MEDICATION MANUAL Policy & Procedure TITLE: Section: Initial Management of Anaphylaxis Following Immunization Medication Specific NUMBER: MM 20-005 Date Issued: October 2009 Source: Distribution: Capital Health Nurse Pharmacy Committee Holders of Medication Manual Date To Be Reviewed: Issuing Authority: October 2012 Director Professional Practice THIS IS A POST- ENTRY LEVEL COMPETENCY FOR REGISTERED NURSES AND LISENCED PRACTICAL NURSES (IN SPECIFICALLY APPROVED PRACTICE SETTINGS) AND REQUIRES ASSESSMENT OF COMPETENCY PRIOR TO PERFORMING PREAMBLE Anaphylaxis is a life threatening reaction to a foreign substance that requires immediate treatment. It is important to be prepared to respond to anaphylaxis prior to administration of any product. The recommended first line of treatment of anaphylaxis is the timely administration of epinephrine and diphenhydramine (Benadryl ). POLICY 1. Management of anaphylaxis following immunization (see definition) is a post-entry level competency for RNs and LPNs which requires assessment of competency, by successful completion of the Immunization Learning Module. 1.1. Additionally, LPNs working in specifically approved practice settings require successful completion of an approved Post- Entry Level Competency program in immunization (e.g.: NSCC Immunization Program of LPNs) 2. An authorized prescriber s order or pre-printed order is required for all programs and services administering medications required in the management of anaphylaxis following immunization. Exception: Public Health Services; acting under the direction of the Medical Officer of Health. Initial Management of MM 20-005 Page 1 of 5
3. The RN/LPN is responsible and accountable for the management of anaphylactic reactions, including: 3.1. Completion of informed consent for management of anaphylaxis; to be obtained at the time of informed consent for immunization (Refer to CH Policy: Immunization Administration MM 20-010) 3.2. Assessment of response to immunization. 3.3. Initiation of anaphylaxis management following immunization based on assessment. 3.4. Documentation and reporting. 4. Patients are to be screened carefully to differentiate reactions along the spectrum from mild (e.g., soreness, itching) to severe and life threatening (e.g., anaphylaxis). Note: While anaphylaxis is extremely rare following immunization, at a rate of 0.4-1.8 per 1,000,000 in Canada, all vaccines have the potential to cause an adverse reaction. DEFINITIONS Anaphylaxis: A severe systemic life threatening reaction involving at least 2 body systems (affecting the skin, respirations, circulation). It develops over several minutes. Cardinal features include: Itchy, urticarial rash ( in over 90% of cases), Progressive painless swelling about face and mouth, Respiratory symptoms including sneezing, coughing, wheezing, labored breathing and upper airway swelling, possibly causing airway obstruction, Hypotension. (Reference Canadian Immunization Guide Page 81) EQUIPMENT Anaphylaxis Kit: Quick Reference Management of Anaphylaxis Initial Management Following Immunization (CD2018MR) 3 x 1mL ampoules of epinephrine (1:1000 aqueous solution) 1 x 1mL vials of diphenhydramine (50mg/ml) 1 x 50 mg diphenhydramine pill 2 x 25 mg chewable diphenhydramine pill 3 x 1mL syringes with safety needles (25 gauge, 1") 4 x 3mL syringes 5 x 25 gauge 1" needle (extra) 5 alcohol swabs 5 cotton swabs Initial Management of MM 20-005 Page 2 of 5
PROCEDURE 1. In the event of anaphylaxis, activate the emergency response as applicable to your practice area (Call 911 for EHS services or 3333 for Code Blue response). 1.1. Position the patient in the recumbent position with legs elevated. 1.2. Provide the ABCs of resuscitation (Airway,( Breathing, Circulation ). 2. As per the authorized prescriber s order, immediately administer aqueous epinephrine intramuscularly (IM), 1:1000 in appropriate dose according to age/body weight. (Dosage: 0.01ml/kg to a maximum of 0.50 ml) 2.1. Administer epinephrine IM preferentially into an anterolateral, unimmunized thigh site (vastus lateralis). Note: This is applicable for all ages. The injection can be made through clothing. 2.2. If administration into a thigh is problematic, epinephrine may be administered IM into the deltoid muscle of children greater than or equal to 12 months of age and to adults. 2.3. When both thighs have been used as immunization sites, administer epinephrine into a site in the thigh that is at least 2.5 cm (1 inch) away from any immunization site. 2.3.1. As this may not be possible in some young infants with small thigh muscle mass, separate the sites with as much distance as possible. 2.4. DO NOT inject epinephrine directly into an IM immunization site as it dilates blood vessels and speeds absorption of the vaccine (i.e. the offending allergen). Table 1: Appropriate Dose of Epinephrine (1:1000) AGE Weight (kg)* In kg Weight (lbs)* In lbs Dosage 1 mg/ml (1:1000) 0.01 ml/kg 2 to 6 months 4-7 kg 9-15 lbs 0.07 mg (0.07 ml) 7 to 18 months 7-11 kg 15-24 lbs 0.10 mg (0.10 ml) 19 to 48 months 11-17 kg 24-37 lbs 0.15 mg (0.15 ml) 49 months to 5 years 17 23 kg 37 51 lbs 0.20 mg (0.20 ml) 6-9 years 23 35 kg 51-77 lbs 0.30 mg (0.30 ml) 10-13 years 35 45 kg 77 99 lbs 0.40 mg (0.40 ml) Greater than or equal to 14 years 45+ kg 99+ lbs 0.50 mg (0.50 ml) * Dosing by body weight is preferred Source: CIG (2006), p. 83., Red Book (2006) 3. Assess need to administer ONE dose diphenhydramine (Benadryl ). (Dosage: 1-2 mg/kg to a maximum single dose of 50 mg. See Table 2.) Note: Oral Treatment is preferred for conscious patients (appropriate dose according to age) in non-hospital settings. 3.2. Administer IM injection in the unimmunized site as a separate injection (thigh or deltoid) Initial Management of MM 20-005 Page 3 of 5
Table 2: Approximate Dose by Age of Diphenhydramine (Benadryl ) AGE Oral Route IM (50 MG/ML) (1-2 mg/kg) Less than 2 years 12.5 mg 12.5mg (0.25 ml) 2-4 years 25 mg 25 mg (0.50 ml) 5-11 years 25-50 mg 25-50 mg (0.50-1.00 ml) Greater than or equal to 12 years 50 mg 50 mg (1.00 ml) Source: CIG (2006), p. 83-84. 4. Repeat epinephrine at 5 minute intervals as needed (i.e. if breathing becomes more laboured or level of consciousness decreases) to a maximum of three doses. Alternate right and left thigh or arm sites for repeat doses of epinephrine (to maximize absorption of epinephrine). 5. Transport to acute care/emergency services, as needed (dependent on the setting in which the immunization/anaphylaxis occurred). 6. Documentation and Reporting 6.1. Complete documentation in the health record using Management of Anaphylaxis Initial Management Following Immunization form (CD2018MR). 6.2. Report to the Manager and/or Attending Physician/Ordering Physician 6.3. Complete the Capital Health Patient Safety Report (on-line occurrence report) 6.4. Complete the Adverse Event Following Immunization (AEFI) (previously known as the Vaccine Associated Adverse Event form) and send to the Medical Officer of Health at Public Health Services through inter-office mail or fax to 481-5803. Note: Form can be found in the back of the CPS or at the Public Health Agency of Canada link: http://www.phac-aspc.gc.ca/im/pdf/hc4229e.pdf RELATED CAPITAL HEALTH DOCUMENTS Policies Immunization Administration and Learning Module (MM 20-010) Forms Management of Anaphylaxis Initial Management Following Immunization form (CD2018MR) Initial Management of MM 20-005 Page 4 of 5
REFERENCES American Academy of Pediatrics. (2006). Red book: Report on the committee on infectious diseases. (27 th ed.). Elk Grove Village, IL: Author. College of Registered Nurses of Nova Scotia (2007). Immunization Guidelines for Registered Nurses. Canadian Society of Allergy and Clinical Immunology 2005 BC Centre for Disease Control (2005). Communicable Disease Control: Immunization Program. Communicable Disease Control Manual, Chapter II. Retrieved November 30, 2007 from http://www.bccdc.org/content.php?item=193 Ellis, A.K. & Day, J.H. (2000). Anaphylaxis: Diagnosis and treatment. Allergy Asthma, 23-25. Johnson, R.F. & Peebles, R.S. (2004). Anaphylactic shock: Pathophysiology, recognition, and treatment. Seminars in Respiratory and Critical Care Medicine, 25 (6), 695-703. Joint Task Force on Practice Parameters: American Academy of Asthma and Immunology; American College of Allergy Asthma and Immunology; Joint Council of allergy, Asthma, and Immunology (2005). The diagnosis and management of anaphylaxis: an updated parameter. Journal of Allergy and Clinical Immunology,115:S483-523. Public Health Agency of Canada (2006). Canadian Immunization Guide. Ottawa: PHAC. Saskatchewan Health (2006). Saskatchewan Immunization Manual. Retrieved November 30, 2007 from http://www.health.gov.sk.ca/immunization-manual Simons, F.E.R., Gu, X., & Simons, K.J. (2001). Epinephrine absorption in adults: Intramuscular versus subcutaneous injection. Journal of Allergy and Clinical Immunology, 108, 871-873. Simons, F.E.R., Roberts, J.R., Gu, X., & Simons, K.J.(1998). Epinephrine absorption in children with a history of anaphylaxis. Journal of Allergy and Clinical Immunology, 101, 33-37. Thibodeau, J.L. (1993). Office management of childhood vaccine-related anaphylaxis. Canadian Family Physician, 40, 1602-1610. HISTORICAL DATES November 2003 Initial Management of MM 20-005 Page 5 of 5