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Emergency Care and Treatment

Emergency Care and Treatment


Anaphylaxis

Definition:

Anaphylaxis: An acute and potentially lethal multi-system reaction.  Unlike common allergy, anaphylaxis onset may be sudden and requires instant action to prevent fatality.  Anaphylaxis can be presented as severe symptoms in at least one body system OR it can be presented as a combination of symptoms in two or more body systems.

Treatment Guidelines

Epinephrine is the first line choice for treatment of anaphylaxis.  ALL student that receive epinephrine should be sent to the emergency department for further evaluation.  “It is now recommended that children who normally have epinephrine in the school in case of emergency have at least two doses on hand.  Twelve percent of children who needed on dose of epinephrine needed a second dose,” (Selekman2013).  A second dose is recommended if symptoms are not resolved within 5-20 minutes (consult student’s provider order).
 

>>PROTOCOL FOR EMERGENCY USE OF EPINEPHRINE<<

 

Dosing Guidelines of Epinephrine

<66 pounds (second grade and lower)

Use junior dose: 0.15mg

>66 pounds (3rd grade and older)

Use adult dose: 0.3mg


“Antihistamines may be administered with epinephrine, but never instead of epinephrine…” (Selekman 2013).  Consult student’s physician and guardian to develop protocol for the use of antihistamines, and document in student Emergency Care Plan.

Consider anaphylaxis treatment if any of these signs and symptoms are present and severe:

OR if there are a COMBINATION of symptoms from different body areas:

Lungs:  Short of breath, wheeze, repetitive cough

Heart: Pale, blue, faint, weak pulse, dizzy, confused.

THROAT: Tightness, hoarse, trouble breathing/swallowing.

MOUTH: Obstructive swelling (tongue and/or lips)

SKIN: hives over body

SKIN: hives, itchy rashes, swelling (eyes, lips)

GUT: Vomiting, cramping pain, diarrhea

HEENT: Runny nose, sneezing, swollen eyes, phlegmy throat

OTHER: Confusion, agitation, feeling of impending doom.

Guidelines for administering Epinpehrine (taken from the sample protocol developed by the Epinephrine Policies and Procotols Workgroup of the National Association of School Nurses, 12/2014)

Planning Care for Students with Life Threatening Allergies

  • Identify students diagnosed with allergies
  • Obtain history from parents on their history of anaphylaxis. 
  • Establish Emergency Care Plan.  Consider IHP or 504 for accommodations.
  • Obtain orders for student’s medications (epinephrine autoinjector, Benadryl).  Students may self-carry emergency medication with MT Self Carry Authorization form filed. (See MT Authorization to Self-Carry)
  • Medication:  Where will medication be stored?  “It is now recommended that children who normally have epinephrine in the school in case of emergency have at least two doses on hand.  Twelve percent of children who needed on dose of epinephrine needed a second dose,” (Selekman2013)
  • Accommodations:  does this student need special diet order?  Do they need a “nut free” table?  Are their airborne issues with their allergen?  What will the child do when there is a class party?  Can they have classroom snacks?  Are their items in art class or other classrooms that may cause an allergic reaction.
  • If your school is going to have a “nut free classroom” or “nut free policy” make sure that all parents are aware.  Letters should be sent home.  Administrators may choose to have parents sign and return letters.
  • Make sure teachers and other team members are familiar with child, their allergies, and their ECP.
  • Plan appropriately for field trips and extracurricular activities.
  • Train staff in use of epinephrine autoinjector.
  • Communicate with transportation department if child rides the bus.
  • Consider sending letter home to parents. (Sample letter)

Laws and Regulations

20-5-420, MCA Self-administration or possession of asthma, severe allergy, or anaphylaxis medication
27-1-714, MCA Limits on liability for emergency care rendered at scene of accident or emergency
20 USC 1232 Family Education Rights and Privacy Act

Stock Epinephrine

According to MCA 20-5-420 Section 2 it is legal for Montana schools to possess a stock supply of epinephrine auto injectors .  “Approximately 20-25% of epinephrine administration in schools involve individuals who allergy was unknown at the time of the reaction,” (NASN SCHOOL NURSE.  “The Case for stock Epinephrine in Schools.  Vol. 27. No 4. July 2012).  Stock epinephrine is to be used in the event that an individual (student, staff, visitor, etc) is having an allergic reaction. Many of these incidents will be first time exposures.

Free epinephrine auto-injectors are currently available at www.epipens4schools.com

Resources:

 

AEDs

MT Statutes and Rules for Automatic External Defibrillators:

http://www.mtrules.org/gateway/Subchapterhome.asp?scn=37.104.6

Sample School Board Policy

Register your school AED with the MT DPHHS at this website: 

http://dphhs.mt.gov/publichealth/EMSTS/aed/aedregistration

AED Use Incident Report:

https://ejs.hhs.mt.gov:8442/ems/default.jsp?page=aedincident.yari

Cardiac Emergencies

Calling 911

 

Head Injury

Concussion and Traumatic Brain Injury

The school nurse is in a pivotal position to implement evidence-based concussion prevention and management protocols at school. The school nurse identifies students with possible concussion, makes appropriate referrals, and assists students and families through the school and activity re-entry process. The school nurse collaborates with the team of stakeholders including healthcare providers, school staff, athletic trainers, parents and students to ensure that the physical and psychosocial needs of the students are met. School nurses provide support for the prevention of concussions by advocating for safe environments and education of students, parents/guardians and staff on concussions.

NASN Position Statement
Concussions- The Role of the School Nurse

HEADS UP SCHOOLS (CDC):

Sample Concussion Policy and Procedure

Management of Concussion in the Schools Setting 
(Wisconsin Public Health Association) 

Other Resources for School Nurses

Accommodations Guide for Students with Brain Injury

Classroom Interventions for Students with Traumatic Brain Injuries

Returning to School After a Traumatic Brain Injury
Returning to School After a Concussion: A Fact Sheet for School Professionals- Centers for Disease Control and Prevention

 

*​For more information on concussion rules and regulations and other resources for school personnel visit the MT DPHHS School Health Website

Neck Injury

 

Opioid Overdose

Protocol for Use of Stock Medications in School—Naloxone (Narcan©)

Naloxone is medication indicated for use in the reversal of opioid overdose in the setting of respiratory depression or unresponsiveness.  In accordance with MT HB 323 and GFPS School Board Policy, schools may implement the use of stock Naloxone.  Naloxone may be administered by a school nurse or other authorized and trained personnel to any student or non-student as needed for an actual or perceived opioid overdose.

What are Opioids? Opioids include illegal drugs such as heroin, as well as prescription medications used to treat pain such as morphine, codeine, methadone, oxycodone, hydrocodone, fentanyl, hydromorphone, and buprenophrine. Opioids work by binding to specific receptors in the brain, spinal cord, and gastrointestinal tract.  In doing so, they minimize the body’s perception of pain.  However, stimulating the opioid receptors or “reward centers” in the brain also can trigger other systems of the body, such as those responsible for regulating mood, breathing, and blood pressure.

Signs and Symptoms of Opioid Overdose

Suspected or confirmed opioid overdose consists of:

  • Respiratory depression evidenced by slow respirations or no breathing (apnea)
  • Unresponsiveness to stimuli (such as calling name, shaking, sternal rub)

Suspicion of opioid overdose can be based on:

  • Presenting symptoms
  • History
  • Report from bystanders
  • School nurse or staff prior knowledge of person
  • Nearby medications, illicit drugs or drug paraphernalia

What it looks like: OPIOID HIGH vs. OPIOID OVERDOSE

OPIOID HIGH

OVERDOSE

Muscles become relaxed

Pale, clammy skin

Speech is slowed/slurred

Infrequent or no breathing

Sleepy looking

Deep snoring or gurgling

Responsive to stimuli

Not responsive to stimuli

Normal heartbeat/pulse

Slow heartbeat/pulse

Normal skin tone/color

Blue lips or fingers

Emergency Response for Known or Suspected Opioid Overdose:

  • Call for help
  • Call 911 and activate school medical response team
  • Check for breathing-administer rescue breaths or start CPR as indicated.
  • Administer Naloxone kit when it arrives to the scene.
  • Remain with person and place in “recovery position” (on left side), and continue to monitor breathing.
  • May repeat dose of Narcan every 2-3 minutes if patient remains unresponsive or repeat dose as needed for loss or decrease in consciousness after response to initial dose.  Alternate nostrils when administering.
  • Notify emergency contact, administrator, and school nurse as soon as possible.
  • Patient should be transported by EMS to hospital for further evaluation
  • Complete Naloxone Administration Report and debrief incident at appropriate time and place with school nurse, administrator, and others as indicated.

Maintenance of Naloxone:

  • Each school electing to maintain a stock supply of naloxone will work with a school nurse to obtain a standing order for the medication and implement protocol.
  • The Naloxone kit will be stored in a secure and easily-accessible location chosen by the building administrator and school nurse.
  • Naloxone will be available for use during school hours and is not required to be available for use during before or after school activities.
  • The school nurse will be responsible for performing regular checks on stock medication and for requesting replacement kits for those that have been used or expired.  Standing orders will be updated when medication is replaced.

Training and Education: 

Training will be provided by a school nurse, certified emergency responder, or other health care professional.  All trainings will include causes of opioid overdose, recognition of signs and symptoms of opioid overdose, indications for the administration of an opioid antagonist, administration technique of the opioid antagonist carried by the school, and the need for emergent medical follow up.  Each school that maintains stock Naloxone will designate a team of staff members to be trained annually.  A list of trained personnel will be maintained by the building administrator.

References and Resources

  1.  Kentucky Department for Public Health Clinical Protocol for Intranasal Naloxone in the School Setting.  http://education.ky.gov/districts/SHS/Pages/Epinephrine-and-Naloxone-(Narcan)-Protocols.aspx
  2. Montana HB 323: Emergency use of opioid antagonist in school setting—limit on liability.
  3. Great Falls Public Schools Board Policy 3416
  4. National Association of School Nurses (NASN) Naloxone in Schools Toolkit and Narcan Administration Protocol.  https://www.pathlms.com/nasn/courses/3353

Parent Notification