1. Is this a problem at school?
What is Anaphylaxis?
Is this a problem at school?
Introduce yourself. Ask if anyone has heard of Anaphylaxis.

2. Goals for today
Understand what anaphylaxis is and what the signs and symptoms of a reaction are
Learn how we are going to manage anaphylaxis at school
Practice using an EpiPen and Twinjet auto-Injector for epinephrine
Part of the management at school is to have an emergency plan... But it is also important to talk about how we can avoid an emergency! And YES, we are going to practice giving a shot.

3. Anaphylaxis is... An allergic reaction that can affect the entire body
It can be fatal
It happens quickly
It often has an identifiable cause
Anaphylaxis is a sudden, severe, potentially fatal systemic allergic reaction that involve various areas of the body.

4. It can affect the whole body
Skin
Breathing
Heart
Stomach
Head
About 90% of reactions include some sort of rash, redness , or itching. Over 50% of the reactions include breathing difficulty. Along with that, about 1/3 will complain of dizziness, nausea, diarrhea and abdominal cramps. Recognizing the symptoms and early treatment are important components for the school management plan. If the reaction continues it can cause severe difficulty breathing and even death.

5. How fast is fast?
Symptoms can occur within minutes to two hours after contact with the allergy causing substance
In rare instances, it may occur up to four hours later
Some individuals have a reaction and the symptoms go away only to return two to three hours later. This is called a “biphasic reaction”. Often the symptoms occur in the respiratory tract and take the person by surprise.

6. Common Causes Food Medication Insect stings Latex
Some have an unknown cause
Antibiotics (such as penicillin) and vaccines are not usually a problem at school, but foods (such as peanuts) or insect bites are a daily experience. Latex from protective gloves or balloons is a growing concern.

7. Who is at risk? Anyone with a previous history
Individuals with food allergies (Particularly allergies to shellfish, peanuts, and tree nuts)
People with asthma are at an increased risk
A recent study showed that teens with food allergy and asthma appears to be at the highest risk for a reaction because they are more likely to dine away from home, they are less likely to carry medications, and they may ignore or not recognize symptoms.

8. Signs and symptoms Tingling sensation Rash...itching... burning
Metallic taste
Sensation of warmth
Breathing difficulty... Changes in skin color
Nausea, vomiting, diarrhea, or cramps
Anxiety, dizziness, headache
Drop in blood pressure
Loss of consciousness
As we look at this list of symptoms, we notice that it affects whole systems of the body. Probably the first system to be affected is the skin. If it is something the child has eaten the rash may start around the mouth. If it is a bee sting it may be at the site of the sting. Or, it can be a whole body rash. Sometimes it can be itching without a visible rash. The respiratory tract is of great concern. The difficulty with breathing can be a result of the swelling or the spasm in the throat which is a result of the reaction. The anxiety can also contribute to breathing difficulties. If the student has a known history of anaphylaxis it is easy to recognize what is happening. Quick treatment could save a life!

9. Essentials of school Management…
Written Classroom Health Care Plan developed by the school nurse and signed by the health care provider.
Able to recognize of the signs and symptoms of anaphylaxis at school
Prompt administration of epinephrine.
Transport to closest emergency facility
Being prepared can save a life.

10. Management of Anaphylaxis at school
This is really a 4 tiered effort...
Developing a Classroom Health Care Plan that includes the emergency plan
The Immediate phase at exposure
The phase after the initial treatments
The Prevention Plan
This is why we are here today. We want to be ready. We want to be prepared and know what to look for and how to respond. Does this mean we will not be nervous if this should ever happen? Absolutely not. But, we will be better able to do what needs to be done if we have a plan, and practice what to we need to do.

11. Developing the Classroom Health Care Plan
Your school nurse can help here.
The plan should cover the emergency steps to follow.
It should include the necessary trainings.
It also should cover prevention plans as well.
I have prepared a Classroom Health Care plan. We will review the emergency steps. By the end of this training you should feel like you can recognize the signs and symptoms of an anaphylaxis and know how to administer the EpiPen.

12. Immediately
Clear and secure the airway as needed. Observe for breathing.
Rapidly assess level of consciousness
Consider Epinephrine... Is this anaphylaxis?
Have someone call 911
If there is a history of anaphylaxis, we know this is probably another reaction. If there is no breathing we must also begin CPR.

13. Second Phase
If this is anaphylaxis, give the epinephrine and/or benedryl as ordered by the Health Care Provider
Stay with the student
Have them stay laying down. Elevate their legs if possible.
Make sure 911 has been called
If the history is positive waste no time in treating.

14. Transport… 3rd Phase
Once epinephrine has been given, the student must have further care at the closest emergency facility
Epinephrine lasts for only about minutes.
Follow the advice of the emergency responders.
Part of the plan is that once the need for epinephrine has been established, the student must seek further treatment at an emergency care facility or their primary care provider.

15. What is Epinephrine?
It is a hormone produced by all of us in the adrenal glands
It is often referred to as Adrenaline
Our adrenal glands release epinephrine in response to stress. An injection of epinephrine is therefore a way to give a higher dose of something our bodies are already making.

16. How Does Epinephrine Work?
Epinephrine has three major actions that are of critical importance in the treatment of anaphylaxis because it:
Constricts blood vessels and
It is a Bronchodilator
Help keeps the blood pressure stable.
First, it constricts blood vessels- this is important because the swelling that occurs in an allergic reaction is due to dilation of blood vessels and leakage of fluid from blood vessels. Epinephrine therefore prevents or reverses the swelling that may occur in the skin or, more importantly the airway. Second, epinephrine is a bronchodilator that serves to open the airways in the lungs, and makes breathing easier. Third, epinephrine helps to prevent or reverse the fall of blood pressure that may occur in anaphylaxis by improving the pumping ability of the heart and preventing the leakage of fluid from the blood stream.

17. Epinephrine...
Adverse reactions to epinephrine include a fast heart rate; transient, moderate anxiety; apprehensiveness; restlessness; tremor; weakness; shakiness; dizziness; sweating; palpitations; pallor; nausea and vomiting; headache; and/or respiratory difficulties.
It reminds me of how you might feel after seeing a fire or witnessing an accident.

18. Epinephrine! EpiPen Twinjet
There are two different preparations... EpiPen and Twinjet. They are the same medication, but the Twinjet includes two doses. Many Epipens are now coming in sets of two to also provide for a second dose.

19. Prevention of anaphylaxisis the 4th Phase
Medic-Alert identification
Teach appropriate avoidance measures
Be observant... watch for the signs and symptoms of an anaphylactic reaction.
Prevention! Prevention! Prevention! It is easier than treating!

20. Avoidance! What about nut free zones?
Consider a nut free table in the cafeteria.
A nut free classroom is another consideration
Avoidance, avoidance, avoidance... This is the best way to help. Nut free zones are helpful, but we live in a world where people eat nuts. A true nut free zone includes participation from other parents and students. In the cafeteria a nut free table can be established. Any student may sit at the table as long as they do not have any nuts or nut products in their lunch. This table is washed separately from the other tables with clean, soapy water and designated cloths.

21. Quiz Time What is anaphylaxis? What are the symptoms of a reaction?
Who is at risk for an anaphylactic reaction?

22. What is an EpiPen
EpiPen® is an auto-injector that administers epinephrine (also known as adrenalin).

23. How to use the EpiPen
This is why we are here today. We want you to practice all the steps necessary to give this medication.

24. Remove the Epipen from the plastic tube Remove the gray cap

25. Put the gray cap against the middle of the outer side of the upper leg
It is acceptable to go through clothing if need be. Some parents and students have learned the swing and jab technique, but care must be taken that you do not swing and miss. It is safer to hold the gray cap against the middle of the outer side of the upper leg.

26. Hold for 10 seconds

27. To insure the dose was given...
Check for the red bar
Check to make sure the needle came out
Give your used EpiPen to a healthcare worker for proper disposal. Do not throw away in a regular trash can

28. Let’s Practice
If two doses of Epipen are needed the procedure is the same.

29. How to use a Twinjet
Pull off the GREEN end cap labeled "1." You will now see a GRAY cap. Never put your thumb, finger, or hand over the GRAY cap.

30. Next...
2. Pull off the RED end cap labeled "2."

31. Then...
3. Put the GRAY cap against the middle of the outer side of your thigh (upper leg) as shown. It can go through clothes, if necessary.
4. Press down firmly until the needle enters the middle of the outer side of your thigh through your skin. Hold it in place while slowly counting to 10.

32. After 10 Seconds Remove the Twinjet from your skin.
Check the GRAY cap; if the needle is exposed, the dose was given. If not, repeat #3 and #4. Get ready for the second dose. Get emergency medical help right away.

33. Get Ready in Case You Need a Second Dose
Unscrew and remove the GRAY cap. Beware of the exposed needle.
Holding the BLUE hub at the needle base, pull the syringe from the barrel.

34. Then...
Slide the YELLOW or ORANGE collar off the plunger.

35. Decide if You Need a Second Dose
If your symptoms have not improved within about 5 minutes since the first injection, you need a second injection.
If a second dose is not needed, throw away the unused medication as directed.

36. Inject the Second Dose
Put the needle into your thigh (upper leg), through your skin, as shown.
Push the plunger down all the way.
Remove Twinjet from your skin.

37. Proper Disposal
Give your used Twinjet to a healthcare worker for proper disposal. Do not throw away in a regular trash can.

38. Prepared by: Mary Clark RN, NCSN
Reviewed by: Paula Peterson APNP
Primary Children’s Hospital
Salt Lake City, Utah
JMJ Publishers
1156 Wilson Ave.
Salt Lake City, Utah 84105