1. Allergies & Anaphylaxis
Staff will have an increased awareness and understanding of anaphylaxis including:
identification of signs and symptoms of anaphylaxis
avoidance strategies
emergency treatment protocols; what to do in an emergency and how to use a single use, single-dose auto-injector

2. What is an Allergy? Allergies occur when the immune system becomes
unusually sensitive and overreacts to common
substances that are normally harmless. Examples are:
Foods – eggs, milk, peanuts/nuts, shellfish and some food additives
Stings from bees, wasps, hornets and some ants
Medications – penicillin, sulfa drugs
Exercise
Latex (gloves/medical devices)
9 priority food allergens: eggs, milk, peanuts, tree nuts, soy, shellfish, wheat, sesame seeds and sulphites (food additives)

3. What is Anaphylaxis?
Occurs when a person is exposed to an allergen causing a severe, life-threatening allergic response
Reactions can occur within minutes of exposure to an allergen, but can be delayed for 2-3 hours
Affects various organ systems including the skin, respiratory, cardiovascular and gastrointestinal
Anaphylaxis is a serious, acute, allergic reaction that may cause death. It has a sudden onset and generally lasts less than 24 hours. Because anaphylaxis is a generalized reaction, a wide variety of clinical signs and symptoms may be observed.

4. Why is this life-threatening?
Causes airway obstruction/lack of oxygen to the brain
Increases risk of SHOCK, which leads to widespread tissue damage, organ failure and eventually death
Delayed reactions (reactions usually occur within 2 hours of exposure, but in rarer cases can develop hours later)
Bi-phasic reactions (as many as 25% of people who have an anaphylactic reaction will experience a recurrence in the hours following the beginning of the reaction and require further medical treatment, including additional epinephrine injections)
Relationship with asthma (people with asthma who are diagnosed with anaphylaxis are more susceptible to severe breathing problems when experiencing an anaphylactic reaction. If there is uncertainty whether or not the person is experiencing an anaphylactic reaction or asthma attack, epinephrine should be used first. Epinephrine can be used to treat life-threatening asthma attacks as well)

5. Prevention = Having a Plan
Check the School Medical Alert List to familiarize yourself with students in your school/class who have medical conditions and allergies
Note all students who require single dose, single-use auto-injectors (EpiPens) and where these are stored for each student
Review emergency care plans for individual students
Recognize allergy sources and triggers
Know how and when to administer medication
How do I store my EpiPen®?
A.   Always store EpiPen® in the carrier tube with the safety release on until you need to use it. Store at 25°C (77°F); EXCURSIONS PERMITTED TO 15°-30°C (59°-86°F). Do not refrigerate. Protect from light. Periodically check to make sure the solution in the EpiPen® is not brown in colour. Replace if it is discoloured or contains a precipitate.
Having a plan: Teachers and school should have a plan for inside and outside the classroom. Consider the use of student runners to get help.
Consider field trips (where is auto-injector located, how many are being brought, location of nearest emergency services, access to cell phone, protecting auto-injector from extreme temperatures i.e. ski trip or beach trip)

6. Common Symptoms
Skin – hives , swelling, itching, warmth, redness, rash
Respiratory (breathing) – wheezing, shortness of breath, throat tightness, cough, hoarse voice, chest pain/tightness, nasal congestion or hay fever-like symptoms (runny itchy nose and watery eyes, sneezing), trouble swallowing
Review common symptoms. Specific symptoms, severity and intensity can vary from person to person and sometimes from attack to attack in the same person)
The Food Allergy & Anaphylaxis Network (
How a Child Might Describe a Reaction
Children have unique ways of describing their experiences and perceptions, and allergic reactions are no exception. Precious time is lost when adults do not immediately recognize that a reaction is occurring or don’t understand what a child is telling them.
Some children, especially very young ones, put their hands in their mouths or pull or scratch at their tongues in response to a reaction. Also, children’s voices may change (e.g., become hoarse or squeaky), and they may slur their words.
The following are examples of the words a child might use to describe a reaction:
• “This food’s too spicy.” • “My tongue is hot [or burning].” • “It feels like something’s poking my tongue.” • “My tongue [or mouth] is tingling [or burning].” • “My tongue [or mouth] itches.” • “It [my tongue] feels like there is hair on it.” • “My mouth feels funny.” • “There’s a frog in my throat.” • “There’s something stuck in my throat.”
• “My tongue feels full [or heavy]. • “My lips feel tight.” • “It feels like there are bugs in there.” (to describe itchy ears) • “It [my throat] feels thick.” • “It feels like a bump is on the back of my tongue [throat].”
Revised July 2009

7. Hives and Swelling of face
Anaphylactic Reaction
Normal appearance
Hives and Swelling of face
Important: Not all reactions have hives
Revised July 2011

8. Common Symptoms
Gastrointestinal (stomach): nausea, pain/cramps, vomiting, diarrhea
Cardiovascular (heart): pale/blue colour, weak pulse, passing out, dizzy/lightheaded, shock
Other: anxiety, feeling of “impending doom”, headache, uterine cramps in females
Revised July 2009

9. Swollen lips/face and hives present
Revised July 2009

10. Revised July 2011
health.yahoo.com/media/healthwise/h jpg

11. Anaphylaxis: What should I do?
Administer single dose, single-use auto-injector (EpiPen ®)
Call 911
Notify Parent/Guardian
Administer second auto-injector in 5 to 15 minutes IF symptoms do not improve or if symptoms recur
Have ambulance transport student to hospital
*Epinephrine is the only way to reverse the effects of anaphylaxis & therefore needs to be given ASAP
**Remember, the Epinephrine may only last for 15 minutes, calling 911 is very important
Epinephrine is the drug of choice to treat an anaphylactic reaction and needs to be given immediately at the first sign of a reaction. If in doubt, give EpiPen; there are no contraindications to using epinephrine. Simply put, this means that in normally healthy individuals, epinephrine will not cause harm if given unnecessarily. Delaying the EpiPen may make it more difficult to get the reaction under control.
The second dose of epinephrine should only be given in situations where they allergic reaction is not under adequate control; that is, the reaction is continuing or getting worse.
Signs that the reaction is not under adequate control are that they patient’s breathing becomes more difficult or there is a decreased level of consciousness. Patients who have been prescribed epinephrine are advised to have at least one epinephrine auto-injector with them at all times. Optimally, patients should also have access to a back-up auto-injector in case a second dose of epinephrine is required. Anaphylaxis in Schools & Other Settings (Second Edition, 2009) p.12
Revised June 2010

12. Anaphylaxis: What should I do?
Symptoms of anaphylaxis can be as simple as tingling of the lips or as severe as cardiac arrest. When in doubt, administer epinephrine
If a person says they are having a reaction it is important to believe them, and immediately administer epinephrine regardless of the symptoms present.
Slide 11A

13. What is a Single Dose, Single-Use Epinephrine Auto-injector?
A single dose, single-use auto-injector is an easy way to give epinephrine/adrenaline to someone having an allergic reaction
EpiPen®
EpiPen® 0.3mg: Yellow label, will typically see in the school setting. For adults and children weighing more that 30 kg (66lbs).
EpiPen ®Juniors 0.15mg: Green label, used in the exact same manner. May see in younger grades. For children weighing between kg (33-66lbs).
EpiPen® Regular EpiPen® Junior
Slide 12
Revised July 2011

14. What is in an EpiPen®? Single dose of epinephrine
Easy-to-read instructions
Easy-grip body
Built-in needle protection
New EpiPen came onto market in March 2010.
Please show staff the EpiPens demonstrators and have staff practice with demonstrators:
Features:
 1. The safety release is now blue and the needle tip is orange. These bright new colours will help you distinguish the needle end more easily.  
2. The instruction labels are now larger and easier to read.
3. We've changed the shape of the EpiPen® Auto-injector slightly, to make it easy to grip.
4. After administration, the labeled orange tip will automatically cover and protect the needle so that you – and anybody around you – don't have to worry about an exposed needle.
And finally, the sleek new carrier tube has a flip-top cap to make it easy to access your EpiPen® Auto-injector in an emergency.
See next slides for how to use.
Labeled orange needle cover contrasts with blue safety release for easy orientation*
Single dose of epinephrine
Source:
Slide 13
Revised July 2011

15. Using the EpiPen® Auto-Injector
Remove auto-injector from carrier tube.
Hold firmly with orange tip pointing downward.
Remove blue safety release.
If student is agitated prior to injection, have adult use comfort measures. Rather than hold child down or overpower the child, the adult can steady and control the injection limb by embracing child and holding arms (similar to a kindergarten immunization).
Source:
Slide 14
Revised July 2011

16. Using the EpiPen® Auto-Injector
4. Swing and push orange tip firmly into mid-outer thigh until you hear a “click”.
Hold on thigh for several seconds.
Why should I swing my arm to inject?4
A.   It is recommended that you swing your arm to inject EpiPen®. Not only does this provide sufficient momentum to ensure the auto-injection deploys but it also aids in providing enough load on the tip of the EpiPen® to deliver an intramuscular (IM) injection. Further, by administering EpiPen® in this manner it helps facilitate the ideal angle for the intramuscular (IM) injection into the anterolateral aspect of the thigh, which is perpendicular or at 90 degrees to the injection site.
How many seconds should I hold the re-designed Epipen® in place when I inject?4
A.   The instructions on the EpiPen® cartridge state you should swing the arm and push the orange tip firmly into the mid-outer thigh so it 'clicks' and hold it on the thigh for several seconds. By holding the EpiPen® in place at the injection site for several seconds, it helps assure that the dose of epinephrine has been delivered satisfactorily
Can I inject EpiPen® through my clothes?
A.   Yes. If necessary, you can inject EpiPen® through clothing.4
Source:
Slide 15
Revised July 2011

17. Using the EpiPen® Auto-Injector
6. When the EpiPen ® auto-injector is removed, the orange needle cover automatically extends to cover the injection needle.
How do you know the medication has been received?
There is a viewing window on the barrel of the EpiPen® which prior to delivery is clear and after delivery is obscured or shaded. Also, once the dose is administered and the EpiPen® is released from the injection site, the orange needle cover extends and immediately locks in place encasing the needle to prevent accidental needle sticks. Both of these things serve as a visual indicator that the dose of epinephrine has been delivered. Further, after the orange needle cover is extended the EpiPen® will not fit back into the carrier tube.
Source:
Slide 15a
Revised July 2011

18. What to do after giving a single dose, single-use auto-injector?
Have student lie still on his or her back with feet higher than the head
Loosen tight clothing and cover student with blanket
If there is vomiting, turn student on side to prevent choking
Don’t give anything to drink
Send auto-injector with student to hospital
Patient Posture
Individuals with anaphylaxis who are feeling faint or dizzy because of impending shock should lie down unless they are vomiting or experiencing severe respiratory distress.
To improve blood circulation, caregivers should lift the person’s legs above the level of the heart, keeping the legs raised by putting something (e.g. a pillow) underneath. Keep the person lying down until emergency responders arrive. If the person feels nauseated or is vomiting, lay them on their side, head down, to prevent aspiration of vomit. (Note: If the person is having difficulty breathing, they should be sitting up.)
It is important that the patient not be made to sit or stand immediately following a reaction as this could result in another drop in blood pressure.
Source: Pumphrey RSH. Fatal posture in anaphylactic shock. Journal of Allergy and Clinical Immunology August
(Letters to the Editor).
Source: Anaphylaxis in Schools & Other Settings. Canadian Society of Allergy and Clinical Immunology.
Slide 16

19. Conclusion: Follow the three A’s
Awareness
Know the triggers
Know the emergency plan and how to administer medication
Avoidance
Avoid contact with allergens, make classrooms safe
Action
Give single dose, single-use auto-injector and call 911.
Don’t delay!
Awareness
Know the triggers
Know the Emergency Plan, where EpiPens® are located and how to give medication
Avoidance
Avoid contact with allergens (Reduce the risk of exposure: do not trade or share food, food utensils or food containers, use of foods for crafts and cooking classes may need to be modified, no eating rule if traveling on buses, all children should wash their hands before and after eating, clean surfaces on a regular basis)
Take extra precautions for field trips
Action
Give EpiPen® DON’T DELAY
Call 9-l-1
Bring second EpiPen® for field trips
Slide 17

20. Resources For more information contact your Public Health Nurse
(Allergy/Asthma Information Assoc.)
(Food Allergy Canada)
(EpiPen®)
Slide 18

21. References
AAIA Anaphylaxis Reference Kit (2014) by the Allergy and Asthma Information Association, Health Canada
Anaphylaxis in Schools & Other Settings Second Edition (2014) by the Canadian Society of Allergy and Clinical Immunology.
Slide 19

22. Any Questions?
Slide 20