2019 bev unger, rn - ontario camps association · april 2019 bev unger, rn global rate of...

OCA Health Conference

2019

Bev Unger, RNOCA Health Care Committee

Camp Robin Hood:

Director Health and Wellness

April 2019 Bev Unger, RN

• Occurrence

• Triggers

• Risk Factors

• Signs and Symptoms of an Anaphylactic Reaction

A brief overview

Anaphylaxis

• considerations when administering Epinephrine

• Administration options

Treatment Options

• Identification of the individual with anaphylaxis

• Establish relationship with family

• Anaphylactic Emergency Plan

• Raising Awareness

• Staff Training

• How to avoid exposure to an allergen

• Camp program considerations

Camp Protocols:

Keeping Camps Safe for Campers


World Allergy Organization definition:

Anaphylaxis is an acute, potentially life-threatening hypersensitivity reaction, involving the release of mediators from mast cells, basophils and recruited inflammatory cells.

Anaphylaxis is defined by a number of signs and symptoms, alone or in combination, which occur within minutes, or up to a few hours, after exposure to a provoking agent.

It can be mild, moderate to severe, or severe. Most cases are mild but any anaphylaxis has the potential to become life-threatening.

Anaphylaxis develops rapidly, usually reaching peak severity within 5 to 30 minutes, and may, rarely, last for several days. [1]


"a serious allergic reaction that is rapid

in onset and might cause death.” [2]



Global rate of occurrence from all triggers is unknown because of: under-recognition by patients and caregivers…

under-diagnosis by healthcare professionals….

under-reporting….

Hospital admissions increasing…..

under 18 years more than doubled from 2000 - 2009……

more pronounced in aged 5–14 years [3]

2009-2010

estimated 8% of USA children have food allergy

2.4% have multiple food allergies

about 3% experience severe reactions [4]


Figure 1

FOOD

STINGING INSECTS

NATURAL LATEX

MEDICATIONS

EXERCISE

UNKOWN CAUSES (idiopathic)


Peanuts

Tree nuts(Almonds, Brazil nuts, cashew nuts, hazelnuts, macadamia nuts, pecans, pine nuts, pistachios, walnuts)

Seafood Fish Crustaceans (crab,

crayfish, lobster, shrimp) Shellfish(clams,mussels,oysters,

scallops)

Eggs

Milk

Wheat

Soy

Sesame

Sulfites (food additives)

Mustard

not an inclusive listMore than 200 allergens


Honey BeesBumble Bees

Yellow Jackets

Hornets

Wasps

Fire Ants


Surgical gloves

Dental supplies

Condoms

Erasers

Bandages (i.e.: Band-Aid®)

Balloons

Carpet backing

Fidget toys

Sport Balls

Medical tubing / supplies


Not Common

A combination of exercise and other

contributing factors such as food,

weather conditions, or medications can

cause exercise-induced anaphylaxis.

Itching, hives, swelling, nausea, tiredness

common – any anaphylactic S & S


Trigger is unknown

Hard to diagnose

Very frightening type of anaphylaxis as unable to identify allergy


• People with asthma andanaphylaxis are more susceptible to severe breathing problems during an anaphylactic reaction

• Epinephrine can be used to treat life-threatening asthma attacks.

Asthma

• Epinephrine must be given early

• There are no contraindications to using epinephrine for a life-threatening allergic reaction

Delay in use of

Epinephrine Auto injector

• Beta-blockers and ACE Inhibitors (Angiotensin Converting Enzyme) may slow down the effect of epinephrine and worsen allergic reaction

Underlying Cardiac Disease


Asthma a chronic inflammatory disease of the airway

Eczema a skin condition that causes redness and itching

Eosinophilic Esophagitis (EoE) a swallowing disorder that affects the esophagus

an allergic response that happens when eosinophils (a type of white blood cell) collect in the esophagus

Food Protein-Induced Enterocolitis Syndrome (FPIES) an inflammation involving both the small and large

intestine

Food Intolerance different than food allergies, involves the digestive

system.

Oral Allergy Syndrome an allergic reaction to certain proteins in fruit,

vegetables and nuts



Signs & Symptoms

of an

Anaphylactic Reaction


Symptoms of anaphylaxis generally include two or more of the following body systems:

Figure 2

Range from:

Mild – rash or hives – sometimes NO hives!

To severe - life threatening

- difficulty breathing and sudden drop in BP

The initial presentation can be delayed

S & S could develop rapidly - no way to tell how quickly a

reaction may progress

May develop some symptoms, but usually not all

There is no "typical” reaction

every reaction may be different

Effects many different body systemsApril 2019 Bev Unger, RN

Swelling of the airways

Difficulty breathing

a severe asthma attack for people who have asthma

A drop in blood pressure

causing dizziness, light-headedness, feeling faint

or weak, or passing out

Without immediate medical aid death can occur


The first step

to control an anaphylactic

reaction is to administer

Epinephrine

ASAP!


Synthetic form of the hormone adrenaline

MUST be administered immediately!

Used for potentially life threatening allergies

Can be used for severe asthma attacks

Reverses symptoms of anaphylaxis by:

opening the airways

increasing blood pressure

accelerating heart rate



Epinephrine Auto Injector

EAI

EpiPen® The Right Dose Matters!

“Canadian Society of Allergy and Immunology (CSACI) has issued a new

Position Statement clarifying the need to treat all incidents of

anaphylaxis with an epinephrine auto-injector, stating that the risks of

using epinephrine for a child weighing under 15 kg are “expected to

be mild and transient” — but the consequences of not using an

epinephrine auto-injector “can include fatality.” [5]

The amount recommended by the CSACI is equivalent to an EpiPen Jr.

……0.15 mg/0.15mL (1mg/mL). [5]


Ampoules


• Inexpensive

• Skill set to prepare

and administer

Incorrect & Correct Technique


Figure 3 Figure 4

Who can administer the Auto Injector?

YOU !!!!!An individual may NOT be able to self-

administer their epinephrine

You may need to do it for them!

BUT can you???

If you have access to an EAI can you give it?

There are no contraindications!

Better safe than sorry???


Avoid Injuries

Hold a squirmy child's leg to

avoid movement

Hold EpiPen for a few

seconds only!

Hold the injector firmly


Figure 5


Figure 6

Proposed child restraint options

for the administration of an epinephrine auto-injector. [9]


Site – Intramuscular injection in the lateral thigh (vastus lateralis muscle)

Difficulty breathing: sit in an upright position

Sitting or standing may cause drop of BP

Feeling faint or dizzy: Place on back with legs raised above heart

level

If pale - lift the tail

Vomiting: Place on side

Call 911 after administration of Epi

Epinephrine is light sensitive store at a temperature between 15-30° C

Ok outside in a bag / fanny pack at camp

Hang out of direct sunlight when not worn

Check solution window regularly Ensure no brown discoloration or precipitate

Check the expiry date Short shelf life – approx 12 months

Do not refrigerate

Tube is NOT waterproof


The need for a 2nd dose of epi cannot be predicted

Always have 2 or more auto injectors available

At least one must be carried by the individual

2nd (the spare) kept in an UNLOCKED location

2nd dose may be given as early as 5 minutes after the first doseIf symptoms are not improving or getting worse

Signs of a reaction getting worse may be increased breathing difficulty, decreased level of consciousness, fainting

More than 2 doses should only be given under medical supervision= consider this before sending campers on a trip!


Antihistamines

Benadryl or other antihistamines should

NOT be used as the first line of treatment

Antihistamines:

will not stop an anaphylactic reaction

can be used as secondary medication for hives and skin reactions


Identification of the person who is anaphylactic

Establishing relationships with family

Anaphylactic Emergency Plan

Raising Awareness

Staff Training

How to avoid exposure to an allergen

• Food Policies / Kitchen / Meal Time

• Maintenance

Program Considerations

• Activity areas

• Swim and Waterfront

• Out Tripping and Off Site Excursions


Identification of the allergic individual and the

allergy should be on the :

Camp Registration Form

The Camp Health Card / Form

Ana Poster

See Food Allergy Canada web site for sample posters

Identification of the Auto Injector:

Label the auto injector if there is no pharmacy label

Easily identifiable bag/ case/ fanny pack for camper

to carry auto injector


Health Staff should speak with a guardian before

camper’s first day to discuss:

Camp Anaphylaxis Emergency Plan

Full medical history

Details of allergy and management

Documentation - is it complete?

Health form, emergency contact info, ana action plan

How the camper will carry their EAI at camp

Substitution of food if required for special events



A poster with clear instructions on how to treat symptoms and strategies to reduce risks.

The plan should have a photo of the individual

The action to be taken after an EAI administration

Emergency contact information

*See Food Allergy Canada Web site for a sample form

Communicate with your camp community

(all families, all staff, bus drivers )

and inform them of anaphylactic allergies

Ask all families to:

read labels before sending food to day camp

Avoid sending food to overnight camp

Have campers wash hands and mouth before & after eating

Talk to campers about not sharing food


Everyone

counsellors, kitchen, bus drivers, life guards, program specialists, senior staff

Identify who has the anaphylactic allergies

What the allergy is

Precautions for avoiding exposure

S & S of an anaphylactic reaction

How to initiate the camps emergency plan

Location of EAI – easily accessible!

campers should carry their own!

camps supply

When, how and who is to administer an EAI

When to deliver a second dose of epinephrine

What to do after an EAI is given

The unknown allergic reaction – action planApril 2019 Bev Unger, RN

Food policies should include:

allergy “aware” or “safe” – NOT “free”

no food from home (overnight camps)

eat only food from own home (day)

no sharing of food policies!

read labels

know ingredients and alternate names

connect with food suppliers for lists of ingredients – share

with parents so they can substitute where necessary


Kitchen Avoid cross-contamination during food prep AND serving

Use allocated utensils

knowledge of food and ingredients:

Alternate names for ingredients

Is it a nut or a seed?

designated sponges and cloths

clean all surfaces well with proper cleanser


Meal and Snack Time

Staff should have knowledge of food ingredients / names

Know the campers and their allergies

Meal and snack time supervision = active observation

No “peanut free tables” – eliminate nuts!

peanut is extremely potent and often hidden

“schools with peanut-free tables, compared with those

without, had lower rates of reactions: 2 versus 6 per 100,000

student” [4]

Watch for insects flying into open juice boxes and onto straws

Hand washing is a must - before and after eating!

hand sanitizer is not substitute


Maintenance

Removal of hives or nests = immediate!

Keep lids on garbage cans to avoid insects

Weed and grass control to decrease bees

Good hand washing done by all

Clean with appropriate cleansers


Activity Areas

be aware of food and other products used

i.e.: eggs, pine cones, marshmallows (fish

gelatin in kosher marshmallow), bird seed

often contains nuts etc…

wash all surfaces well – dish soap is not effective

substitiute food related prizes or rewards


Swim and Waterfront Make sure the “fanny pack” is

hung or held in a secure location central easy access to everyone

Keep the auto-injector Dry If wet – discard!

Out of direct sunlight

Pick up of the “fanny pack” at the end of the period


Out Tripping and Off Site Excursions

Who administers the auto injector? Anyone who is trained Individual themselves – IF able! Must know where auto-injectors are stored

Must carry back ups / spare auto injectors A second dose may be necessary

Safe Storage Separate auto injectors into 2 different areas

if one is lost still have one

To keep from overheating: pack in middle of packs bottom of canoe so cooled by water

Access to doctor or health staff by phone

After administration – immediate EMS!


Remember……

Epinephrine is the first-line medication for anaphylaxis.

Antihistamines and asthma meds can be used after epinephrine, if needed

A second dose of epinephrine may be given as early as 5 minutes after the first

dose if symptoms do not improve or become worse.

Call 911 as soon as an allergic reaction is expected

Persons feeling faint or dizzy should lie down

Always go to to hospital is necessary (ideally by ambulance)

Phone emergency contact!


Keeping Camps Safe for

Campers With Anaphylaxis

Have up to date allergic protocols

Display ana posters in appropriate areas

Staff can identify the S & S

Those who are anaphylactic carry their own EAI

Make sure the right people know how to administer

the EAI

These steps May SAFE A LIFE!April 2019 Bev Unger, RN


On line training module and certificates:Allergyaware www.allergyaware.ca EpiPen® www.epipen101.ca

World Allergy www.worldallergy.org/anaphylaxis/

EpiPen® www.epipen.ca and www.epipen.com

Food Allergy Canada (formerly Anaphylaxis Canada)

www.foodallergycanada.cawww.allergysafecommunities.cawww.safe4kids.ca

A site for teens / youth www.whyriskit.ca

Food Allergy Research and Education (FARE) foodallergy.org

Allergy Safe Communities allergysafecommunities.ca

Allergy/Asthma Information Association (AAIA) www.aaia.ca

Sabrina’s Law Regulation 137/15 (anaphylaxis) and Ryans Law (asthma) www.edu.gov.on.ca/eng/healthyschools/anaphylaxis.html

Health Canada www.hc-sc.gc.ca/

Prescribing Information EpiPen® Mylan, January 12, 2017 www.pfizer.ca/pm/en/EPIPEN.pdfAsthma and Allergy Foundation of Americawww.aafa.org/page/anaphylaxis-in-america.aspx


Anaphylaxis in Schools & Other Settings, 3rd Edition

available from www.foodallergycanada.ca

On line:

http://foodallergycanada.ca/wp-content/uploads/Anaphylaxis-in-Schools-

Other-Settings-3rd-Edition-Revised_a.pdf

AAIA Anaphylaxis Reference Kit Allergy/Asthma Information Association

Available on line:

http://www.aaia.ca/en/anaphylaxis_reference_final.pdf

http://www.foodallergycanada.ca/

http://foodallergycanada.ca/wp-content/uploads/Anaphylaxis-in-Schools-Other-Settings-3rd-Edition-Revised_a.pdf

http://www.aaia.ca/en/anaphylaxis_reference_final.pdf


1. Lockey, Richard F. “Anaphylaxis: Synopsis.” WAO, Sept. 2012, www.worldallergy.org/professional/allergic_diseases_center/anaphylaxis/anaphylaxissynopsis.php.

2. Simons, F Estelle R, et al. “World Allergy Organization Guidelines for the Assessment and Management of Anaphylaxis.” World Allergy Organization Journal, BioMed Central Ltd, 23 Feb. 2011, www.waojournal.org/content/4/2/13.

3. Simons, F. Estelle R., et al. “2015 Update of the Evidence Base: World Allergy Organization Anaphylaxis Guidelines.” World

Allergy Organization Journal, BioMed Central, 28 Oct. 2015, waojournal.biomedcentral.com/articles/10.1186/s40413-015-0080-

1.

4. Sampson, Hugh A. “Food Allergy: A Review and Update on Epidemiology, Pathogenesis, Diagnosis, Prevention, and

Management.” Journal of Allergy and Clinical Immunology, vol. 141, no. 1, Jan. 2018, pp. 41–58.,

doi:https://doi.org/10.1016/j.jaci.2017.11.003.

5. “Epinephrine for Infants and Toddlers: New CSACI Position Statement.” Food Allergy Canada, 19 Dec. 2015,

foodallergycanada.ca/2015/12/epinephrine-for-infants-and-toddlers-canadian-allergists-position-statement/.

6. Anaphylaxis in Schools and Other Settings. 3rd ed., Canadian Society of Allergy and Immunology, December 2005, Revised

third printing: August 2016

7. AAIA Anaphylaxis Reference Kit . Allergy/Asthma Information Association, 2004 – Revised June 2007 and October 2014

8. “Food Allergens.” Food Allergy Canada, foodallergycanada.ca/about-allergies/food-allergens/

9. Posner, Larry S, and Carlos A Camargo. “Update on the Usage and Safety of Epinephrine Auto-Injectors, 2017 Usage and Safety

of Epinephrine Auto-Injectors, 2017.” Drug, Healthcare and Patient Safety, Dove Medical Press, 21 Mar. 2017,

www.ncbi.nlm.nih.gov/pmc/articles/PMC5367766/

Figure 1:Allergic Reactions - https://goo.gl/images/FZDhfW

Figure 2: https://foodallergycanada.ca/food-allergy-basics/preventing-and-treating-allergic-reactions/reaction-signs-and-symptoms/

Figure 3: shutterstock.com, Oswald, Kirsty. “All Schools Can Now Purchase Emergency Adrenaline Auto-Injectors without Prescription.” The Pharmaceutical Journal, 2 Oct. 2017, doi:10.1211/pj.2017.20203662.

Figure 4:Medscape, https://img.medscape.com/thumbnail_library/am_151013_epipen_epinephrine_800x600.jpg

Figure 5: American College of Emergency Physicians. "EpiPens save lives but can cut like a knife." ScienceDaily. ScienceDaily, 8 October 2015. www.sciencedaily.com/releases/2015/10/151008142408.htm

Figure 6: Proposed child restraint options for the administration of an epinephrine auto-injector.

Note: Reprinted from The Journal of Allergy and Clinical Immunology: In Practice, Volume 4/edition 3, Brown JC, Tuuri RE, Lacerations and embedded needles due to EpiPen use in children, Pages 549–551


https://goo.gl/images/FZDhfW

https://foodallergycanada.ca/food-allergy-basics/preventing-and-treating-allergic-reactions/reaction-signs-and-symptoms/

https://img.medscape.com/thumbnail_library/am_151013_epipen_epinephrine_800x600.jpg

http://www.sciencedaily.com/releases/2015/10/151008142408.htm

2019 bev unger, rn - ontario camps association · april 2019 bev unger, rn global rate of...

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