Anaphylaxis: Epinephrine First, Period.

[SchoolNurseK, BSN, RN]

Here is a quick read about anaphylaxis and epinephrine use.

 Epinephrine First, Period

This really stuck out to me because so many docs write for me to give Benadryl first:

Quote

American Academy of Pediatrics (AAP) made it absolutely clear in their clinical report entitled “Epinephrine for First-aid Management of Anaphylaxis” published this February: Give epinephrine immediately when anaphylaxis is suspected.

What about the role of Benadryl and other antihistamines? Aren’t you supposed to administer those first?

No. The report clarifies the use of antihistamines as well:

H1-antihistamines prevent and relieve itching and hives but do not relieve life-threatening respiratory symptoms, hypotension, or shock; therefore, like H2-antihistamines and glucocorticoids, they are adjunctive treatments and are not appropriate for use as the initial treatment or the only treatment.

[k1p1ssk, BSN, RN]

I use the FARE Anaphylaxis Emergency Action Plan, which includes an antihistamine as a "give first" option, but since this is the EAP that I send on field trips, I have begun just crossing out that section with a sharpie before sending it to the MD for sign off. If we are following that plan and they fill out the antihistamine section, I or the field trip designee would have to give that first and we cannot delegate benadryl, etc. This news just makes thing so much clearer! Hopefully FARE will update their form accordingly...

[JenTheSchoolRN, BSN, RN]

The general plan I have that was also green lighted by my school doc is antihistamine first only if very minor hives are only symptom. Be monitoring the student. Have Epi on stand-by for any other symptom. That is my allergy action plan on school property.

But I can't delegate Benadryl. So for field trips it is Epi only and for any symptom with a student with a known allergy. (I can't delegate Epi to be given by a non medical professional to a student without a diagnosed allergy.)

I also teach that if the student has ingested vs touched their known allergen, Epi is the go to despite initial symptoms. (Have student with egg allergy, for example. Touches eggs, gets localized hives, treated with benadryl. Eats eggs, anaphylaxis. But does have clear allergy action plan from doctor stating this.)

 

[SchoolNurseK, BSN, RN]

We are able to delegate Benadryl to trained med backups (unlicensed) but I do not think it is fair to expect them to use clinical judgment to decide if it is a Benadryl vs. EpiPen reaction.  This gave me some things to think about at my school.  

[ruby_jane, BSN, RN]

3 hours ago, SchoolNurseK said:

We are able to delegate Benadryl to trained med backups (unlicensed) but I do not think it is fair to expect them to use clinical judgment to decide if it is a Benadryl vs. EpiPen reaction.  This gave me some things to think about at my school.  

BAZINGA. Yes. Well-said.

[Mavnurse17, BSN, RN]

I can't even fathom that benadryl (PO, since it's assumed school kiddos don't have IV access......) would be considered first-line in an anaphylactic emergency.  I do get orders for benadryl but it seems logical to only give that for a mild rxn; hives, itching, those sorts.  ?

[chare]

Epinephrine for First-aid Management of Anaphylaxis 

[jnemartin, BSN, RN]

I went to a SN conference before the pandemic and an allergist was one of the main speakers. He said EPI should be given... "basically as soon as you ask yourself if you need to get the EPI." Sounds elementary now, but it really revolutionized my thinking at the time because of my reliance on Benadryl first! He said if there is ANY symptom involving the mouth/throat/airway, including coughing or tingling lips, you should give EPI. Or, if there are two lesser symptoms, like a small rash and itchiness. 

 

Another awesome piece of info he spoke about was that you should always keep expired EPI pens until they are replaced. It's better to use an expired one than not have any at all. He said they typically maintain their full effectiveness for ~18 mo after the exp. Since I've become a school nurse 3 years ago, there has been an ongoing EPI pen shortage. It seems better, but still some of my kids are having trouble getting them

[BrisketRN, BSN, RN]

3 hours ago, jnemartin said:

Since I've become a school nurse 3 years ago, there has been an ongoing EPI pen shortage. It seems better, but still some of my kids are having trouble getting them

I know we had a major shortage beginning of the 2018-2019 school year, but since then I've encouraged parents to ask their pediatrician/allergist about the generic epi (especially through CVS) and they've had a much easier time getting it within a few days.  

[JenTheSchoolRN, BSN, RN]

9 hours ago, BrisketRN said:

I know we had a major shortage beginning of the 2018-2019 school year, but since then I've encouraged parents to ask their pediatrician/allergist about the generic epi (especially through CVS) and they've had a much easier time getting it within a few days.  

This. Much easier to get. 

But also why Stock Epi is HUGE. Game changer for me when I finally got it. Now I know I have an Epi-pen available and non-expired when I need it vs ever debating giving an expired Epi-pen. I ask for a back-ups from families, but I mainly use them to pack with the student on a field trip. 

(And my rule of thumb there is I actually toss those about 18 months after - if the solution isn't discolored - if I have tried to get a replacement from the family. That piece has been much better with the generic Epi-pens.)

[SchoolNurseK, BSN, RN]

13 hours ago, jnemartin said:

I went to a SN conference before the pandemic and an allergist was one of the main speakers. He said EPI should be given... "basically as soon as you ask yourself if you need to get the EPI." Sounds elementary now, but it really revolutionized my thinking at the time because of my reliance on Benadryl first! He said if there is ANY symptom involving the mouth/throat/airway, including coughing or tingling lips, you should give EPI. Or, if there are two lesser symptoms, like a small rash and itchiness

Looking back, there were several times with my own son that I should have done epinephrine instead of giving the benadryl and watching him.  I even once drove toward the hospital "just in case" and now I am wondering what I was even thinking!?!?  Anyone else seem to have a block of nursing judgment when it comes to your own children?

[JenTheSchoolRN, BSN, RN]

44 minutes ago, SchoolNurseK said:

Looking back, there were several times with my own son that I should have done epinephrine instead of giving the benadryl and watching him.  I even once drove toward the hospital "just in case" and now I am wondering what I was even thinking!?!?  Anyone else seem to have a block of nursing judgment when it comes to your own children?

Haha. I don't have kids myself, but have seen so many times with parents who are nurses.

When I talk a situation through with a few of them, they are often like "you are right. Why didn't a think like a nurse?" I tell them because in that moment they are not a nurse, they are a parent. And that I will always talk with them like a parent first - it is my job to be the nurse for them.