1. Fainting and Anaphylaxis Needlestick Injuries Bryna Warshawsky, MDCM, FRCPC Associate Medical Officer of Health Middlesex-London Health Unit

2. Fainting - Definition n Weak, lightheaded, pale, nauseated n Falls on floor n Brief seizure activity

3. Fainting Study n VAERS - 1990- October 1995 n 697 syncopal episodes reported n Peak age 10-19 year olds - 45.4% n Females 57.5% n 80% occurred within 15 minutes of vaccine n 27% had tonic or clonic movements n 6 serious head injuries - 5 were male

4. Fainting Prevention n Stress free clinics - limit standing and waiting n Watch for people who look anxious, pale, sweaty, trembling or complain of dizziness, numbness or tingling n Vaccinate them when seated n Escort them to mat or chair after vaccination

5. Fainting Management n Elevate feet n Fan n Cold cloth n Seizures - avoid injury n Vomits - recovery position, watch neck n Prolonged - proceed as per anaphylaxis n Serious injury - 911

6. Post Fainting Management n Get up slowly n Check vitals n Offer juice n Keep in clinic for a half hour or longer n Leave with an adult to continue to observe n Avoid driving

7. Post Fainting Management n Advise client to contact doctor if head injury or seizure activity n Document incident n Follow-up with client later if seizure activity, injury or prolonged fainting episode

8. Anaphylaxis - Definition n Occurs in.11 to.31 per 100,000 vaccines n Progresses over several minutes from mild to severe n Usually evident within 15 to 30 minutes n Symptoms: – hives, swelling of face and mouth, itchiness, tearing, nasal congestion, facial flushing, sneezing, coughing, wheezing, laboured breathing, hypotension, shock, collapse

9. Anaphylaxis - Prevention n Screen for allergy to egg or egg products n Screen for allergy to past influenza vaccine n Screen for allergy to other components of the vaccine n Screen for allergy to other vaccines which may contain the same components

10. Anaphylaxis - Management n Two nurses n Call ambulance n Lay down and raise feet n Assess airway, breathing, circulation

11. Anaphylaxis - Adrenaline n 0.01 ml/kg of 1:1000 adrenaline (maximum 0.5 ml) in opposite limb of vaccine n Subcutaneously if mild reaction n Intramuscularly if severe reaction

12. Adrenaline by Age n Estimate dose based on age n Mild reactions maximum 0.3 ml subQ n Severe reactions maximum 0.5 ml IM n Watch for elderly and people with cardiac disease - may cause heart trouble n Watch for people on beta-blockers - may not respond to adrenaline

13. Adrenaline - Additional Doses n If vaccine subQ, give additional half dose of adrenaline subQ at injection site. n No adrenaline at injection site if vaccine IM as with influenza. n Mild reactions can repeat adrenaline two additional times at 20 minute intervals n Severe reactions can repeat adrenaline two additional times at 10 to 15 minute interval

14. Adrenaline - Additional Doses n Different limb for each additional dose n Avoid limb which received vaccine

15. Anaphylaxis - Benadryl n Give after initial dose of adrenaline if client not responding well n Also give if responding well but need to maintain control because transfer to acute care facility more than 30 minutes away n Comes as elixir, capsule or injection n Oral preferred if possible as injections are painful

16. Anaphylaxis n Document all actions with times of events n Vaccination Incident Report n Follow-up with client later in day n Should be kept in hospital to be sure stable - at least 12 hours for all but mildest case

17. Anaphylaxis - Preparation n Have kit with all necessary equipment n Content of Emergency Bag n Have instructions very handy n Always keep people in the clinic area for at least 15 minutes after vaccination n Advise clients of the “What to Watch for..” on the “After receiving the Influenza Vaccine Sheet”

18. Needlestick Injuries n Prevention is most important: – Never recap the needle – Never put the needle down on your table – Put needle directly into the sharps container – Watch where you are going when heading towards the sharps container – Secure the client well; get your partner or team leader to help hold if necessary

19. Hepatitis B Vaccine n Be sure to receive your vaccine series n Know your titre - tells you that vaccine worked n If you ever had a titre (10 IU/L), no concern re: hepatitis B

20. After the Poke n Let it bleed n Wash with soap and water n Remain calm - it will be alright

21. Follow-up of the Client n Most exposures are low risk, and reassurance is gained by testing the client n We will ask that the client be tested for: – HIV – Hepatitis B – Hepatitis C

22. Follow-up of Needlestick n Will make specific recommendations depending on situation, results of tests, your hepatitis B vaccination status n Report to occupational health or human resources and complete the required forms