1. POLICIES AND PLANNING FOR STOCK EMERGENCY MEDICATIONS IN NEW MEXICO SCHOOLS Head 2 Toe 2016 Training information for school nurses Rebecca Trujillo, MSN, RN School Health Advocate, SE Region

2. UNDIAGNOSED ANAPHYLACTIC EMERGENCIES

3. Objectives Your staff should be able to:  List the facts about allergies and asthma  Identify the signs and symptoms of allergic reactions and respiratory distress  Describe emergency protocols for asthma and allergies  Skills to administer epinephrine auto-injector  Skills to use albuterol inhaler

4. Know District’s Policy and Procedures 1.Written district policy and school procedures 2.Require a Food Allergy Emergency Action Plan for all students with diagnosed food allergies KNOWN/UNKNOWN 3.Educate / Train staff on how to recognize and care for students with KNOWN/UNKNOWN allergies

5. Is Epinephrine Safe suspected Administering an epinephrine auto-injector for a suspected anaphylactic reaction is safe.

6. What is an allergic reaction?  Immune system perceives harmful or foreign substance  Histamine, response resulting in an allergic reaction  The symptoms may be mild or severe  May be delayed response

7. What is Anaphylaxis? Anaphylaxis  Rapid in onset  life-threatening  Intervention required “Early recognition...intervention... vital to survival.” - National Association of School Nurses

8. How Common Is It? 1 in 13 Children 6 Million Children ANAPHYLAXIS

9. Did You Know? 25% anaphylaxis at school no previous allergy 16 - 18% food allergies related ingestion of an allergen at school. 4% of students are affected by food allergies 1 of 5 students will have reaction at school http://www.cdc.gov/healthyschools/foodallergies/toolkit.htm

10. What Triggers Anaphylaxis? Food Insect stings Medications Latex https://www.aaaai.org/Aaaai/media/MediaLibrary/PDF%20Documents/Librarie s/What-you-Should-Know-about-Anaphylaxis.pdf

11. 8 Most Common Food Allergens Dairy Eggs Peanuts Tree Nuts Soy Wheat Fish Shellfish

12. Allergic Reactions Mild mild skin symptoms Doesn’t affect respiratory treat with antihistamines Life-Threatening (Anaphylaxis) Difficulty breathing Feeling faint Multiple systems involved Treatment = NOW Epinephrine Important to make the distinction based on the signs and symptoms seen in a student! Fineman, 2014

13. Recognize an Anaphylactic Reaction Symptoms of an anaphylactic reaction can vary and usually involve at least two of these four body systems  Skin  Gastrointestinal  Respiratory  Cardiovascular

14. Skin Symptoms May appear swollen (esp. around eyes and mouth) Swollen tongue Swollen extremities Itchy Warm Redness or rash Hives (not always) Paleness

15. Respiratory Symptoms Coughing Wheezing Shortness of breath Chest pain or tightness Hoarse voice Nasal congestion Runny, itchy nose and eyes Onset of sneezing Trouble swallowing

16. Gastrointestinal Symptoms Swelling of mouth and tongue Nausea Pain Cramping Vomiting Diarrhea Trouble swallowing

17. Cardiovascular Symptoms Pale, blue or dusky skin Weak pulse Dizziness or lightheadedness Fainting Confusion Shock

18. Other Concerning Signs Anxiety Feeling of impending doom Headache Metallic taste in mouth BE AWARE! Specific warning signs as well as the severity and intensity of symptoms can vary from person to person and sometimes episode to episode in the same person.

19. Most Dangerous Symptoms Breathing difficulties Low blood pressure (Both may lead to death if untreated) Please Note: A rapid drop in blood pressure may make it impossible for a person having the reaction to seek help or to use an auto-injector to self- administer.

20. Positioning the Student If having difficulty breathing: UPRIGHT & SEATED If feeling faint or dizzy: LYING with FEET ELEVATED If feeling nauseous or vomiting: SIDE-LYING

21. Risk of a Severe Reaction 1. Having Asthma 2. Under-utilization of or delayed use of epinephrine “ Epinephrine is the first drug that should be used in the emergency management of a child having a potentially life-threating allergic reaction…There are no contraindications for the use of epinephrine for a life-threating allergic reaction.” American Academy of Allergy, Asthma, and Immunology

22. Types of Epinephrine Auto-Injectors

23. Practice with Auto-Injectors Always check the manufacturer’s website for indications and safety information. https://www.epipen.com/en/about-epipen/how-to-use- epipen https://www.epipen.com/en/about-epipen/how-to-use- epipen https://www.auvi-q.com/auvi-q-demo http://www.adrenaclick.com/how_to_use_adrenaclick _epinephrine_injection_USP_auto_injector.php http://www.adrenaclick.com/how_to_use_adrenaclick _epinephrine_injection_USP_auto_injector.php

24. Enacting Emergency Protocols for Students Not Previously Diagnosed with an Allergy 1. Recognize Symptoms of Anaphylaxis 2. Give epinephrine auto-injector at the first sign of a known or suspected anaphylactic reaction as per standing orders and the NM Rules and Recommendations (p. 16 &18) 3. Call Emergency Medical Services and advise that epinephrine was given. 4. Stay with student. If symptoms persist or recur, repeat dose after 5-15 minutes. 5. Provide EMS with used auto-injector labeled with name, date, & time given to take to hospital. 6. Contact parent/guardian

25. Student with Asthma and Anaphylaxis Asthma symptoms:  Shortness of Breath  Tightness in chest  Difficulty breathing  Coughing  Wheezing or whistling noises If you suspect a student with asthma is having an anaphylactic reaction: ALWAYS ADMINISTER EPINEPHRINE FIRST The student can use their inhaler after

26. Post-Event Actions In some reactions, the symptoms go away, only to return one to three hours later. This is called a “biphasic reaction.” Often these second-phase symptoms occur in the respiratory tract and may be more severe than the first-phase symptoms. Therefore, follow up care with a health care provider is necessary. The student will not be allowed to remain at school or return to school on the day epinephrine is administered. Request an Allergy Action Plan for the student. Document the event. Complete incident report and submit per usual procedure. Complete an Adverse Events form when epinephrine is administered on an emergency basis and submit within 3 working days to the NM Department of Health School Health Advocate (SHA) / Regional Health Officer (RHO).

27. NM Emergency Allergy Action Plan Name & Picture of Student and Contact Information Allergens Signs & Symptoms Emergency Protocols Provider Orders (type of auto-injector & dose) Signatures /Consent

28. NM Allergy Emergency Care Plan STUDENT’S NAME & PICTURE CONTACT INFORMATION ALLERGENS & ASTHMA SIGNS & SYMPTOMS EMERGENCY PROTOCOLS SCHOOL NURSE SIGNATURE

29. NM Allergy Emergency Care Plan – Side 2 EPI-PEN DIRECTIONS AUVI-Q DIRECTIONS ADENACLICK/ADRENACLICK GENERIC DIRECTIONS ADDITIONAL INSTRUCTIONS NAMES OF TRAINED STAFF & LOCATION

30. UNDIAGNOSED ASTHMA EMERGENCIES Head 2 Toe 2016

31. Objectives Your staff should be able to:  List the facts about allergies and asthma  Identify the signs and symptoms of allergic reactions and respiratory distress  Describe emergency protocols for asthma and allergies  Skills to administer epinephrine auto-injector  Skills to use albuterol inhaler

32. School Policies and Procedures 1.Written district policy and school procedures 2.Require an Asthma Action Plan for all students with diagnosed food allergies 3.Educate / Train staff on how to recognize and respond to students with asthma

33. Is Albuterol Safe? Albuterol is the most effective treatment for providing prompt relief from worsening asthma symptoms and is recommended for use, guided by an Asthma Action Plan (AAP). http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&ret mode=ref&cmd=prlinks&id=19558010

34. What is Asthma? http://www.lung.org/assets/video/what-is-asthma.swf chronic  A chronic disease of the lungs  Asthma is chronic inflammation (swelling) that makes the airways very sensitive and narrows the airways to some extent  If the inflammation associated with asthma is not kept under control, each time the airways are exposed to an asthma trigger, the inflammation increases, and the student who has asthma is likely to have symptoms that may worsen.

35. How Common Is It? 1 in 11 children have asthma 7 In a classroom of 30 students, about 3 currently have asthma. (CDC, 2014) Estimated that 7% of children with current asthma-like symptoms have no diagnosis (JAMA, 2003) ASTHMA

36. Common Asthma Triggers  Environmental & Tobacco Smoke  Pets  Dust Mites  Mold  Cockroach Allergen  Outdoor Air Pollution  Foods and food additives  Strong emotional states  Other Triggers (Strenuous physical exercise; strong odors, some medicines; bad weather such as thunderstorms, high humidity, high ozone levels or freezing temperatures)

37. Recognizing Severe Asthma Symptoms  Coughing, wheezing, noisy breathing, whistling in the chest.  Difficulty or discomfort when breathing, tightness in chest, shortness of breath  Chest pain, breathing hard and/ or fast  Nasal flaring  Can only speak in short phrases or not able to speak  Blueness around the lips or fingernails  Changes in alertness  Difficulty walking

38. Enacting Emergency Protocols for Students Not Previously Diagnosed with Asthma If RN (NM PED Licensed School Nurse) is Available, Follow This Protocol Below. If no RN present, call EMS (9-1-1) 1. Assess Symptoms of Asthma 2. Treat with inhaled albuterol as per standing order and the NM Rules and Recommendations (p. 17). Use spacer or mask. 3. Call Emergency Medical Services and advise that albuterol was given. 4. Administer oxygen if appropriate and available. 5. Stay with student. If symptoms persist or recur, repeat dose after 20 minutes. 6. Provide EMS with used inhaler and supplies labeled with name, date, & time medication was given to take to hospital. 7. Contact parent/guardian.

39. Types of Albuterol Inhalers

40. How to use a metered dose inhaler: http://www.stlouischildrens.org/our-services/allergy- immunology-and-pulmonary-medicine/asthma- education/video-living-with-asthma/d-1 From St. Louis Children’s Hospital:

41. How to use an inhaler with a spacer and mask: https://www.youtube.com/watch?v=A8WT5moNJ0I https://www.youtube.com/watch?v=hCAsW7OM9Ns http://docvid.com/pediasthma.php#4_2

42. Positioning the Student Help student to an upright sitting position

43. Things to Remember: Albuterol is the first-line medication for asthma emergencies. It is known as a “rescue inhaler.” Antihistamines and asthma medications must not be used as first-line treatment for symptoms of an anaphylactic reaction in a student who has not been previously diagnosed. A second dose of albuterol may be given 10 - 20 minutes after the first if a poor response is assessed. Poor response consists of persistent wheezing and dyspnea. Consider epinephrine if poor response to albuterol and EMS has not arrived. Oxygen can be used per standing orders (if appropriate and available) Emergency Medical Services (EMS) should be called to transport the student to the hospital. No person should be expected to be fully responsible for self- administration of an epinephrine auto-injector.

44. Post Event Actions Follow up care with a health care provider The student will not be allowed to remain at school or return to school on the day albuterol is administered. Request an asthma action plan for the student. Document the event. Complete incident report and submit per district policy Complete an Adverse Events Form when Albuterol is administered on an emergency basis and submit within 3 working days to the NM Department of Health School Health Advocate (SHA) / Regional Health Officer (RHO).

45. NM Asthma Action Plan for Schools School Policy & Procedures should include requiring schools to utilize the NM Asthma Action Plan form for students currently diagnosed with asthma

46. Resources for Training NASN – Get Trained Program F.A.R.E. – Food Allergy & Research Education AllergyReady.com Foodallergy.org NHLBI.NIH.gov CDC.gov - “Voluntary Guidelines for Managing Food Allergies In Schools and Early Care and Education Programs” CDC.gov – “Strategies for Addressing Asthma within a Coordinated School Health Program” Anaphylaxis Canada American Academy of Pediatricians American Academy of Allergy Asthma & Immunology https://www.aaaai.org/conditions-and-treatments/library/school- tools.aspx CDC Food Allergies in Schools Toolkit http://www.cdc.gov/healthyschools/foodallergies/toolkit.htm

47. For more information: Northeast:Northwest: Veronica A. Trujillo, RNJanie Lee Hall, RNSchool Health Advocate (SHA) VeronicaA.Trujillo@state.nm.usVeronicaA.Trujillo@state.nm.us Janie.Hall@state.nm.usJanie.Hall@state.nm.us Southeast:Southwest: Becky Trujillo, RNBrandi Gorzeman, RNSchool Health Advocate (SHA) Rebecca.Trujillo@state.nm.usRebecca.Trujillo@state.nm.us Brandi.Gorzeman@state.nm.usBrandi.Gorzeman@state.nm.us Metro Area: State Nurse Consultant: Susan Acosta, RN Cindy Greenberg, MSN, RN, NCSN School Health Advocate (SHA) State School Nurse Consultant Susan.Acosta@state.nm.usSusan.Acosta@state.nm.us Cynthia.greenberg@state.nm.usCynthia.greenberg@state.nm.us