Anaphylaxis Recognition and Out of Hospital Management

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1 Western Canada Immunization Forum Anaphylaxis Recognition and Out of Hospital Management Joy Loewen, Manager Province-wide Immunization Program March 6,

2 Presenter Disclosure Joy Loewen Relationships with commercial interests: Grants/Research Support: Not Applicable Speakers Bureau/Honoraria: Not Applicable Consulting Fees: Not Applicable Other: Not Applicable 2

3 Learning Objective: Be competent at recognition and out-of-hospital treatment of anaphylaxis. Guide for the initial management of a vaccinee who develops a vaccine reaction following immunization in a non-hospital setting e.g. public health or physician or pharmacist clinic 3

4 Immunization Competency: Anticipates, identifies, and manages adverse events following immunization as appropriate to the practice setting, including knowledge of the early recognition and initial management of post-immunization emergencies. 4

5 Today we will review: Signs and symptoms of anaphylaxis How to distinguish between anaphylaxis, vasovagal syncope and anxiety Responding to a post-immunization emergency Use of emergency medications: Epinephrine and Benadryl Additional components of anaphylaxis management 5

6 Anaphylaxis: is a serious potentially life threatening allergic reaction that has been associated with vaccines is a rare post vaccine annual reported rates of anaphylaxis have been documented as range of occurrence of 1-10 episodes per million doses of vaccine administered¹ is treatable in all cases generally occurs as part of a continuum changes develop over several minutes ¹Canadian Immunization Guide, Evergreen edition 6

7 Anaphylaxis: usually occurs within 30 minutes of vaccine administration. should be anticipated with every individual being immunized can be confused with syncope and immunization anxiety Important: In cases of anaphylaxis, the failure to use epinephrine/adrenalin is more dangerous than using it in a situation where anaphylaxis is not truly present. 7

8 Did you know that: Syncope (fainting), anxiety and breath-holding occur more frequently when associated with immunization than anaphylaxis. 8

9 Vasovagal Syncope Caused by a decrease of cerebral blood flow in response to a stimulus Causes a temporary loss of consciousness usually with a sudden onset Not life threatening Rare in children under the age of 3 years 9

10 Signs and Symptoms of Syncope Musculoskeletal Muscles relax (incontinence rare), clonic jerks of limbs and face, dizziness, weakness Respiratory Normal or yawning Dermatologic Pallor/grey color, sweating Gastrointestinal Nausea/vomiting Cardiovascular Hypotension, ringing in the ears, slow weak pulse, dazed / loss of conscious 10

11 Intervention for Syncope Call for help Lie client down in side lying position if nauseated or on back with feet elevated; loosen clothing Note the time Check pulse and respiration Assess level of consciousness Assess for symptoms of allergic reaction Keep warm 11

12 Signs and Symptoms of Immunization Anxiety Pale, diaphoretic Complain of lightheadedness, dizziness, numbness Tingling of the face and extremities Hyperventilation Appear fearful 12

13 Intervention for Immunization Anxiety Reassurance Assess for allergic reaction Rebreathing using a paper bag 13

14 Anaphylaxis An acute hypersensitivity reaction with multi-organ involvement Potentially life threatening Can occur at any age Usually evident in 30 minutes however physiological changes can begin immediately but develop over several minutes and Usually involves at least two body systems Initial signs and symptoms do not necessarily reflect the severity, duration or progression of the reaction 14

15 Cause of Anaphylaxis Antigen-antibody reaction resulting in a release of histamine and other mediators Physiology of Anaphylaxis Capillary permeability results in escape of plasma into tissues Dilation of arterioles and capillaries (vasodilation) Smooth muscle contraction Over-secretion by mucous glands 15

16 16

17 Remember: Anaphylaxis signs and symptoms develop over several minutes By definition involve at least two body systems For example an anaphylactic reaction may involve the skin, respiratory, GI or circulatory systems 17

18 Cardinal Features of Anaphylaxis are: Itchy, urticarial (hive like) rash Progressive, painless swelling about the face and mouth may be proceeded by itchiness, tearing, nasal congestion or facial flushing Respiratory symptoms including sneezing, coughing wheezing, labored breathing and upper airway welling (indicated by hoarseness and/or difficulty swallowing) possibly causing airway obstruction GI symptoms including crampy abdominal pain and vomiting Sudden hypotension or symptoms of end-organ dysfunction 18

19 Signs and Symptoms of Anaphylaxis Respiratory Dyspnea, wheezing, sneezing, choking, drooling, cyanosis, angioedema, tightness in the throat/chest, grunting Dermatologic Urticaria, pruritis, erythema, flushing, pale/grey, facial swelling, tingling of the mouth or face followed by a feeling of warmth Cardiovascular Rapidly falling blood pressure, rapid thready pulse, feeling of uneasiness, restlessness, weakness or dizziness, throbbing in the ears or a headache Gastrointestinal Nausea, vomiting, diarrhea, abdominal cramps 19

20 When one or more of the following symptoms occur, the situation should be managed as anaphylaxis: Progressive painless swelling about the face or mouth New onset of hoarseness or stridor Hypotension/collapse if accompanied by one or more of the following symptoms or if two or more of the following symptoms occur: Rash/hives at the injection site, facial flushing, sneezing/nasal congestion/tearing, lump in the throat, coughing without shortness of breath, vomiting/diarrhea 20

21 Assessment of Anaphylaxis If symptoms are exclusively dermatologic or gastrointestinal...monitor carefully and be prepared to intervene. If the symptoms are respiratory and/or circulatory... call 911 and begin treatment 21

22 Anaphylaxis Intervention Call for help Lie client on back with feet elevated Loosen restrictive clothing around neck and establish an adequate airway Check pulse/respirations and continue to monitor Note the time Assess for symptoms of allergic reaction Assess need for and use epinephrine Assess for level of consciousness 22

23 Management of Anaphylaxis Step 1 through 4 should be done promptly and simultaneously Step 1: Assess (circulation, airway, breathing, mental state, skin) Step 2: Call for assistance, call for an ambulance Step 3: Place patient in recumbent position elevate feet if possible Step 4: Administer epinephrine intramuscularly (0.01 mg/kg body weight of 1:1000 (1 mg/ml) solution Note: Subsequent doses of epinephrine can be administered every 5 to 15 minutes as needed (for a maximum of 3 doses). 23

24 Management of Anaphylaxis Step 6: Stabilize vaccinee (perform CPR if necessary) Step 7: Administer adjunctive treatment (Benadryl) if indicated. Step 8: Monitor vital signs and reassess the situation frequently. Step 9: Transport to an emergency department for observation All clients who receive emergency epinephrine must be transported to a hospital for evaluation and observation as symptoms of anaphylaxis can reoccur after the initial reaction. Note: Record details Report AEFI form Restock anaphylaxis kit 24

25 Management of Anaphylaxis Education / Preparation Written protocol that include Necessary emergency equipment, Epinephrine and Benadryl and dosages Annual review of protocol that includes practice or rehearsal Pre-stocked anaphylaxis management kit All immunizers must have immediate access to an anaphylaxis management kit that contains Epinephrine and Benadryl. Anaphylaxis management kits must be checked prior to immunization clinics to ensure they are complete and Epinephrine and Benadryl are not expired. If an anaphylaxis management kit is used to manage anaphylaxis it must be removed from the clinic setting and be restocked 25

26 Management of Anaphylaxis Observation Period Post-Immunization: Advise vaccine recipients to remain in waiting area for at least 15 minutes after immunization Advise vaccine recipients who have had a anaphylactic reaction to any other agent to wait for 30 minutes post immunization. 26

27 Prevention of Anaphylaxis: Pre-immunization screening for: history of anaphylaxis to vaccines in particular the vaccine to be administered or to any components of the vaccine history of severe allergies to other agents 27

28 Contents of an Anaphylaxis Management Kit List of recommended contents can be found in the Canadian Immunization Guide, Evergreen edition Recommended Dosages for Epinephrine and Benadryl Dosage for Epinephrine and Benadryl by age can be found in the Canadian Immunization Guide, Evergreen edition 28

29 Syncope versus Anaphylaxis What is the key difference between vasovagal syncope and anaphylaxis? Key difference is rapidity of onset Fainting has a more sudden onset Anaphylaxis generally has a gradual onset or changes develop over several minutes (as part of a continuum) 29

30 Management of Anaphylaxis In summary: Anaphylaxis is a medical emergency therefore rapid recognition and management is essential. Immunizer must know the signs and symptoms of anaphylaxis and be prepared to act! Anaphylaxis is a serious potentially life threatening allergic reaction that has been associated with vaccines however it is rare post vaccine Anaphylaxis is treatable in all cases 30

31 References: National Advisory Committee on Immunization. (2012). Canadian immunization guide (Evergreen Edition). Ottawa, ON: Public Health Agency of Canada. Alberta Health, Acute Care and Population Health Division, Adverse Events Following Immunization (AEFI) Policy for Alberta Health Services, Public Health (2014, January). Rϋggeberg, J.U., et al and The Brighton Collaboration Anaphylaxis Working Group. (2007). Anaphylaxis: case definition and guidelines for data collection, analysis, and presentation of immunization safety data. Vaccine. doi: /j.vaccine British Columbia Centre for Disease Control, Management of Anaphylaxis in a Non-Hospital Setting, April 2013 Communicable Disease Control Immunization Program. Sampson, H.A. et al. (2006). Second symposium on the definition and management of anaphylaxis: summary report - Second national institute of allergy and infectious disease/food allergy and anaphylaxis network symposium. Journal of Allergy and Clinical Immunology; 117(2),

32 Questions? 32

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