long enough to ensure that the drug is injected into the muscle. Standard UK needle gauges and lengths Blue needles (25mm,23G) are best and are suitable for all ages. Use orange needles (16mm or 25mm, 25G) for pre-term or very small infants. IM injections should be given with the needle at a 90º angle to the skin. The skin should be stretched, not bunched. Resuscitation Council (UK) Frequency of administration Repeat the IM adrenaline (Epinephrine) dose if there is no improvement in the patient s condition. Further doses can be given at about 5-minute intervals according to the patient s response. Resuscitation Council (UK) Records All incidents of anaphylactic reaction must be recorded in patient s records and an incident form completed. The line manager must be informed as soon as is practically possible. All cases of adverse drug reactions including anaphylaxis should be reported to the Medicines and Healthcare Products Agency (MHRA) using the Yellow card scheme The British National Formulary (BNF) includes copies of the Yellow card at the back of each edition. All anaphylactic reactions should be reported to the patient s GP or inpatient doctor for follow up to a specialist allergy clinic. Resuscitation Council (UK) Web site Link for Emergency Treatment of Anaphylactic Reactions The key steps for the treatment of an anaphylactic reaction are shown in the algorithm in Appendix 1 The standard emergency packs that must be carried by staff are detailed in Appendix 2 5

6 TRAINING Staff employed by NHSCT who are expected to deal with anaphylactic reactions during their usual clinical role, must attend annual mandatory Life Support and Anaphylaxis Training appropriate to their field of practice. REFERENCES Emergency treatment of anaphylactic reactions Guidelines for healthcare providers Working Group of the Resuscitation Council (UK), January 2008 Published by the Resuscitation Council (UK). 6

7 Appendix 1 Repeat the IM adrenaline (Epinephrine) dose if there is no improvement in the patient s condition. Further doses can be given at about 5-minute intervals according to the patient s response. NB Where a patient /child is found to be unresponsive, not breathing or has no pulse present, cardio pulmonary resuscitation (CPR) must be commenced. 7

8 TREATMENT OF ANAPHYLAXIS EMERGENCY PACK Appendix 2 SECTION CONTENTS BATCH NO/ EXPIRY DATE ONE 1 amp Adrenaline (Epinephrine) Injection 1mg in 1ml (1 in 1000) Needles 1 filter needle, 2 blue needle, 2 orange needle 1 Syringe (2ml) 1 Syringe (1ml) TWO 2 amps Adrenaline (Epinephrine) as above Needles 1 filter needle, 2 blue needle, 2 orange needles 2 x 2ml Syringes 2 x 1ml Syringes THREE Gloves 3 pairs Spare Needles / including filter needle Syringes x 4 (1 ml) Laerdal Pocket Mask/Adult/Paediatric Alcotip swabs Sharps box NB - All emergency packs must be laid out as directed above for expediency in the event of an emergency. The above proforma must be completed on a monthly basis to ensure drugs are within the expiry date and a record kept at local level. 8

9 Appendix 3 Supply and Administration of Medicines. Patient Group Direction (PGD) for administration of Adrenaline (Epinephrine) for emergency use in the event of an Anaphylactic Reaction in adults and children. 9

10 Adrenaline (Epinephrine) injection 1:1000 BP Clinical Condition Indication STAFF GROUP Emergency treatment of anaphylaxis Community Adult Nursing Services Public Health Nursing Services i.e. School Health, Health Visiting and Health Protection Nursing Services and Community Paediatrics Professional Qualification: Part 1 of NMC Register Children s or Adult Training/Experience: NMC Guidelines for the Administration of Medicines Completed the course approved by NHSCT on Life Support, Anaphylaxis and Immunisation Demonstrate that this has been updated annually VALIDITY OF PGD Valid from: 18 th September th September 2011 To be reviewed: June 2011 THE DRUG Name of Product: Adrenaline (Epinephrine) Injection BP 1in 1000 (1mg/1ml) Manufacturer: Hameln Legal Status: POM Route of administration: Intramuscular - slowly Dose to be Administered: Age Dependant as Follows: Age Dose of Adrenaline (Epinephrine) 1:1000 BP Under 6 months 0.15ml (150 micrograms) 6 months 6 years 0.15ml (150 micrograms) 6-12 years 0.3ml (300 micrograms) Child more than 12 Years 0.5ml (500 micrograms) (use 0.3ml (300micrograms) if child small or prepubertal) Adult 0.5ml (500 micrograms (Resuscitation Council (UK) Jan 2008) Frequency of administration: Repeat the IM adrenaline (Epinephrine) dose if there is no improvement in the patient s condition. Further doses can be given at about 5-minute intervals according to the patient s response. Resuscitation Council (UK)

11 Preferred Injection Site The best site for IM injection is the anterolateral aspect of the middle third of the thigh. The needle used for injection needs to be sufficiently long to ensure that the adrenaline is injected into muscle. A 25mm needle is best and is suitable for all ages. In pre-term or very small infants, a 16mm needle is suitable for IM injection. In some adults, a longer length (38 mm) may be needed. Standard UK needle gauges and lengths Brown 26G 10 mm Orange 25G 16 mm or 25 mm Blue 23G 25 mm Green 21G 38 mm Give IM injections with the needle at a 90º angle to the skin. The skin should be stretched, not bunched. Actions and documentation to be completed If an event requiring intervention or treatment occurs notify the person with parental responsibility /school principal /GP as soon as possible. Complete NHSCT incident form before the end of the working day and submit to line manager. All adverse drug reactions that include an anaphylactic reaction should be reported to the Committee on the Safety of Medicines on yellow cards Record details in child s /patient record as follows 1. Date, time, location 2. Dosage/s of Adrenaline (Epinephrine) administered 3. Batch number, expiry date and manufacturer 4. Injection site 5. Presumptive cause of anaphylaxis 6. Name and status of person administering Adrenaline (Epinephrine) 7. Details of child s condition, and any other actions taken regarding emergency care. STORAGE OF ADRENALINE Store at less than 25 c and protected from light 11

12 INCLUSION CRITERIA/CLIENT GROUP Any person (adult or child) presenting with symptoms of anaphylaxis. Although there is a spectrum of signs & symptoms, anaphylaxis is likely if the following are present: Acute onset of illness (usually within minutes of exposure to allergen) Skin or mucosal changes Life threatening Airway and/or Breathing and/or Circulation Problems: Airway e.g. swelling, hoarse voice, stridor Breathing e.g. fatigue, rapid breathing, wheeze, shortness of breath, confusion, cyanosis Circulation e.g. pale, clammy, faintness, shock, tachycardia, hypotension, decreased consciousness. Patients with anaphylaxis may also have other symptoms, including gastrointestinal (abdominal pain, incontinence) and or neurological (anxiety, confusion, etc). For further details, please see national guidelines from the Resuscitation Council. EXCLUSION CRITERIA PATIENT ASSESSMENT AND TREATMENT POSSIBLE ADVERSE REACTIONS TO ADRENALINE PERSONNEL/ FACILITIES/ SUPPLIES WHICH MUST BE IMMEDIATELY AVAILABLE There are none Call for an Paramedic Ambulance- (dial 999) Use the ABCDE approach to recognise and treat anaphylaxis as per algorithm in Appendix 4 Airway: secure the airway o Breathing: administer oxygen treatment if available (high flow 10-15l/min). o Circulation: if low BP lay patient flat and raise legs (if breathing not impaired) Give Intramuscular Adrenaline (Epinephrine) if there are lifethreatening features present. The following adverse reactions may occur Anxiety and tremor, Headaches /nausea/vomiting Weakness/dizziness, Hypertension Tachycardia/cold extremities/pulmonary oedema) Arrhythmias,, Palpitation,,Hyperglycemia, Hypertension, Urinary retention,,dyspnoea NOTE: Protocol & PGD Adrenaline must be easily accessible for staff. Paramedic Ambulance must be requested (Dial 999) Emergency pack (in community settings) Contact on call GP (if in treatment room setting) Emergency Drug box (in treatment rooms) 12

13 Appendix 4 Repeat the IM adrenaline (Epinephrine) dose if there is no improvement in the patient s condition. Further doses can be given at about 5-minute intervals according to the patient s response NB Where a patient /child is found to be unresponsive, not breathing or has no pulse present, cardio pulmonary resuscitation (CPR) must be commenced. 13

14 PGD/Adrenaline The Pharmacy department and Policy Standards Committee have approved the PGD/Adrenaline as per protocol. However we have been advised that the signed PGD should not be inserted on protocol documents on the intranet. For original signed copy please contact: Professor Scott, Head of Pharmacy and Medicines Management, Pharmacy Department, Antrim Area Hospital, Bush Road, Antrim, BT41 2RL Managers must authorise nursing staff by name under a signed PGD before staff work to it This Patient Group Direction has been approved for use in the NHSCT by: Head of Pharmacy and Medicines Management Prof Scott Date (Signature) Deputy Medical Director: M. Mannion Date (Signature) Director of Nursing: Date (Signature) Head of Pharmacy and Medicines Management Patient Services M. Hetherington Date (Signature) Deputy Head of Pharmacy and Medicines Management Patient Services D Trimble: Date (Signature Consultant Paediatrician D Walsh: Date (Signature) Nurse: I have received training in all aspects of immunization, including the contra-indications to specific vaccines and the treatment of anaphylactic reaction including CPR. I am willing to perform this duty in accordance with the conditions laid down in this protocol and in accordance with the current Resuscitation Guidelines. Signature of nurse Date Copy sent to manager Date of Review of Patient Group Direction July 2011 Ref: Summary of Product Characteristics 22 May 2009 BNF 57 th Edition March 2009.Emergency Treatment of Anaphylactic Reactions Guidelines for Healthcare Providers Working Group of the Resuscitation Council (UK) January

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