MULTIDISCIPLINARY PROCEDURE
PROCEDURE FOR MANAGING AN ANAPHYLACTIC EMERGENCY
First Issued
Issue Version
June 2011
Two
Purpose of Issue/Description of Change
Planned Review Date
To promote safe and consistent practice when managing an anaphylactic emergency
2014
Named Responsible Officer:-
Approved by
Date
Medicines Governance Pharmacist
Quality, Patient Experience and Risk Group
April 2012
Multi Disciplinary Procedure
Target Audience
MMSOP24
All Clinical Services
UNLESS THIS VERSION HAS BEEN TAKEN DIRECTLY FROM TRUST WEB SITE THERE IS NO ASSURANCE THIS IS THE CORRECT VERSION
CONTROL RECORD Title Purpose Author Impact Assessment Subject Experts Document Librarian Groups consulted with :Date formally approved by Risk and Governance Group Infection Control Approved Method of distribution Archived Access
Procedure for Managing an Anaphylactic Emergency To promote safe and effective practice when managing an anaphylactic emergency Quality and Governance Service (QGS) Completed Yes No Actions Yes No Required Lisa Knight / Tom Meade / A Baker QGS Medicines Management Group 2nd April 2012 Yes - 28.04.2011 Email Date: June 2011
Intranet Location: S Drive QGS
VERSION CONTROL RECORD Version Number Version 1
Author Medicines Governance Pharmacist
Version 2
Medicines Governance Pharmacist
Status R/ TC
Changes / Comments Procedures now applies to all clinical services across the Trust
To incorporate NICE guidance
Status – New / Revised / Trust Change
PROCEDURE FOR MANAGING AN ANAPHYLACTIC EMERGENCY ACROSS THE TRUST 2/8
PROCEDURE FOR MANAGING AN ANAPHYLACTIC EMERGENCY INTRODUCTION Anaphylaxis can be triggered by a very broad range of triggers. Most commonly identified triggers in the UK include food, medicines and venom from insect stings. Trust staff may have to respond to an anaphylactic emergency resulting from any trigger; however it is essential that practitioners anticipate the possibility of an anaphylactic reaction occurring in a patient resulting from medication they may have administered or supplied to the patient. Anaphylaxis is more likely to occur after a number of exposures to a particular antigen, but it can take place when there has been no prior sensitisation. A staff member may only have seconds in which to deal with the situation effectively. Although an anaphylactic reaction can result from medication administered via any route, there is a higher possibility of a rapid onset anaphylactic reaction from an injected medication. All practitioners who administer any medication by injection or the application of topical products must therefore ensure they have access to an anaphylactic shock kit as detailed in this document P R OC E DUR E OUT C OME • Check allergy status of all patients prior to administration or supply of any medication • Distinguish between an anaphylactic reaction, fainting (syncope) and panic attacks • Respond appropriately to an anaphylactic emergency in a community setting T AR G E T G R OUP All clinical staff in Trust required to undertake this role T R AINING It is mandatory that all practitioners attend two yearly ‘Essential Learning’ training which includes basic management of anaphylaxis. Faculty of Sexual and Reproductive Healthcare Standards require Basic Life Support and Anaphylaxis training yearly, for all Cytology and Sexual Health Service staff. (October 2010) T R US T P OL IC IE S AND P R OC E DUR E S Refer to current Trust Policies and Procedures DE F INIT IONS Anaphylaxis Anaphylaxis is a severe, life-threatening, generalised or systemic hypersensitivity reaction. It is characterised by rapidly developing life-threatening airway and/or breathing and/or circulation problems usually associated with skin and mucosal changes PROCEDURE FOR MANAGING AN ANAPHYLACTIC EMERGENCY ACROSS THE TRUST 3/8
R E C OG NIT ION OF AN ANAPHYLACTIC REACTION Onset of anaphylaxis is rapid, typically within minutes and its clinical course is unpredictable with variable severity and clinical features this causes diagnostic difficulty. The most serious symptoms of anaphylaxis include cardiovascular collapse, bronchospasm, angioedema (localised oedema of the deeper layers of the skin or subcutaneous tissues), pulmonary oedema, loss of consciousness and urticaria. Asthmatic patients with anaphylaxis often develop bronchospasm. DIF F E R E NT IAL DIAG NOS IS Practitioners should be able to distinguish between an anaphylactic reaction, fainting (syncope) and panic attacks. Fainting is relatively common in adults and adolescents, but infants and children rarely faint. Sudden loss of consciousness in young children should be presumed to be an anaphylactic reaction, particularly if a strong central pulse is absent. A strong central pulse persists during a faint or seizure. Panic attacks should be distinguished from anaphylaxis. Symptoms include hyperventilation that may lead to paraesthesiae (numbness and tingling) in the arms and legs. There may be an erythematous rash associated with anxiety, although hypotension and pallor or wheezing will not be present. If the diagnosis is unclear, anaphylaxis should be presumed and appropriate management given C L INIC AL F E AT UR E S OF F AINT ING AND A NA P HY L AX IS Symptoms and/or signs
Fainting
Anaphylaxis
Skin
Generalised pallor, cold clammy skin
Respiration
Normal respiration- may be shallow, but not laboured
Cardiovascular
Bradycardia, but with strong central pulse, hypotensionusually transient and corrects in supine position. Sense of light-headedness, loss of consciousness –improves once supine or head down position, transient jerking of the limbs and eye-rolling which may be confused with seizure, incontinence Before, during or within minutes of vaccine administration
Neurological
Skin itchiness, pallor or flushing of skin, red or pale urticaria (weals) or angioedema Cough, wheeze, stridor, or signs of respiratory distress (tachypnoea, cyanosis, rib recession) Tachycardia, with weak/ absent central pulse, hypotension-sustained
Sense of severe anxiety and distress, loss of consciousness –no improvement once supine or head down position
Onset following Usually within 5 minutes, but can injected occur within hours of vaccine medication such administration as vaccine administration Taken from Chapter 8 Immunisation against infectious disease May 2011 PROCEDURE FOR MANAGING AN ANAPHYLACTIC EMERGENCY ACROSS THE TRUST 4/8
AL L E R G Y S T AT US • It is the responsibility of the practitioner administering any treatment - to assess the patient for the risk of development of an anaphylactic reaction e.g. determines any history of relevant allergies. • Any allergy must be recorded in the patient’s care plan or health record • Where there is any previous history of allergy to a particular medication, the medication should not be given and the authorised prescriber should be contacted for advice on alternative treatments • There is a risk of an anaphylactic reaction to any medication given by any route • If a medication has been prescribed for which there is a documented history of allergy in a particular patient, an incident form must be completed. ANA P HY L AC T IC S HOC K K IT Adrenaline may be administered to patients suffering from an anaphylactic emergency, in the absence of a prescription or Patient Group Direction. This is because it is exempt from prescription only status when it is used for the purpose of saving life in an emergency. The anaphylactic ‘shock kit’ contains:Adrenaline Injection 1:1000 (1mg in 1ml) for intramuscular use (Minimum of 5 kept in original manufacturer’s packaging with information leaflet) Hypodermic Needles (23G) x5 Hypodermic Syringes (1ml) x5 Pre–printed current laminated card with adrenaline dosage P R AC T IT IONE R R E S P ONS IB IL IT IE S • All health practitioners must identify where adrenaline is stored prior to any preparation for the administration of an injected medication • All health practitioners must have adrenaline available in either the clinical room or the patients home in the event of an anaphylactic reaction • All health practitioners who administer any medication by injection must ensure they have access to an anaphylactic shock kit on their daily visits. • All bank staff when covering for permanent staff must have access to an adrenaline ‘shock kit’ • Adrenaline should be stored in a locked cupboard in the clinical area when not in use. • Staff delivering care in community clinics must not draw up adrenaline in advance, adrenaline should only be drawn up for use when required to manage an anaphylactic reaction. • It is the responsibility of the practitioner to check that the ‘shock kits’ are complete and fully equipped and the adrenaline has not expired. • Do not split the manufacturer’s packaging. Essential product information is contained in the packaging with the medication. • If the patient lives alone the practitioner can administer the medication unassisted, provided there is access to a phone to summon appropriate help should an emergency occur
PROCEDURE FOR MANAGING AN ANAPHYLACTIC EMERGENCY ACROSS THE TRUST 5/8
• Adrenaline needs to be checked for discolouration prior to commencing visits/clinic sessions as adrenaline may be affected by extreme temperatures i.e. in a car and protected from direct sunlight. • All equipment must be stored safely in all environments. Follow manufacturer’s storage instructions. Note: Chlorphenamine (chlorpheniramine) and hydrocortisone are not first-line treatments and therefore are not included in the ‘shock kit’ MANAG E R S R E S P ONS IB IL IT Y • To monitor attendance at Essential Learning Training, via management supervision and annual appraisals • To ensure all staff have access to ‘anaphylactic shock kits’ and have a system in place to monitor compliance • Inform new starters of anaphylaxis distance learning resource, if required • All service managers must ensure the ‘shock kit’ is labelled property of Wirral Community NHS Trust and if found to return box to relevant service MANAG E ME NT OF AN ANA P HY L AC T IC E ME R G E NC Y Emergency contact number:• All staff must be familiar with the relevant emergency contact number for their base, as this differs across clinical premises on the Wirral. Also there is a need for a coordinated system to guide emergency staff to where the patient is, otherwise there can be a time delay in attending to the patient • If bank or agency staff are working with clinical teams they must be advised of procedure how to contact emergency services for that clinical area • Staff who are based at Wirral University Teaching hospital must follow their own service guidance on urgent referral to secondary care ANA P HY L AX IS IS AL W AY S AN E ME R G E NC Y S IT UAT ION R E QUIR ING IMME DIAT E AC T ION If a patient shows signs of anaphylaxis e.g. stridor; wheeze; respiratory distress or clinical signs of shock the following steps must be followed: 1. Telephone for an ambulance immediately (or if already on Arrowe Park Hospital site, arrange for urgent transfer to secondary care) and state that there is a case of suspected anaphylaxis 2. If available call for help from other Trust employed staff or responsible adult if needed and:• Assess the patient; check central pulses and respiration • Maintain a clear airway PROCEDURE FOR MANAGING AN ANAPHYLACTIC EMERGENCY ACROSS THE TRUST 6/8
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Lie the patient down, ideally with the legs raised (unless the patient has breathing difficulties or in the case of pregnant patients, lay the patient on their left side to prevent caval compression). Administer oxygen if available If breathing stops, mouth to mouth/mask resuscitation should be performed All patients with clinical signs of shock, airway swelling or definite breathing difficulties should be given adrenaline (epinephrine) 1:1000 1mg in 1ml administered by intramuscular (IM) injection (never subcutaneously). For information on dosing see below. The preferred site is the mid-point of the anterolateral aspect of the thigh. Stay with the patient at all times
Dosages of adrenaline (epinephrine) 1:1000 (1mg in 1ml) to be administered by intramuscular injection (IM) Age Dose of Adrenaline Volume of 1:1000 (1mg in (epinephrine) 1ml) Under 6 months 150 micrograms IM 0.15ml 6 months to under 6 150 micrograms IM 0.15ml years 6 – 12 years 300 micrograms IM 0.3ml Adults and children 500 micrograms IM 0.5ml over 12 years (or 300 micrograms if (or 0.3ml if patient is small or patient is small or prepre-pubertal) pubertal) •
If there is no improvement in the patient’s condition repeat the same dose at 5 minute intervals until the ambulance arrives (or patient has been transferred to secondary care), monitor pulse and respirations and blood pressure, if machine available.
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Because of the possibility of delayed reactions, all individuals who have had an anaphylactic reaction must be transferred immediately to secondary care, even if they may appear to have made a full recovery.
•
Record all care in the patient’s records including if known, the time of onset of the reaction and the circumstances immediately before the onset of symptoms. This information must be transferred with the patient to secondary care to help identify the possible trigger.
•
Complete a Trust incident form and inform line manager or on call duty manager, within at least an hour of the incident or earlier if practicable.
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Sexual Health Services to inform the doctor on duty at the clinic and the ‘on call manager’ for the Trust within at least an hour of the incident or earlier if practicable. If it is an evening clinic they should inform their line manager the next day.
PROCEDURE FOR MANAGING AN ANAPHYLACTIC EMERGENCY ACROSS THE TRUST 7/8
R E F E R E NC E S Anaphylaxis training resource pack can be accessed via the Trust intranet National Institute for Health and Clinical Excellence (2011) Anaphylaxis: assessment to confirm an anaphylactic episode and the decision to refer after emergency treatment for a suspected anaphylactic episode Department of Health (2011) Immunisation Against Infectious Disease, Chapter 8. Vaccine safety and the management of adverse events following immunisation. May. Emergency Treatment of Anaphylactic Reactions (2008) Resuscitation Council (UK) January. Faculty of Sexual and Reproductive Healthcare of the Royal College of Obstetricians and Gynaecologist (2010). Service Standards for Resuscitation in Sexual Health Services. October.
PROCEDURE FOR MANAGING AN ANAPHYLACTIC EMERGENCY ACROSS THE TRUST 8/8
