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.
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).
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 Epinephrine (taken from the sample protocol developed by the Epinephrine Policies and Protocols 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
According to MCA 20-5-421, 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.epipen4schools.com
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 Montana Code Annotated 20-5-426, 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
- 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
Muscles become relaxed
Pale, clammy skin
Speech is slowed/slurred
Infrequent or no breathing
Deep snoring or gurgling
Responsive to stimuli
Not responsive to stimuli
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.
NASN Position Statement
It is the position of the National Association of School Nurses (NASN) that the safe and effective management of opioid pain reliever (OPR)-related overdose in schools be incorporated into the school emergency preparedness and response plan. The registered professional school nurse (hereinafter referred to as school nurse) provides leadership in all phases of emergency preparedness and response. When emergencies happen, including drug-related emergencies, managing incidents at school is vital to positive outcomes. The school nurse is an essential part of the school team responsible for developing emergency response procedures. School nurses in this role should facilitate access to naloxone for the management of OPR-related overdose in the school setting.
Deaths from prescription painkillers (opioid or narcotic pain relievers) have reached epidemic levels in the past decade according to the Centers for Disease Control and Prevention (CDC) (2014a). A crucial mitigating factor involves the nonmedical use of prescription painkillers—using drugs without a prescription or using drugs to obtain the "high" they produce. In 2010, the CDC stated about 12 million Americans (age 12 or older) reported nonmedical use of prescription painkillers in the past year (CDC, 2014a). The 2013 Partnership Attitude Tracking Study (PATS) stated almost one in four teens (23 percent) reported abusing or misusing a prescription drug at least once in his or her lifetime, and one in six (16 percent) reported doing so within the past year (Feliz, 2014). According to the Substance Abuse and Mental Health Services Administration’s (SAMHSA) National Survey on Drug Use and Health in 2013, there were 2.2 million adolescents ages 12 to 17 who were current illicit drug users (SAMHSA, 2014). Given the magnitude of the problem, in 2014 the CDC added OPR overdose prevention to its list of top five public health challenges (CDC, 2014b).
Schools should be responsible for anticipating and preparing to respond to a variety of emergencies (Doyle, 2013). The school nurse is often the first health professional who responds to an emergency in the school setting. The school nurse possesses the education and knowledge to identify emergent situations, manage the emergency until relieved by emergency medical services (EMS) personnel, communicate the assessment and interventions to EMS personnel, and follow up with the healthcare provider. Harm reduction approaches to OPR overdose include expanding access to naloxone, an opioid overdose antidote, which can prevent overdose deaths by reversing life-threatening respiratory depression. When administered quickly and effectively, naloxone has the potential to immediately restore breathing to a victim experiencing an opioid overdose (Hardesty, 2014).
Naloxone saves lives and can be the first step towards OPR abuse recovery. It provides an opportunity for families to have a second chance with their loved ones by getting them into an appropriate treatment regimen (Lagoy, 2014). Ensuring ready access to naloxone is one of the SAMSHA’s five strategic approaches to prevent overdose deaths (SAMHSA, 2013).
OPR overdose kills thousands of Americans every year. Many of these deaths are preventable through the timely provision of an inexpensive, safe, and effective drug and the summoning of emergency responders (Davis, Webb & Burris, 2013). School nurses must be familiar and sensitized to the legal issues, which vary from state to state in terms of the prescription and availability of naloxone. They should review local and state policy on how to access naloxone and implement its use as part of their school emergency response protocol.
It is also important to prevent students from ever misusing opiates. School nurses are crucial primary prevention agents in school communities. Through utilization of prevention materials, school nurses can provide valuable awareness and education on the dangers of prescription drug misuse to K-12 students and their families. In addition, school nurses can help families recognize signs and symptoms of substance abuse, guide them to locate resources, and assist them in making referrals for treatment of OPR addiction.
References and Resources
- Kentucky Department for Public Health Clinical Protocol for Intranasal Naloxone in the School Setting.
- Montana HB 323: Emergency use of opioid antagonist in school setting—limit on liability.
- Great Falls Public Schools Board Policy 3416
- National Association of School Nurses (NASN) Naloxone in Schools Toolkit and Narcan Administration Protocol.