1. Use of EPI-pen Dr Rida Javaid Iqbal Pediatric Resident Texas Tech University of Health Sciences

3. Anaphylaxis Life-threatening allergic reaction that may involve multiple body systems. Medical emergency Immediate intervention and treatment

4. Food Allergy Management Education: Challenges Limited education time – Not enough time to become competent or confident in food allergy management – Large Volume of Information – Significant Lifestyle Changes – Train the trainer Studies of parental knowledge demonstrate clear deficits in – Competency in epinephrine administration – Allergen avoidance – Information provision

5. Who is at risk? Risk Factors Delayed administration of epinephrine. Reliance on oral antihistamines alone to treat symptoms. Consuming alcohol and the food allergen at the same time. Groups at Higher Risk Adolescents and young adults. Children with a known food allergy. Children with a prior history of anaphylaxis. Children with asthma, particularly those with poorly controlled asthma.

6. Food Allergy Fatal and Near Fatal Anaphylaxis Most away from the home Unintentional ingestion with known food allergy Majority are peanut & tree nut Asthma is a significant risk factor Adolescents and young adults are at greatest risk ‐ 70% of mortalities between ages 12 and 21 Delayed or lack of administration of epinephrine – 88% of fatalities

7. How do you know? “my tongue feels funny”, “There’s a frog in my throat”, “There’s sth stuck in my throat” S&S Swelling eyes, lips, itchiness, flushing, hives, NVD, cramping, congestion, sneezing, wheezing, deep breathing, chest feels tight, hoarseness, pallor, cyanosis, dizziness, sense of ‘impending doom’ Takes 1 to 2hrs after exposure

8. Pillars of Food Allergy Management These must be applied at all times and in all settings: 1.Prevention Emergency 2.Preparedness

9. Prevention Routes of Food Allergen Exposure Oral Inhalation Skin Contact

10. Cross contact Allergens can be transferred by objects, saliva, and food Exposure to small amounts of allergen is enough to cause a serious allergic reaction Allergens withstand heating and drying Routine training for all caregivers about sources of cross ‐ contact and prevention of exposure is essential Saliva and pets can be a source of cross contact Be aware of the developmental level and capabilities of the child Different issues with different age groups

11. Cleaning to Prevent Cross‐Contact Establish a cleaning protocol to avoid cross ‐ contact What Works: Soap and water, commercial hand wipes, commercial cleaners, What Doesn’t: Hand sanitizers

12. In short.. Read Labels Prevent Cross-contact Avoid Hidden Ingredients

13. Emergency preparedness Must be applied at all times and places 1.Identify children with food allergies 2.Develop a plan to manage and reduce risk of food allergies 3.Help students manage their own food allergies

14. Implementation of SB 66 The Texas Legislature passed SB 66 in the 2015 Legislative Session. This bill allows for the stocking of epinephrine auto- injectors in Texas public schools and publicly funded charter schools to be used in case of emergency, and gives legal liability protection to those involved.

15. What is an emergency care plan? This form should be kept in each child’s school health record, and it may include the following: ° A recent photo of the child. ° Info about the food allergen, + a confirmed written dx from the doctor ° Info about S&S of the child’s possible reactions to known allergens. ° Info about the possible severity reactions, + any hx of anaphylaxis ° A Rx plan for responding to allergy reaction or emergency, including whether an epinephrine auto-injector should be used. ° Info about other conditions, such as asthma that might affect food allergy management. ° Contact info for parents and doctors, including alternate phone numbers for notification in case of emergency.

16. Food Allergy and Anaphylaxis Emergency Care Plan Simplified criteria to identify potential allergic emergencies for use by patients, families, caregivers and school staff Accessible and understandable Strongly encourage submission to school/daycare Train families to use ECPs

17. Food Allergy and Anaphylaxis Emergency Care Plan Clearly Convey the Critical Role of Epinephrine Auto ‐ injector Trainers Call 911 for Suspected Anaphylaxis

18. This is what auto injectors look like

19. What do they contain? Epinephrine AKA adrenaline Improves all symptoms immediately But is short acting

20. What to do.. Follow the anaphylaxis protocol Administer the epinephrine (always have 2 injectors ready) Call EMS Place patient on back with legs up Notify guardian Place AED, portable O2, ambu bag, pulse ox, nebulizer kit, albuterol, close to pt Vitals q 5 mins Bronchospasm? Give albuterol neb! Notify Health services, to reorder epinephrine Document

21. The biphasic reaction Food-induced anaphylaxis is SERIOUS Can cause death due t cardiopul compromise in 30mins to 2hrs of exposure 20% of the time, even if the initial symptoms are successfully treated, the anaphylaxis recurs within 4 to 8hrs. They might need additional emergency care.

22. Bust A Myth Myth Food allergy? Give antihistamine first Fact Epinephrine is the treatment of choice for anaphylaxis

23. Bust A Myth Myth Call an ambulance because epinephrine is dangerous Fact Call an ambulance because the reaction was bad enough to need epinephrine and might need additional treatment

24. Bust A Myth Myth The needle for epi pen is HUGE Fact The needle is shorter than the width of a dime

25. Bust A Myth Myth All anaphylactic reactions have skin reactions Fact 10 to 20% of anaphylactic reactions have NO skin problems

26. In short.. Know how and when to give epinephrine Always have 2 epinephrine doses available Call 911 for anaphylaxis

27. video https://youtu.be/EN83hen4D-Y

28. Sources Texas Allergy Asthma and Immunology Society Epipen.com CDC guidelines