Managing Life-Threatening Allergies in School Prepared by the Hanover Public Schools Health Services Department March 18, 2010
Goals of the Presentation To understand the significance of life threatening allergies. To learn the pathophysiology and treatment of anaphylaxis, including EpiPen administration. To understand the challenges schools face everyday when there are children in school with life threatening allergies.
What is a Life-Threatening Allergy? People with allergies have over-reactive immune systems that react to otherwise harmless elements of our diet and environment. During an allergic reaction, a sequence of events in the cells of the immune system occurs resulting in the release of chemical mediators such as histamine. This triggers inflammatory reactions in the tissues of the skin, respiratory system, gastrointestinal tract and the cardiovascular system. When symptoms are wide-spread and systemic, the reaction is termed anaphylaxis, a potentially life-threatening event.
Examples of LTA A student with a milk allergy walks near the cafeteria where milk is being steamed and inhales the airborne milk protein, which causes hives, swelling and respiratory distress. A student with a peanut allergy is in his classroom and complains of itchy, swollen eyes and a tight chest only to discover later that the arts and craft products in the classroom contain peanuts. A student is stung by a bee at recess, she soon develops hives and complains of trouble breathing.
What is anaphylaxis? Anaphylaxis is a potentially life-threatening medical condition occurring in allergic individuals after exposure to their specific allergens. Anaphylaxis refers to a collection of symptoms affecting multiple systems in the body. The most dangerous symptoms include breathing difficulties and a drop in blood pressure or shock, which are potentially fatal. Common examples of potentially life-threatening allergies are those to foods and stinging insects. Life threatening allergic reactions may also occur to medications or latex rubber and in association with exercise or change in temperature. Approximately 50 deaths per year are caused by insect sting anaphylaxis and 150 200 deaths per year from food anaphylaxis, mostly from peanut and tree nut allergies. Anaphylaxis can occur immediately, or up to two hours following allergen exposure. In about a third of anaphylactic reactions, the initial symptoms are followed by a delayed wave of symptoms two to four hours later.
Possible Symptoms of Allergic Reaction Skin: Hives, itching, swelling. Eye/Ear/Nose/Throat: Itchy/scratchy lips, tongue, mouth and/or throat, difficulty swallowing, throat tightness or closing, red, watery eyes. Respiratory: Swelling, change of voice, coughing, wheezing, difficulty breathing, shortness of breath,. Gastrointestinal: Vomiting, stomach cramps. Cardiovascular: Fainting or loss of consciousness, flushed, pale skin, cyanotic (bluish) lips and mouth. Neurologic: Dizziness, change in mental status, fainting or loss of consciousness, sense of doom. Anaphylaxis is a collection of symptoms affecting multiple systems of the body. If you suspect anaphylaxis, act quickly and treat as an emergency.
What do you do if you suspect anaphylaxis? Assess the situation. Identify an adult who will remain with the student. Identify an adult to manage other students. Activate the emergency response team. School Nurse or designated individual administers epinephrine according to the student s Individual Health Care Plan. Simultaneously, another adult is identified to call 911. Identify an adult who will meet EMS at the school entrance and direct to the student. Provide supportive care until EMS arrives. Only a registered nurse may administer a second dose of epinephrine if it is needed. Identify an adult who will accompany the child to the hospital. Notify the parent/guardian. Notify school administration. Notify student s physician and/or allergy specialist. If School Nurse is not present, communicate with another district nurse. Complete epinephrine administration form with the school nurse. Plan for student s re-entry to school. Provide for education/counseling of other students as needed.
What should you know before an emergency happens? Complete the LTA tutorial and competency checklist, including EpiPen administration demonstration. Be familiar with students in your building with known allergies. Be familiar with your classroom students individual health care plan. Student-specific allergen, symptoms, medication sequence and dose. Know the location of Individual Health Care Plan and Epinephrine Auto-Injector (unlocked in health office). Know how to quickly access the emergency response team and 911 from all locations.
How is epinephrine administered? Epinephrine is administered via an auto-injector that is pressure-activated. There are two doses based on weight: EpiPen Junior (0.15 mg) for individuals 33 66 lbs. EpiPen (0.30) for individuals 66 lbs or more. Know the 5 R s (From the Allergy Action Plan). Right Student. Right Medication (EpiPen). Right Dose (.15 or.30 mg). Right Route (Outer thigh via auto injector). Right Time (Anaphylaxis).
Epinephrine Administration (continued) Pull off gray or blue safety cap. Place black or orange tip on outer thigh. Using a swing and jab motion at a 90 degree angle. Press hard into thigh until Auto-Injector mechanism functions. Hold in place and count to 10. The EpiPen unit should then be removed and discarded. Massage the injection area for 10 seconds.
How do I dispose of the EpiPen after it is used? After using an EpiPen, throw away the gray or blue cap. Slip the EpiPen into the tube, and close it. If the EpiPen has an orange tip it will self cover the needle. Return the used EpiPen to your school health office for disposal. The EMT s may also dispose of it.
How Does Epinephrine Work? It quickly constricts blood vessels, raising blood pressure. It relaxes smooth muscles in the lungs to improve breathing. It stimulates the heart beat. It works to reverse hives and swelling.
What are possible side effects of epinephrine? Fast or irregular. heart beat Nausea. Breathing difficulty.
What do the Hanover Public Schools do to keep students with allergies safe in school? Create awareness among staff. Identify students with LTA. Eliminate, where ever possible, allergens from the school. Enforce no food sharing. Enforce no food in classrooms. Keep eating/food preparation areas clean. Maintain allergen precaution tables. Ensure students wash hands thoroughly with soap and water or wipes before and after eating. Teachers and School Nurse collaborate when a student with LTA is in his/her classroom. Train nurses and other school personnel to avoid, recognize and respond quickly to an allergic reaction. Refer to Hanover Public School s policy on the web: www.hanoverschools.org/schoolcommittee/lta.htm
Managing Allergies Everyday A Guide for School Personnel
Teachers/Administrators Be aware of allergy action plans and IHCP s of individual students. Keep all health information in the sub folder. Work with parents, rely on their expertise. Collaborate with the parent and the school nurse when planning a celebration that will involve food. Be able to avoid, recognize and respond quickly to an allergic reaction. Make sure Art/Science/Classroom projects are free of allergens including LATEX. Enforce no food sharing, no food or eating in classroom. Ensure student wash hands before and after eating.
Cafeteria Staff Collaborate with School Nurse. Make list of ingredients available. No food sharing taught and enforced. Alternative lunch available for food allergic children. Offers allergen precaution tables. Allergic students access to wash hands before and after eating with either soap and water or wipes (not hand gel or hand sanitizer). Wash all surfaces prior to meal. Avoid cross contamination during preparation and serving. Allergy action plan with child s picture in cafeteria.
School Bus NO EATING ON THE BUS strictly enforced. All buses in Hanover have a list of children with medical needs these have been provided with parental permission. Bus driver has portable communication device and will pull over and call 911 for help if needed.
Class Trips Notify the nurse in advance Collaboration is the key to success. Plan ahead. Be sure the trip does not expose students to allergens (i.e. visit to a farm where the animals eat peanuts, etc.). Designated trained adult carries allergy action plan and EpiPen or School Nurse accompanies student.
Coaches, Before/After School Coordinators Maintain a working communication device, access to a phone or individual to call 911 if necessary. Address issues with the school nurse/principal. Adhere to safe practices (no sharing food, peanut precaution table, no latex balloons).
Medication Administration Plan Individualized Health Care Plan Written by nurse in collaboration with parent/guardian, student, physician, and nurse. Emergency Allergy Action Plan Identifies allergen. Medication/dose/route. Emergency phone contact numbers. Outlines special plan in the event of exposure.
Multi-Disciplinary Attention MDPH and DESE have collaborated on guidelines to provide school personnel with basic knowledge and skill to administer EpiPen in a life threatening situation. Recommended training is a minimum of twice per year, good idea to refresh if you will be the adult responsible on a field trip. Diligence and a focus on prevention is necessary to assure the safety of all persons with life threatening allergies.
Legal Considerations Hanover Public Schools are registered with MDPH to delegate EpiPen administration to trained unlicensed staff during school hours. School has the responsibility to make accommodations under Section 504 Rehabilitation Act of 1973 no otherwise qualified individual with a disability shall solely by reason of his or her disability be excluded from the participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance. School Staff are protected under MGL Chapter 71, Section 55A: No public school teacher and no collaborative school teacher, no principal, secretary to the principal, nurse or collaborative school employee who, in good faith, renders emergency first aid or transportation to a student who has become injured or incapacitated in a public school building or collaborative school building or on the grounds thereof shall be liable in a suit for damages as a result of his actor or omissions either for such first aid or as a result of providing emergency transportation to a place of safety, nor shall such person be liable to a hospital for its expenses if under such emergency conditions he causes the admission of such injured or incapacitated student, nor shall he be subject to any disciplinary action by the school committee, or collaborative board of such collaborative for such emergency first aid or transportation.
What do I need to do next? Complete competency checklist. Complete post test. Bring test and checklist to your school nurse. Demonstrate use of EpiPen. Repeat training twice per year and/or immediately before taking responsibility for carrying an EpiPen on a field trip. If you have any questions, please ask your school nurse.
Thank you for participating in Managing Life Threatening Allergies at School.