CLINICAL PRACTICE GUIDELINE: ANAPHYLAXIS REGISTERED NURSE INITIATED MANAGEMENT AUTHORIZATION: Integrated Professional Practice Council Page 1 of 10 ADAPTED from BC Health Authorities Provincial Decision Support Tool 1 : Registered Nurse Initiated Activity Decision Support Tool: Treatment of Anaphylaxis, 2008 1.0 FOCUS Initiation of adult and pediatric anaphylaxis treatment by Registered Nurses through the administration of EPINEPHrine and diphenhydramine to stabilize the client until further assistance can be obtained. This decision support tool does not reflect ongoing management of anaphylaxis. Anaphylaxis is a serious and potentially fatal systemic allergic reaction. 2 EPINEPHrine can be life saving. 3 Immediate treatment with PUBLIC HEALTH NURSES: use BCCDC Management of Anaphylaxis in a Non-Hospital Setting decision support tool 4 2.0 BACKGROUND Anaphylaxis is an acute multisystem life-threatening allergic reaction that results from the sudden systemic release of mast cells and basophil mediators. 5 It has varied clinical presentations, but respiratory compromise and cardiovascular collapse cause the most concern because they are the most frequent causes of anaphylactic fatalities. Anaphylaxis is characterized by involvement of one or more body systems in addition to the skin. Urticaria (hives) and angioedema (swelling underneath skin) are the most common manifestations of anaphylaxis and often occur as the initial signs of severe anaphylaxis. However, these findings might be delayed or absent in rapidly progressive anaphylaxis. The more rapidly anaphylaxis develops, the more likely the reaction is to be severe and potentially life-threatening. Symptoms not immediately life-threatening might progress rapidly unless treated promptly and appropriately. The Registered Nurses (RN s) scope of practice has changed under the British Columbia Health Profession s Act (2008) 6, authorizing RNs to compound, dispense and administer Schedule II, Schedule III and unscheduled medications without an order to treat a condition following client assessment and nursing diagnosis. 7 The College of Registered Nurses has established Standards of Practice: Acting without an Order 11 To ensure Fraser Health compliance with this legislation and the CRNBC standards of practice this protocol supports RN s ability to Administer EPINEPHrine for the purpose of treating anaphylaxis 8, Administer diphenhydramine (Benadryl ) for the purpose of treating an allergic reaction condition This document standardizes the practice of initial anaphylaxis management across Fraser Health based on the literature and expert evidence, and provides decision support resources for the RN to manage hypoxemia. It is intended for use by RNs and other health care providers as applicable within their regulated scope of practice in various care delivery settings. Scope of Practice Implementation. Registered Nurse Initiated Activity Decision Support Tool: Treatment of Anaphylaxis, March 2008.
Page 2 of 10 3.0 DEFINITIONS Anaphylaxis: defined as a severe systemic allergic reaction to a foreign protein or other substance, affecting all ages and, in its most critical form, is characterized by life-threatening upper airway obstruction, 4, 9, 10, 11, 19, 22 bronchospasm and hypotension. Biphasic Reaction: two phased anaphylaxis with second phase occurring within 8-12 hours after the first. 4 4.0 OUTCOMES: 4 Intended Outcomes: With the safe and effective administration of EPINEPHrine and follow-up treatment criteria, signs and symptoms of anaphylaxis will be reduced or eliminated. Unintended Outcomes: Signs and symptoms of anaphylaxis continue or become worse. Acute Hypertension. 5.0 ASSESSMENT: 4, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22,23 21 Presentation of anaphylaxis is on a continuum of early to late signs and symptoms but in its most critical form, is characterized by life-threatening upper airway obstruction, bronchospasm and hypotension. Respiratory and cardiac failure is the most common causes of anaphylactic fatalities. There are no contraindications to EPINEPHrine administration for anaphylaxis. General Information ASSESSMENT DATA RATIONALE History History of anaphylaxis History of reaction to specific foods, drugs, insect stings, latex and exercise Medication history, including vaccination administration Indications for treatment Possibility of biphasic reaction
CLINICAL PRACTICE GUIDELINE: ANAPHYLAXIS REGISTERED NURSE INITIATED MANAGEMENT AUTHORIZATION: Integrated Professional Practice Council Page 3 of 10 SYSTEM EARLY SIGNS AND SYMPTOMS RATIONALE Integumentary diffused/local erythema (redness) pruritus (itchiness) urticaria (hives) angioedema (swelling underneath skin) vasodilatation Initial immune response SYSTEM LATE SIGNS AND SYMPTOMS RATIONALE Neurological decreased LOC dizziness weakness seizure headache feeling of doom Respiratory cough wheezing SOB hoarseness/stridor hypoxemia (actual/suspected) Cardiovascular rapid/weak/irregular pulse hypotension chest pain/tightness cardiac arrest Gastrointestinal nausea/vomiting/diarrhea abdominal pain Hypoxia Circulatory collapse Upper airway swelling & bronchospasm Circulatory collapse Increased vascular permeability Vasoconstriction of blood vessels leading to GI system 5.2 Diagnosis: Anaphylaxis, 2.4, 5, 11, 12, 13, 14, 15, 16, 17, 21, 24 5.3 Precautions / Special Considerations: Delayed administration of EPINEPHrine in anaphylaxis is associated with poor outcomes including fatality. Research indicates that intramuscular (IM) administration of EPINEPHrine has a faster rate of absorption in comparison to subcutaneous (SC) administration. The vastus lateralis (thigh) muscle is the preferred site of IM injection of Epinephrine. EPINEPHrine can be administered through clothing into the lateral thigh. The deltoid muscle should be used only in adults and children 12 months or older. If the anaphylaxis is due to a vaccine, do NOT give EPINEPHrine IM into the same muscle mass as the vaccine was given. Because intravenous (IV) administration of EPINEPHrine can cause lethal arrhythmias and requires strict Scope of Practice Implementation. Registered Nurse Initiated Activity Decision Support Tool: Treatment of Anaphylaxis, March 2008.
Page 4 of 10 monitoring, its use should be limited to situations of cardiac arrest or unresponsiveness to IM EPINEPHrine and diphenhydraminein consultation with a physician and in accordance with Fraser Health protocols. Some beta blockers may inhibit or block response to Epinephrine. Administration of glucagon may be considered. EPINEPHrine can cause acute hypertension. Caution should be taken when administering EPINEPHrine to individuals with hyperthyroidism, hypertension, diabetes, heart disease or arrhythmias, asthma or emphysema, in the elderly or with recent cocaine use. diphenhydramine (Benadryl ) is not life-saving. It is given as an adjunctive to Epinephrine, mainly for relief of skin symptoms (urticaria and angioedema). Administration of diphenhydramine in adjunct to EPINEPHrine is recommended for symptom control and/or if transfer from community or residential setting will be longer than 30 minutes. A vasovagal response may be confused with anaphylaxis. There are important differences that distinguish one from the other. Anaphylaxis vs. Vasovagal Response Vasovagal Response Anxiety/fear SOB/hyperventilation Pale/clammy skin Dizziness/Fainting Bradycardia Hypotension Anaphylaxis Feeling of doom Hypoxia/bronchospasm Skin rash/swelling Tachycardia Hypotension 4, 13, 14, 15, 21, 22, 24 6.0 INTERVENTIONS:
Page 5 of 10 Failure to use EPINEPHrine promptly when indicated can be life-threatening. 1. Discontinue the causative agent (IV medication and tubing) if applicable. 2. Call 911 or ambulance (non-acute care settings) or initiate cardiac arrest management if indicated (acute care) immediately after or in conjunction with first dose of Epinephrine. 3. Administer EPINEPHrine 1:1000 IM into thigh (vastus lateralis) which is the preferred site or IM site opposite to or away from the site of causative agent. See precautions for administration. If both thighs were used for immunization (or causative agent): patient is (greater than) 12 months old: give EPINEPHrine IM into deltoid muscle patient is < (less than) 12 months old: give EPINEPHrine subcutaneously into upper outer triceps area of the arm(s) EPINEPHrine Dose Adult: 0.5 mg (0.5 ml) Child: 0.01 ml/kg up to 0.5 ml See Table 1 for specific dosing. EPINEPHrine can be repeated every 5 minutes (maximum 3 doses). 4. Position person in recumbent position with legs elevated, if necessary ensure open airway via head tilt, chin lift, or jaw thrust or artificial airway and apply oxygen (if available), preferably by non-rebreather mask, to maintain oxygen saturation greater than or equal to 92%. Turn individual on side if vomiting is likely. 5. If response to EPINEPHrine is poor (EPINEPHrine is fast acting) or to maintain symptom control administer diphenhydramine 50 mg/ml IM preferably at a different site to that of the Epinephrine. diphenhydramine dose Adult: 50-100 mg (1-2 ml) Child: 1-2 mg/kg See Table 2 for specific dosing. 6. Monitor vital signs every 5 minutes to detect deterioration or adverse reaction to medication administration or initiate cardiac arrest management as per client situation. 7. If in non-acute care setting, call 911 or ambulance and prepare for transfer to acute care setting. 7.0 DOCUMENTATION: 4, 17
Page 6 of 10 Diagnosis of Anaphylaxis Initial recording of vital signs (every 5 minutes to detect deterioration) and ongoing assessment data Cause of anaphylaxis (if known) Date and time EPINEPHrine and diphenhydramine were administered Dose, route, site and method of administration Oxygen concentration or flow Client response to treatment Consultation with Physician or appropriate health care professional and any related orders Client teaching Report causative agent if known as required by Fraser Health protocols, i.e. post-immunization, medication, dye/contrast, food, etc. 4, 25.8.0 CLIENT EDUCATION: The individual presenting with anaphylaxis is acutely ill therefore limit discussion to treatment explanations that are brief and to the point and provision of support for the individual and accompanying parties. After resolution of the acute episode, ongoing management of subsequent anaphylactic reactions should be discussed including Avoidance of the suspected trigger of anaphylaxis until a formal assessment by an allergistimmunologist can be arranged per their physician or other health care provider. instruction for self-administration of EPINEPHrine 9.0 EVALUATION Client improvement/prevention of deterioration in response to Registered Nurse intervention. Appropriate referral to physician / other HCP / ambulance service for ongoing care and treatment. 10.0 MONITORING Direct observation of initial management assessment, diagnosis, intervention, evaluation and followup. Chart audits.
CLINICAL PRACTICE GUIDELINE: ANAPHYLAXIS REGISTERED NURSE INITIATED MANAGEMENT AUTHORIZATION: Integrated Professional Practice Council Page 7 of 10 Table 1: Pediatric Dosage for IM injection of Aqueous EPINEPHrine 1:1000 (0.01 ml/kg up to 0.5 ml) 25 4, 5, Weight 2 kg (4 5 lbs) 0.02 ml 3 kg (6 7 lbs) 0.03 ml 4 kg. (8 10 lbs) 0.04 ml 5 kg (11 12 lbs) 0.05 ml 6 7 kg (13 16 lbs) 0.06 ml 8 9 kg (17 20 lbs) 0.08 ml 10 13 kg (21 29 lbs) 0.1 ml 14 18 kg (30 40 lbs) 0.15 ml 19 23 kg (41 51 lbs) 0.2 ml 24 28 kg (52 62 lbs) 0.25 ml 29 33 kg (63 73 lbs) 0.3 ml 34 38 kg (74 84 lbs) 0.35 ml 39 43 kg (85 95 lbs) 0.4 ml 44 kg ( 96 lbs) 0.5 ml EPINEPHrine Dosage in ml If unable to determine weight 4 EPINEPHRINE 1:1000 (Dose: 0.01 ml/kg to maximum of 0.5 ml) OR: AGE EPINEPHrine 2 6 months 0.07 ml 7 12 months 0.1 ml 13 months 4 years 0.15 ml 5 years 0.2 ml 6 9 years 0.3 ml 10 13 years 0.4 ml 14 years 0.5 ml Scope of Practice Implementation. Registered Nurse Initiated Activity Decision Support Tool: Treatment of Anaphylaxis, March 2008.
Page 8 of 10 Table 2: Pediatric Dosage for IM injection of diphenhydramine Hydrochloride 50 mg/ml (1-2 mg/kg) 4, 5, 25 Weight diphenhydramine Dose in mg diphenhydramine Dose in ml 2 kg (4 5 lbs) 2.5 mg 0.05 ml 3 kg (6 7 lbs) 5 mg 0.1 ml 4 kg (8 10 lbs) 7.5 mg 0.15 ml 6 kg (11 14 lbs) 10 mg 0.2 ml 8 kg (15-20 lbs) 12.5 mg 0.25 ml 10 14 kg (21 31 lbs) 15 mg 0.3 ml 15 19 kg (32 42 lbs) 22.5 mg 0.45 ml 20 24 kg (43 53 lbs) 30 mg 0.6 ml 25 29 kg (54 64 lbs) 37.5 mg 0.75 ml 30 34 kg (65 75 lbs) 45 mg 0.9 ml 35 kg ( 76 lbs) 50 mg 1 ml If unable to determine weight: 4 AGE < 2 years 0.25 ml 2 4 years 0.5 ml 5 11 years 0.5-1 ml 12 years 1 ml diphenhydramine dose (50 mg/ml)
CLINICAL PRACTICE GUIDELINE: ANAPHYLAXIS REGISTERED NURSE INITIATED MANAGEMENT AUTHORIZATION: Integrated Professional Practice Council Page 9 of 10 Author( s): Fraser Health Anaphylaxis Shared Work Team. Adapted from McGarvey, E. in collaboration with BC Health Authority Leads for RN Scope of Practice Implementation. Registered Nurse Initiated Activity Decision Support Tool: Treatment of Anaphylaxis, March 2008.
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