Had to give Epi Today!

[linda1959]

I want to share my experience hoping it can help someone else, and to review for myself what I learned today.

Got a call a student was choking in the classroom, and when I said "choking?" the TA said "well, coughing and she cannot stop." I get to the room to find the 17 year old holding her stomach, drooling, very mild cough, and constant sneezing. Eyes are closed, she is special needs and has a seizure disorder, but this does not look like seizures to me. Staff says she was just finishing her rice meal when this started, and she has not history of allergy and this is a meal she eats all the time.

I first try to talk to her to see if I can calm her, assess her alertness . . . she can follow instructions to squeeze my hand. Lips and nail beds pink, no swelling, no wheezing, no retractions around neck or clavicle area. As I talked to her the coughing intermittently slows and honestly, at times, sounds forced, so there is a part of me that is wondering if there is something behavioral going on (it has happened) but I know the sneezing is real. I wonder if it's some kind of reflex reaction and is the cough and sneezing are related.

After 5 -7 minutes it is not stopping, so I ask office to call 911 for a teen student in respiratory distress. I then start to wonder if this is an unknown allergic reaction. I ask someone to retrieve the EPI pen from my office.

Myself and the teacher continue to try to keep her calm, and while it all continues, there is no worsening or improvement.

At the 15 min mark I tell the teacher I am giving EPI - I don't know what this is but I am concerned about some kind of throat swelling. 30 sec after EPI the cough slows a little, again at the 1 minute mark, and by 2-3 minutes all symptoms stop. In the meantime, EMS arrives. O2 sats are good and lungs are clear. They suspect she started choking and had airway narrowing, and the EPI opened her up.

I am going to have a meeting of all my EPI trained staff next week to share with them the signs I saw, and use this as a teaching moment for all of us. If I was having a hard time deciding what to do, it gave me insight into what it will be like for a lay person. I need to reinforce that better to give it if there is any question than not give it.

I will be honest . . . I think I waited too long to give it. I was trying to be systematic in my assessment and other than the coughing, no signs of respiratory distress. But I kept thinking that if this goes on, it's going to progress to respiratory distress and then I will have a bigger problem.

Off to the hospital she went. I am sure she will be fine. But if anyone has any comments to contribute (and please feel free to offer constructive criticism . . I want to use this as a learning opportunity), please do. Mostly, at what point would you have given it? That is what I am struggling with. I know if there were any signs of worsening, noisy resp., retractions, color change, it would have been an no-brainer. Without any of those signs, it was the longevity of the situation that became concerning to me.

Thanks for listening!

[ruby_jane, BSN, RN]

You didn't wait too long. Your nursing judgement was tested and you were, as it turns out, right. You do not have a policy specific for the thing you did (and you probably won't) but your nursing judgment saved the day!

Having said that - I am not sure I'd want to educate lay people to give Epi for this situation. Because they don't have nursing judgement.

I'm waiting for Old Dude to chime in.

[kidzcare]

I'm waiting for Old Dude to chime in.

Where you at OD?????

I think you did fine! This student was not showing "classic" signs of allergic reaction. Next time (fingers crossed on episodes being few and years between) you may decide to give sooner based on this experience. You did awesome and this student is so fortunate that you were there!!!!

[LikeTheDeadSea, MSN, RN]

I'd also hesitate to discuss this with lay people, they may give it quickly to someone having a classic Asthma attack based on this.

I think the timing of this sounds good. She wasn't tanking rapidly and you waited to see if calming strategies improved anything. It's easy to forget that calming strategies aren't instant and that a few minutes is necessary before deciding they aren't working.

Kudos to you for giving what sounds like a great assessment and treatment of a student with special needs in an atypical situation!

I'm curious as to how EMS reacted to you giving Epi in this situation. I did once for significant facial swelling (unknown insect sting on head) that wasn't swelling around the mouth/tongue, statements of chest tightness, and a LOC that was shifting into slight confusion, with fluctuation in breathing pace. Both EMS and the ER doc were very "I wouldn't have given it unless vomit, mouth swelling, etc." I think when they arrive and see that it's been resolved, it's easy to criticize.

[Flare, ASN, BSN]

Great job! I agree - you didn't wait too long. Having a thorough assessment is important as part of this work up. Yes, the epi wouldn't technically hurt someone that was in distress for a different reason and got epi, but it wouldn't necessarily help them and may end up steering the course of treatment. I agree that the laymen staff propably should not be trained too far outside the general anaphylaxis treatment training. You don't want them to hammer everything that looks like a nail.

[GdBSN, RN]

Great job!!! That student was lucky you were there. I don't feel like you waited too long or rushed into giving the epi. You used your nursing judgment, assessed the situation, and acted when you felt it was necessary.

[nmr79]

I also think you handled it well.

She wasn't rapidly declining, and with her history, it sounds like you were waiting the appropriate time to tease out if it was behavioral or not. Good job! It's scary, even when we do know what to do! It's also easy to second guess ourselves, esp. if the EMTs aren't supportive.

Good job! I have stock epi for precisely this type of scenario- an undiagnosed allergic reaction. But a lay person is not allowed to administer epi in this case, only RN (in my state).

[OldDude]

Bam!! Another kid snatched from the jaws of death!! School nurses, that what we do!! Linda, what an awesome example of critical thinking and a calm, rational, step by step assessment under very stressful circumstances. You absolutely did the right thing at the right time. This family is blessed that you were there for this event to be a story to tell instead of something tragic. What a save NURSE!! Pat yourself on the back cuz you earned this one!!

[JenTheSchoolRN, BSN, RN]

Good job! I have stock epi for precisely this type of scenario- an undiagnosed allergic reaction. But a lay person is not allowed to administer epi in this case, only RN (in my state).

Same for me - I can only delegate Epi to a layperson for a student with a diagnosed allergy and prescription for Epi (no prescription even with allergy, no delegation). Laypersons lack the nursing judgement and that could be a lawsuit waiting to happen if your state even allows delegation of Epi to give to a student without a diagnosed allergy.

But as for you - GO YOU! You went with your nursing gut and a good outcome was had. That is what school nursing comes down to, having the confidence to access and use what you have at hand, which is so much less than other medical settings.

And the first time you give Epi, you have so many what ifs swirling around. I'd like to say it gets easier, but I just gave my 7th epi pen (yep I remember enough to count and my state makes me fill out so much paperwork when I give one) and it is still the most adrenaline pumping event that when all is calm and student is good, I'll start shaking a bit.

[TinyDancer01]

I think you did everything right! I wouldn't have been sure either. I wouldn't worry too much about teaching the staff on this particular episode other than give if in doubt because how do you teach them to be a nurse in an emergency situation? We have went to school, practiced a lot, given shots, and know all the things to look for and actually remember them yet we are somehow supposed to have a teacher be prepared to do that in a stressful situation? That's why we need a nurse in every school. Of course I'm preaching to the choir! Some of my teachers would stay cool under pressure but there are some who would freak out and make it all worse. Anyway great job!!

[halohg, RN]

Not only did not wait to long but by sharing this story you have better prepared the next school nurse facing a similar situation who is feeling very alone. Sharing these experiences makes all better, so thank you and grateful you were there and your district supports stock Epi.