PROTOCOL AND PROCEDURES FOR ALLERGIC REACTIONS, INCLUDING ACUTE ANAPHYLAXIS IN ADULTS, INFANTS AND CHILDREN DEFINITIONS Allergic

reactions that are potentially life-threatening (anaphylactic) reactions, after exposure to an antigen which has been injected, ingested or inhaled. Reactions range from mild, self-limited symptoms to rapid death: 1. Mild to moderate allergic reactions involve signs and symptoms of the gastrointestinal tract and skin. Observing the client for rapid increase in severity of signs and symptoms is important, as the sequence of itching, cough, dyspnea and cardiopulmonary arrest can lead quickly to death. Severe/anaphylactic reactions involve signs and symptoms of the respiratory and/or cardiovascular systems. These may initially appear minor (i.e., coughing, hoarseness, dizziness, mild wheeze) but any involvement of the respiratory tract or circulatory system has the potential to rapidly become severe. Death can occur within minutes. Therefore, prompt and effective treatment is mandatory if the clients life is to be saved.

2.

ETIOLOGY

Agents commonly associated with allergic reactions/anaphylaxis, include: 1. Antibiotics (especially penicillin). 2. Biologicals (non-human sera, gamma globulin, vaccines, blood and blood products). Local anesthetics. Hymenoptera stings (bee, yellow jacket, wasp, hornet, fire ants). Allergy extracts (skin-testing and treatment solutions). Foods (especially eggs, nuts and shellfish). Intravenous narcotics (heroin). Alternative medicines (e.g., herbal or home remedies). Environmental agents (e.g., pollens, grasses, molds, smoke, animal dander).

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SUBJECTIVE & OBJECTIVE

1.

In 1-15 minutes clients may develop: a. Apprehension. b. Flushing and/or skin edema. c. Palpitations. d. Numbness and tingling. e. Itching. f. Localized or generalized urticaria (rash, welts). g. Choking sensation. (Indicates laryngeal edema which may precipitate closure of the airway.) h. Coughing and wheezing. i. Difficulty breathing. j. Nausea and vomiting. k. Dizziness and fainting. Severe respiratory compromise or shock may develop rapidly with severe hypotension and vasomotor collapse.

2.

ASSESSMENT

Allergic reaction, severe (any respiratory or circulatory signs/symptoms; anaphylaxis) to mild or moderate THERAPEUTIC 1. Mild (minor) or Moderate Reactions (absolutely no respiratory or circulatory signs) Step 1 Diphenhydramine PO or IM NOTE: Children younger than 2 years of age should receive diphenhydramine only under the direction of a physician.

PLAN

For itching, redness, welts/hives without respiratory or circulatory signs or gastrointestinal symptoms of cramplike pain with nausea, vomiting or diarrhea. Diphenhydramine Oral Dosing 12.5 mg/5 mL elixir/solution, OR 25 mg or 50 mg capsules Child older than 2 years of age: 1.25 mg/kg/dose (max 50mg) PO STAT Adult: 50 mg to 100 mg PO STAT Diphenhydramine IM Dosing 1 mg/kg body weight, up to 100 mg

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Diphenhydramine Oral Dosing Chart, Elixir/Solution (12.5 mg/5 mL)

Weight (kg) 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Diphenhydramine Oral Elixir/Solution Dose (mL) 4.5 mL 5 mL 5.5 mL 6 mL 6.5 mL 7 mL 7.5 mL 8 mL 8.5 mL 9 mL 9.5 mL 10 mL 10.5 mL 11 mL 11.5 mL 12 mL Weight (kg) 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 Diphenhydramine Oral Elixir/Solution Dose (mL) 12.5 mL 13 mL 13.5 mL 14 mL 14.5 mL 15 mL 15.5 mL 16 mL 16.5 mL 17 mL 17.5 mL 18 mL 18.5 mL 19 mL 19.5 mL 20 mL

OR Diphenhydramine IM Dosing
(Dosing by body weight is preferred.) (The standard dose is 1 mg/kg body weight, up to 100 mg) Weight* lbs (kg)
24-37 (11-17) 37-51 (17-23) 51-77 (23-35) 77-99 (35-45) >99 (>45)

Diphenhydramine Dose (Injection: 50 mg/mL)

15 mg / 0.3 mL 20 mg / 0.4 mL 30 mg / 0.6 mL 40 mg / 0.8 mL 50 to 100 mg / 1 2 mL

Step 2 Step 3 Step 4 Step 5

Complete Allergic Reaction Record Observe for 60 minutes If any respiratory or circulatory signs develop, proceed to 2. below (Severe Reactions) If, after 60 minutes, the clients symptoms are still limited to the skin and the client is comfortable, then: a. Tell client to take diphenhydramine every 6 hours as long as any signs/symptoms are present. b. Inform the client that he/she has an apparent allergy to the causative agent and advise that this information should be provided to all healthcare givers in the future.
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Emergency Protocol, Policy and Guidelines

If the causative agent was a medication being dispensed for additional use at home, then this plan should be reconsidered and an alternative medication should be used that is in a different chemical family which is not regarded as having cross-reactivity with the causative agent. NOTE: Skin reactions that are extensive, but absolutely confined to the skin, do not qualify as severe allergic reactions; however, if tongue swelling is involved, this does represent an anaphylactic reaction if present, proceed to 2. below. Severe lip swelling (huge, bordering on grotesque) may indicate additional swelling in the oropharynx if present, proceed to 2. below. 2. Severe Reactions (remember, severity is defined by the presence of any respiratory or circulatory signs/symptoms, e.g., wheezing, laryngeal edema [stridor], hypotension, whether these be mild, moderate or severe in themselves, OR tongue swelling or severe lip swelling). Step 1 Call for HELP a. Have someone call EMS/911 and/or the physician. b. Assign one person to keep the anaphylaxis record and be the timekeeper. c. Do not leave the client unattended! If the client received an immunization, apply a tourniquet above the injection site, if possible, to reduce systemic absorption of the antigen. Procedures a. Place patient in supine POSITION, legs elevated. b. Assure OPEN AIRWAY and begin CPR if indicated. c. Begin monitoring VITAL SIGNS with BP every 5 minutes. d. Help to maintain position of comfort (sitting if wheezing; supine with legs elevated if lightheaded or in shock). e. Oxygen at 4-6L/minute by nasal cannula, face mask OR blow-by, if indicated and available. f. Monitor with pulse-oximeter, if available.
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c.

Step 2

Step 3

Emergency Protocol, Policy and Guidelines

Step 4

Administer epinephrine NOTE: Administer into thigh (more effective at achieving peak blood levels than into deltoid area). Epinephrine IM Dosing

(Dosing by body weight is preferred; the standard dose is 0.01 mg/kg body weight [including for low birth weight babies], up to 0.5 mg.) Weight* Epinephrine IM Dose lbs (kg) (1mg/ml=1:1,000 wt/volume)
<9 (<4) 9-15 (4-7) 15-24 (7-11) 24-31 (11-14) 31-37 (14-17) 37-42 (17-19) 42-51 (19-23) 51-77 (23-35) 77-99 (35-45) >99 (>45)
Weigh baby and calculate appropriate dose

0.05 mg/0.05 mL 0.10 mg/0.10 mL 0.13 mg/0.13 mL 0.16 mg/0.16 mL 0.18 mg/0.18 mL 0.20 mg/0.20 mL 0.30 mg/0.30 mL 0.40 mg/0.40 mL 0.50 mg/0.50 mL May repeat every 15-20 minutes PRN for a total of 3 doses (<1.5 mL [1.5 mg] total)

Step 5

Give corticosteroid (methylprednisolone) to decrease the incidence and severity of delayed reactions. Corticosteroids may not influence the acute course of the reaction; therefore, they have a lower priority than epinephrine.

Methylprednisolone Sodium Succinate IM Dosing

(Dosing by body weight is preferred.) (The loading dose is 2 mg/kg/dose, then 1mg/kg body weight every 6 hours for up to 5 days) Weight* lbs (kg)
<9 (<4) 9-15 (4-7) 15-24 (7-11) 24-37 (11-17) 37-51 (17-23) 51-77 (23-35) 77-99 (35-45) >99 (>45)

Methylprednisolone Sodium Succinate Loading Dose (Injection: 125mg/2mL)

Weigh baby and calculate appropriate dose 14 mg / 0.22 mL* 22 mg / 0.35mL* 34 mg / 0..54 mL* 46mg / 0.74 mL* 70 mg / 1.12 mL* 90 mg / 1.44 mL*
Weigh and calculate appropriate dose

* based on maximum weight in category

Step 6

Assure that the Allergic Reaction/Anaphylaxis Record (see pp. 14.11-14.12) has been completed and a copy given to EMS personnel before they transport the client.
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Emergency Protocol, Policy and Guidelines

CLIENT EDUCATION/COUNSELING When a client is given an agent (e.g., antibiotic or vaccine) capable of inducing anaphylaxis, he/she should be advised or encouraged to remain in the clinic for at least 30 minutes. REFERRAL 1. Immediately refer clients with wheezing, laryngeal edema, hypotension, shock or cardiovascular collapse. Refer to primary care provider for further evaluation those clients with itching, redness welts/hives.

2.

FOLLOW-UP 1. 2. Place an allergy label on the front cover of the clients medical record. Educate the client/caretaker about medical alert bracelets for anaphylactic reactions. If the allergic reaction is immunization-induced, complete a vaccine adverse event record (VAERS).

3.

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ALLERGIC REACTION / ANAPHYLAXIS RECORD page 1 District/Clinic Site __________________________________________ Date _________________ Client Demographic Information: Name: ______________________________________ DOB _____/_____/_____ AGE ________ months / years Estimated/Actual Weight
(please circle one)

Infant / Child / Adult _____lbs/kg

Event which preceded reaction: _____ Immunization _____ Medication administered _____ Biologicals administered _____ Other: (please explain) ________________________________________________ TIME OF REACTION: ______ AM / PM Signs and Symptoms: (please check) _____ Apprehension _____ Flushing and/or skin edema _____ Palpitations _____ Numbness and tingling _____ Itching _____ Localized or generalized urticaria (rash, welts) TIME EMS CALLED: ______ AM / PM

_____ _____ _____ _____ _____ _____ _____

Choking sensation Coughing/hoarseness/wheezing Difficulty breathing Nausea and vomiting Severe hypotension Vasomotor collapse Loss of consciousness

Other (e.g., dizziness): ___________________________________________________________ OTHER OBSERVATIONS / COMMENTS: _____________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ SIGNATURE OF RN/APRN: __________________________________________________________ DISPOSITION: __________________________________________________________________ REVIEWER: ____________________________________________________________________ NOTE: Send copies of both pages of this record with client referred to a physicians office or hospital

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ALLERGIC REACTION / ANAPHYLAXIS RECORD page 2

1. Call for HELP. Have EMS called. Assign timekeeper/recorder. Client Name:___________________________

DOB:_________________ 2. Assure AIRWAY. Check VITAL SIGNS q 5 minutes. CPR if necessary.

3. FOR ITCHING, REDNESS, WELTS/HIVES OR GI SYMPTOMS: Diphenhydramine 12. 5 mg/5 mL Elixir OR Diphenhydramine 25 mg or 50 mg Capsules CHILD at least 2 years of age 1.25 mg/kg/dose (up to 50 mg) PO, once ADULT 50-100 mg PO, STAT

VITAL SIGNS Time B/P _____ _ __/_ __ _____ _ __/_ __ _____ _ __/_ __ _____ _ __/_ __ _____ __ _/_ __ _____ __ _/_ __ _____ __ _/_ __

Pulse ____ ____ ____ ____ ____ ____ ____

Resp __ __ __ __ __ __ __

OR Diphenhydramine 50 mg/mL (vial) IM

WEIGHT 24-37 lbs (11-17 kg) 37-51 lbs (17-23 kg) 51-77 lbs (23-35 kg) 77-99 lbs (35-45 kg) >99 lbs (>45 kg) IM DOSE 15 mg / 0.3 mL 20 mg / 0.4 mL 30 mg / 0.6 mL 40 mg / 0.8 mL 50 mg to 100 mg/1 -2 mL

CPR Indicated: ________YES ______NO TIME CPR started:__________AM / PM TIME CPR ended: __________AM / PM

Diphenhydramine 12.5 mg/5 mL (Elixir/Solution) OR 25 mg, 50 mg (Capsules) TIME ORAL DOSE ________ ________

4. FOR RESPIRATORY/CIRCULATORY SIGNS/SYMPTOMS Epinephrine 1 mg/mL = 1:1,000 wt/volume (w/v) WEIGHT IM DOSE
< 9 lbs (< 4 kg) 9-15 lbs (4-7 kg) 15-24 lbs (7-11 kg) 24-31 lbs (11-14 kg) 31-37 lbs (14-17 kg) 37-42 lbs (17-19 kg) 42-51 lbs (19-23 kg) 51-77 lbs (23-35 kg) 77-99 lbs (35-45 kg) >99 lbs (>45 kg) Weigh/calculate dose 0.05 mg / 0.05 mL 0.10 mg / 0.10 mL 0.13 mg / 0.13 mL 0.16 mg / 0.16 mL 0.18 mg / 0.18 mL 0.20 mg / 0.20 mL 0.30 mg / 0.30 mL 0.40 mg / 0.40 mL 0.50 mg / 0.50 mL

_______ _______

Diphenhydramine 50 mg/mL vial TIME _______ IM DOSE ________

Epinephrine 1:1000 w/v ampule TIME DOSE ROUTE _______ _______ _______ ________ ________ ________ IM IM IM

May repeat every 15-20 minutes as needed, for a total of 3 doses (no more than 1.5 mL [1.5 mg] total).

AND, to decrease intensity/severity of delayed reactions Methylprednisolone Sodium Succinate 2 mg/kg IM (according to dosing table on p. 14.10).

Methylprednisolone Sodium Succinate IM TIME DOSE ROUTE _______ IM

TIME EMS ARRIVED:___________AM/PM

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REFERENCES 1. K. F. Austen, Harrisons Principles of Internal Medicine, 17th ed., 2008, Chapter 311, Allergies, Anaphylaxis, and Systemic Mastocytosis, <http://www.accessmedicine.com/content.aspx?aID=2858746> (April 23, 2009). Lexi-Comp Online, Lexi-Comp, Inc., 2009 <http://online.lexi.com> (April 22, 2009). American Pharmaceutical Association, American Hospital Formulary Service, 2009, pp.17-20, 1389-1395. Karen M. Burke, Priscilla LeMone, Elaine L. Mohn-Brown and Linda Eby, Trauma or Critical Illness, Medical-Surgical Nursing Care, 2nd ed., 2007, Chapter 13, Caring for Clients Experiencing Shock, <http://online.statref.com/document.aspx?fxid=187&docid=149> (April 28, 2009). Mark Boguniewicz, Ronina A. Covar and David M. Fleischer, Diagnosis & Treatment: Pediatrics, 19th ed., 2008, Chapter 36, Allergic Disorders, <http://www.accessmedicine.com/content.aspx?aID=3409411> (April 23, 2009). Richard S. Krause, M.D., Anaphylaxis, Department of Emergency Medicine, State University of New York at Buffalo School of Medicine, <http://www.emedicine.com/emerg/topic25.htm#target1> (April 28,2009). Brian H. Rowe and Stuart Carr, J.E. Tintinalli, G.D. Kelen, J.S. Stapczynski, O.J. Ma and D.M. Cline, Tintinallis Emergency Medicine: A Comprehensive Study Guide, 6th Edition, 2004, Chapter 34, Anaphylaxis and Acute Allergic Reactions, <http://www.accessmedicine.com/content.aspx?aID=588677> (April 23, 2009). (Current)

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Emergency Protocol, Policy and Guidelines

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