Management of Anaphylaxis in Adults and Children



Canberra Hospital and Health ServicesClinical GuidelineManagement of Anaphylaxis in Adults and Children Contents TOC \h \z \t "Heading 1,1,Heading 2,2" Contents PAGEREF _Toc487466665 \h 1Introduction PAGEREF _Toc487466666 \h 2Scope PAGEREF _Toc487466667 \h 2Background PAGEREF _Toc487466668 \h 3Key Objectives PAGEREF _Toc487466669 \h 3Section 1 – Reducing the risk of anaphylaxis PAGEREF _Toc487466670 \h 3Section 2 – Symptoms and signs of an acute allergic reaction PAGEREF _Toc487466671 \h 3Section 3 – Emergency management of allergy and anaphylaxis at Canberra Hospital PAGEREF _Toc487466672 \h 4Section 4 – Differential Diagnosis PAGEREF _Toc487466673 \h 5Section 5 – Podiatry Services PAGEREF _Toc487466674 \h 6Section 6 – Justice Health PAGEREF _Toc487466675 \h 7Section 7 – Immunisations PAGEREF _Toc487466676 \h 7Section 8 – Community Nurses (Community Care Program) PAGEREF _Toc487466677 \h 9Implementation PAGEREF _Toc487466678 \h 10Related Policies, Procedures, Guidelines and Legislation PAGEREF _Toc487466679 \h 10References PAGEREF _Toc487466680 \h 12Definition of Terms PAGEREF _Toc487466681 \h 12Search Terms PAGEREF _Toc487466682 \h 12Attachments PAGEREF _Toc487466683 \h 13Attachment A: How to Use an Epipen or Anapen: PAGEREF _Toc487466684 \h 14Attachment B: Anaphylaxis Emergency Treatment Plan for Schools and Preschools PAGEREF _Toc487466685 \h 17Attachment C: Adverse Event Following Immunisation (AEFI) Form PAGEREF _Toc487466686 \h 19Attachment D: Basic Life Support Chart PAGEREF _Toc487466687 \h 21IntroductionThis guideline outlines the emergency management of anaphylaxis in children and adults.Anaphylaxis is a form of immune-mediated hypersensitivity reaction, which means it is an abnormally vigorous immune response. In most cases, but not always, anaphylaxis is triggered by exposure to an exogenous antigen such as venom, food or drug. Sometimes the cause is not obvious. Anaphylaxis is a specific immune response mediated by IgE antibodies, which bind to mast cells and basophils to cause degranulation and release of vasoactive mediators. When liberated in large quantities, these mediators cause many physiological changes including bronchospasm, haemodynamic instability, vascular leak, rash and itchiness.Please note the following online training resources:For clinicians: For childcare and schools: .au/patients/anaphylaxis-e-training-schools-andchildcare Back to Table of ContentsScopeManagement of anaphylaxis in children and adults within inpatient, outpatient and community jurisdictions of ACT Health.This clinical guideline applies to: Medical OfficersRegistered nurses and midwives working within their scope of practicePodiatristsOther authorised prescribersPodiatry Services: this pertains to podiatrists who administer local anaesthetic agents. The podiatrist must have current training in CPR and anaphylaxis management as per the Podiatry Board of Australia requirements. Justice Health Service: this pertains to all anaphylactic events at the Alexander Maconochie Centre (AMC), Periodic Detention Centre (PDC), and Bimberi Youth Justice Centre (BYJC) while Justice Health Service registered nurses are on munity Nursing: this pertains to community nurses who administer intravenous (IV) and intramuscular (IM) antibiotics in patients’ homes and health centre clinics.Back to Table of ContentsBackgroundAlert: Anaphylaxis is a severe allergic reaction with manifestations in more than one organ system. Anaphylaxis is a medical emergency and therefore requires immediate medical managementWithin the hospital setting, common allergenic triggers of anaphylaxis are drugs (especially after parenteral administration), latex, chlorhexidine, a known allergen administered for allergy desensitisation procedures or allergy testing, or a meal containing a food allergen. Not all drug reactions are anaphylaxis or even allergic in origin. In addition, some features of anaphylaxis can result from other mechanisms. Important examples are:Vancomycin can cause erythemaACE inhibitors such as ramipril can cause angioedemaMonoclonal antibodies can cause immune activation and cardiovascular collapseBack to Table of ContentsKey ObjectivesIdentification of the patient with anaphylaxisSafe and effective management of the patient with anaphylaxisBack to Table of ContentsSection 1 – Reducing the risk of anaphylaxisBefore commencing a new treatment, ask the patient if they have any allergies. Consult medical records and drug charts for documented history of drug and other allergies. Back to Table of Contents Section 2 – Symptoms and signs of an acute allergic reactionMild to moderate allergiesSigns or symptoms that might be observed with any form of allergic reaction:swelling of lips or eyelids (angioedema)hives or welts (urticaria)tingling in the mouthcough or wheeze.Severe acute allergic reaction and anaphylaxisSymptoms of mild allergy can occur in patients with severe allergic reactions. Symptoms that might indicate anaphylaxis:shortness of breathtightness in the throatsensation of swollen tonguelight headednessgeneralised itchinesssweatinessnauseasevere anxiety.Signs of anaphylaxis:swelling of the tongue, pharynx, larynxwidespread wheezereduced air entry tachypnoeasevere generalised urticariahypotensiontachycardialoss of consciousness.Back to Table of Contents Section 3 – Emergency management of allergy and anaphylaxis at CHHS FacilitiesMild to moderate allergy:Stop any intravenous treatment currently underwayAdminister an oral antihistamine Adults: (Loratidine 10mg)Children: (Loratidine, according to age and weight)Monitor for improvement or progression to signs and symptoms of anaphylaxis.Anaphylaxis:Stop any intravenous treatment currently underwayAdminister adrenaline by intramuscular injection according to standing orders (see below). Adrenaline dose can be repeated after five minutes if no response to the first doseAdminister oxygen by mask4. Establish intravenous access5. Call Medical Emergency Team (dial 8 within the hospital)6. Call on-call Immunologist or immunology trainee via the Canberra Hospital switchboard.Adrenaline treatment according to standing orders for the emergency management of anaphylaxis:Adrenaline 1:1000 (1mg/mL) Age (years)Weight (kg)Adrenaline volume (mL)<15-100.05 – 0.1 mL1-2100.1 mL2-3150.15 mL4-6200.2 mL7-10300.3 mL10-12400.4 mL>12 and adult>500.5 mLAlert: Treatment can be repeated after five minutes if there is no response to the first doseAdrenaline via Epipen or Anapen*AgeWhich pen?Dose (micrograms)ADULT: Epipen or Anapen 300300 micrograms IMCHILD 10 - 20 kg: Epipen Junior or Anapen 150150 micrograms IMCHILD > 20kg: Epipen or Anapen 300300 micrograms IMAlert: Epipen Junior should be used for patients weighing <20kg. For children weighing >20kg, use adult dose Epipen.See Attachment A for instructions on how to use an Epipen or Anapen.Reporting and documentation should be completed as per the requirements in the Medication Handling Policy.Back to Table of Contents Section 4 – Differential DiagnosisIn cases where the patient does not respond to adrenaline, anaphylaxis might not be the correct diagnosis, or the patient might be on another treatment that prevents adrenaline from working.Examples include:ACE inhibitors such as ramipril can cause angioedemaMonoclonal antibodies can cause immune activation that result in cardiovascular collapseBeta blockers inhibit some actions of adrenaline.In these cases, seek urgent medical advice from Immunology via the Canberra Hospital switchboard about patient management.Back to Table of ContentsSection 5 – Podiatry Services Podiatrists administering local anaesthetic agents must ensure adequate dosages of adrenaline (via autoinjector such as Epipen or Anapen) will be readily available at the time of, and directly after administration. The Podiatry Manager needs to be notified at least 2 weeks prior to administering local anaesthetic to persons between 10-20kg, so that the appropriate adrenaline (Epipen Junior or Anapen 150) can be ordered. Patients who weigh <10 kg would not be deemed suitable for local anaesthetic administration by podiatrists.The podiatrists who administer local anaesthetic agents must be able to recognise and effectively manage anaphylaxis. Prior to administering a local anaesthetic the podiatrist will check the Podiatry Nail Surgery Pre-surgical Assessment Form and confirm with the patient their allergies or previous reactions to antigens.Prior to administering local anaesthetics, podiatrists should ensure there is a duress alarm facility in the health centre clinic.Podiatrists must report to the Podiatry Manager, any incidents of anaphylaxis, or other adverse reactions related to administration of local anaesthetic agent within 24 hours of the event.Management of mild signs and symptoms (Section 2):Cease administration of local anaestheticPlace patient in a supine position whilst remaining in the Podiatry chairNever leave the patient aloneMonitor patient for at least 20 minutes for improvement or progression of signs and symptoms.Contact patient’s General Practitioner and arrange same day patient reviewDocument all interventions in the patient’s clinical recordComplete Riskman reportAdd to ACTPAS alertsReport to the Podiatry Manager within 24 hours.Management of anaphylaxis (Section 2):Assess airway, breathing, circulation and commence Basic Life Support (BLS) protocols (See Attachment D).Administer adrenaline via Epipen or AnapenNever leave patient aloneCall for additional assistance – press duress alarm.Call for ACT Ambulance Service or advise others to request an ambulanceDial 0 to obtain a dial tone, then 000Or 112 for a mobile phone as this is the GSM international standard emergency access numberContinue emergency care until ambulance arrivesDocument all interventions in the patient’s clinical recordComplete Riskman reportAdd to ACTPAS alertsReport to the Podiatry Manager within 24 hours.Back to Table of Contents Section 6 – Justice HealthIn addition to emergency management (see Section 3), the following should be performed:When Justice Health Service staff is notified, the RN will attend the specified areaInitially, the RN will attempt to determine the cause of anaphylaxis by taking a history from the patient (if possible)If the patient is conscious, they should administer an Epipen or Anapen to themselves If the patient is unable to administer the Epipen or Anapen themselves, the attending RN will administer the Epipen or Anapen into the patient’s lateral thigh (see Attachment A for how to administer an Epipen or Anapen)If the patient is having difficulty breathing or is unconscious, assess airway, breathing and circulation and commence emergency procedures as appropriateThe RN should stay with the patientIf Ambulance attendance is deemed necessary, the RN should seek assistance from another staff member present and request for them to call 0-000 for ACT Ambulance ServicePrepare patient and any relevant information for transport to the Canberra Hospital.This event must be documented in the patient’s medical record in accordance with the clinical record documentation policyRiskman should also be completed.Back to Table of ContentsSection 7 – ImmunisationsTo minimise the risk of an adverse event following immunisation all persons prior to vaccination are screened using the pre-vaccination checklist.A protocol for the management of anaphylaxis and adrenaline must always be immediately at hand where ever vaccines are given. For management of anaphylaxis in an emergency, see Section 3.Ensure that emergency equipment is available as follows:TelephoneLaerdal resuscitator age appropriate and pocket face mask Adrenaline 1:1000 (2 vials and 1mL syringes, 23g needles)Note:Pocket face masks are not used in community health centresAlert: Recipients of vaccines must remain under direct observation by a nurse for at least 15 minutes following immunisation.Clinical features which may assist differentiation between a vasovagal episode and anaphylaxis:Vasovagal episodeAnaphylaxisOnsetImmediate, usually within minutes of or during vaccine administration.Usually within 15 minutes, but can occur within hours, of vaccine administration.SkinGeneralised pallor, cool, clammy skin.Skin itchiness, generalised skin erythema (redness), urticaria (wheals) or angioedema (localised oedema of the deeper layers of the skin or subcutaneous tissues).RespiratoryNormal respiration; may be shallow, but not laboured.Cough, wheeze, stridor, or signs of respiratory distress (tachypnoea, cyanosis, rib recession).CardiovascularBradycardia, weak/ absent peripheral pulse, strong carotid pulse. Hypotension – usually transient and corrects in supine position.Tachycardia, weak/absent peripheral and carotid pulse.Hypotension – sustained and no improvement without specific treatment.NeurologicalFeels faint, light-headed.Loss of consciousness – improves once supine or head down position.Sense of severe anxiety and distress.Loss of consciousness – no improvement once supine or head down position.DocumentationAll adverse events are reported on Report of Adverse Event Following Immunisation (AEFI) form, which can be found on the ACT Health Immunisation page (). This is faxed within 48 hours to Health Protection Service on 6205 1738. (example at Attachment C) A Riskman report is also made via the Health Intranet () or by phone via the helpsek when computer access is not available, phone: 6205 4000.Back to Table of ContentsSection 8 – Community Nurses (Community Care Program)This section applies to community nurses who administer IV or IM antibiotics in patients’ homes or in health centre munity nurses do not carry or supply adrenaline. Prior to administering IV or IM antibiotics the community nurse will:Ensure that the patient has received an initial dose of the antibioticNote: Community nurses do not administer the first dose of any parenteral medicationEnsure a medical order for the administration of Adrenaline is documented on the ‘Medical Officers Orders for Medication Administration’ formEnsure that the following is available in the patient’s home or health centre clinic:Two vials of Adrenaline 1:1000 (supplied by the patient)1 mL syringes, drawing up needles and 23 gauge needles (supplied by the Community Care Program)Management of mild to moderate signs and symptoms (Section 2):Cease administration of IV or IM antibioticMonitor patient for at least 20 minutes for improvement or progression of signs and symptomsReport to the patient’s General Practitioner and arrange same day patient review. Advise the patient to call an ambulance if symptoms worsen Document all interventions in the patient’s clinical recordComplete Riskman reportAdd to ACTPAS alertsManagement of severe signs and symptoms (Section 2):Cease administration of IV or IM antibioticLay patient flat, do not stand or walk; and if breathing is difficult, allow the patient to sit.If unconscious, lie the patient on the left side and position to keep the airway clear.Call for ACT Ambulance Service, Ph 000 (112 is the mobile phone number for the GSM international standard emergency access number)Assess airway, breathing, circulation and commence basic life support if required Administer adrenaline (as per doctor’s order), by IM injection into the mid-lateral thigh. If there is no improvement in the patient’s condition the dose can be repeated after 5 minutesNever leave the patient aloneContinue emergency care until ambulance arrivesDocument all interventions in the patient’s clinical recordComplete Riskman reportAdd to ACTPAS alerts.Back to Table of ContentsImplementation This is an update of a pre-existing guideline, rather than a change in practice. The new guideline will be uploaded onto Sharepoint, with advertisement of the update on the Hub.Back to Table of ContentsRelated Policies, Procedures, Guidelines and LegislationAdrenaline standing orderLegislationHealth Practitioner Regulation National Law (ACT) Act 2010Medicines, Poisons and Therapeutic Goods Act 2008 and Regulations 2008Corrections Management Act 2007Health Records (Privacy and Access) Act 1997Health Act 1993Human Rights Act 2004Health Practitioner Regulation National Law (ACT) Act 2010Health Practitioner Regulation National Law Act 2009Health Practitioner Regulation National Law RegulationPrivacy Act 1988Public Health Act 1997Public Sector Management Act 1994Work Health and Safety Act 2011PoliciesACT Health Wide, Occupation Health and Safety Policy. Health Framework for Quality Use of Medicines.ACT Health Medication Management Policy.Nursing & Midwifery Continuing Competence Policy.Work Health and Safety Policy. Adult Corrections Health Service Plan 2008-2012Children and Young Peoples Justice Health Services Plan 2008-2012Canberra Hospital and Health Services. Operational Procedure, Immunisation Service Delivery in Schools and Child Health Clinics 2016 - 2021ACT Health Nutrition Department Procedure: Open Food Challenges, August 2009Standards National Safety & Quality Health Services Standards - Standard 4: Medication Safety.The Australian Council on Healthcare Standards Evaluation and Quality Improvement Program5 (EQuIP5):1.4.1 Care and services are planned, developed and delivered based on the best available evidence and in the most effective way.1.5.1 Medications are managed to ensure safe and effective practice.Standard Operating ProceduresAlcohol and Drug Services The Management of Adverse Events following Immunisation within the Alcohol and Drug Services (ADS).Community Care Medication munity Care Anaphylaxis Management in Podiatry Services.Capital Region Cancer Service Hypersensitivity Reaction Management – Immunological Procedures. Community Care Nursing Management of a Patient Receiving Antibiotics via a Central Venous Access Device or Intramuscular Route in the Community - Adults.Standards Code of conduct for registered health practitioners, Podiatry Board of AustraliaAustralasian Podiatry Council Competency standardsThe Australian Council of Healthcare Standards (ACHS) Evaluation and Quality Improvement Program (EQuIP)ACHS EQuIP 5 - 1.4 - The organisation provides care and services that achieve expected outcomes CompetencyRegistration with the Podiatry Board of AustraliaCurrent First Aid Certificate as per the Podiatry Board of Australia requirementsRelated PoliciesCommunity Care: Podiatric Nail Surgery policyNail Surgery Competency Assessment – Continuing Care PodiatryACT Health Directorate Podiatry Pre-Surgical Assessment FormCommunity Care: Nursing Management of patient experiencing an anaphylactic reaction as result of medication administration in the Community continuing care programCommunity Health: Medication Manual (revised 2010)ACT Health: 5 Step Correct Patient, Correct Site, Correct Procedure Policy Back to Table of ContentsReferencesEllis AK and Day JH. Diagnosis and management of anaphylaxis. CMAJ 2003;169(4):307-312. cmaj.ca/cgi/content/full/169/4/307 Prescriber 34(4), August 2011Australasian Society of Clinical Immunology and Allergy national guidelines (.au)The Australian Immunisation Handbook 10th Edition p 85-97. Back to Table of ContentsDefinition of Terms DET: Department of Education AMC: Alexander Maconochie CentrePDC: Periodic Detention Centre BYJC: Bimberi Youth Justice CentreBack to Table of ContentsSearch Terms Acute, Adrenaline, Adverse, Allergy, Anapen, Anaphylaxis, Epipen, Hypersensitivty, Immunisation, Podiatry, Reaction, Vaccine, VasovagalBack to Table of ContentsAttachmentsAttachment A: How to Use an Epipen or AnapenAttachment B: Anaphylaxis Emergency Treatment Plan for Schools and PreschoolsAttachment C: Adverse Event Following Immunisation (AEFI) FormAttachment D: Basic Life Support ChartDisclaimer: This document has been developed by Health Directorate, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.Date AmendedSection AmendedApproved By01/02/2016RACC and School Immunisation information addedCHHS Policy Committee 11/07/2017Title changed and removal of Special schools sectionCHHS Policy CommitteeAttachment A: How to Use an Epipen or Anapen:Attachment B: Anaphylaxis Emergency Treatment Plan for Schools and PreschoolsAttachment C: Adverse Event Following Immunisation (AEFI) FormAttachment D: Basic Life Support Chart ................
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