WAFEAST - Washington Food Allergy Eczema & Asthma Support Team

On April 2, Washington FEAST had a meeting to discuss our concerns regarding emergency response to 911 calls for possible anaphylaxis in City of Seattle and King County.

We identified several differences between what we as food allergy parents might expect when we call 911 and what actually happens when we make the call. This list of observations is not exhaustive but includes:

- Caregivers are trained to request a medic truck if anaphylaxis is suspected and in contrast dispatcher decision to send a medic truck is influenced by a patient’s prior history of anaphylaxis or lack thereof.

- Caregivers are trained to implement an individuals physician-signed emergency care protocol when a broad range of symptoms of anaphylaxis are present and this is to halt the reaction and prevent the reaction from becoming life-threatening, whereas emergency responders are trained to administer epinephrine when patient is having difficulty breathing or hypotension (low blood pressure and/or loss of consciousness); see protocols below.

- Caregivers are educated on the importance of immediate transport to the closest ER once a reaction is recognized and epinephrine is given.  We are told that two doses of epinephrine should  always be available in case the first dose wears off before the patient arrives at the emergency room.   In contrast, the emergency response system may or may not send a medic car capable of transport.

- Caregivers are educated to understand that anaphylaxis can exhibit a biphasic pattern, meaning that it can disappear with initial treatment only to return later.   It is important that emergency responders understand that clinical findings present when they arrive could change drastically and quickly and that transport to the ER as quickly as possible is desirable.

We all agreed that we are grateful for all that emergency responders to keep all of food allergic individuals safe and hope we can work together for the best outcomes for these individuals.

We discussed two primary ways to address the problem including approaching the heads of the emergency medical systems in Seattle and King County, and eventually the state, as well as possibly working on a grass roots education effort on general awareness and understanding of anaphylaxis.  We have been successful in setting up a meeting with representatives from King County Emergency Medical Systems and are working on setting up a similar meeting with the City of Seattle.

Regarding a more grassroots effort, one possibility is getting the Anaphylaxis Community Experts program going in our area,

http://www.aanma.org/2010/12/find-an-anaphylaxis-community-expert-ace/.

To prepare for these meetings with King County and City of Seattle, we will expanding the list above.  It is very helpful to have real life stories to illustrate what can go wrong when we are working under different understanding of how to respond to anaphylaxis. It would also be great to have examples of times when 911 calls for anaphylaxis went very well.  As a reference for a standard of treatment for anaphylaxis, we are using the NIAID Guidelines for the Diagnosis and Management of Food Allergy in the United States. The link provided is to the clinician summary:

http://www.niaid.nih.gov/topics/foodAllergy/clinical/Documents/FAGuidelinesExecSummary.pdf

Differences in the definition of anaphylaxis and symptoms needed to be present to trigger the decision to use of epinephrine seem to be the major source of concern.  Below I have included the section on anaphylaxis from the King County and Seattle emergency medical training manual. You can see that the list of symptoms that need to be present for an epinephrine to be given is a lot shorter than one you might find on the emergency care plan signed by your allergist!

Thanks to all who attended the meeting on Monday for contributing to the discussion, and to all who have shared their stories of 911 calls over the last few years. WA FEAST successfully advocated for epnephrine autoinjectors to be carried on all emergency response vehicles after the death of Kristine Kastner.  At this juncture, it seems that bringing training protocols more in line with NIAID guidelines is an appropriate goal as well as advocating that this any subsequent changes are included in upcoming trainings as soon as possible.

As a food allergy community, we need to understand the constraints of the emergency response system, primarily being that dispatchers are in a constant process of prioritizing multiple 911 calls at any given moment. Equally important , however, is learning to most effectively interface with the system to ensure the best outcome for individuals experiencing an anaphylactic emergency.

If you have a story to share please write it up with dates if possible, but please omit personal info.

Kelly Morgan, President
Washington FEAST, www.wafeast.org
1-425-24FEAST (messages)
kelly@wafeast.org
Mail: 2400 NW 80th St., #315
Seattle WA 98117

ANAPHYLAXIS

ALS Indicators
Respiratory distress
Signs and symptoms of shock which include:
 Poor skin signs (pale, sweaty)
 Sustained tachycardia (see page 7)
 Hypotension (systolic BP less than 90 mmHg) with an appropriate clinical setting
Unstable vital signs
Use of EpiPen by EMT or healthcare professional.
BLS Indicators
Bite or sting with local reaction or usual reaction to medication or food
Stable vital signs
No anaphylaxis
BLS Care
EpiPen for anaphylaxis (see page 13).
Oxygen as needed.
Reassure patient.
Remove stinger by scraping away from puncture site.
Any patient who receives an EpiPen (pre or post EMS arrival) should be transported (mode of transport depends on clinical findings and symptoms) and evaluated in a hospital.

EPINEPHRINE (EPIPEN)

Indications For Use
EMTs may deliver epinephrine via an EpiPen injector for ANY case of suspected anaphylaxis (respiratory distress and/or hypotension must be present).
Seattle EMTs
 Patient (any age) has a history of same and a prescription for epinephrine
 Patient is less than 18 years of age with no prescription, but permission is obtained from parent or legal guardian. This may be written, oral or implied.
King County EMTs
There are no requirements for:
 Age
 Having a prescription
 Written/oral permission (beyond standard consent)
If there is doubt about the need for EpiPen, consult with local paramedic or local control doctor.
Dosages
 Adult and children equal to or over 30 kg or 66 lbs: use EpiPen (0.3 mg)
 Child under 30 kg or 66 lbs: use EpiPen Jr. (0.15 mg)

Injection Procedure
Confirm that patient is experiencing anaphylaxis and meets above criteria.
1. Check medication date and that the EpiPen dose matches to patient’s size.
2. Remove clothing and prep area of thigh with alcohol pad.
3. Remove safety cap and locate injection site on lateral thigh.
4. Place black tip of injector against thigh and push hard until injector activates.
5. Hold in place for 10 seconds. Note and document time of injection.
6. Remove injector, place in sharps container and massage site for 10 seconds.
7. Reassure patient and monitor for response/side effects to injection.
8. Continue to provide oxygen. Ventilate if necessary.
9. Monitor and document vitals every 5 minutes.
10. Update incoming medics on patient status and response to injection.
Use of EpiPen by EMT or healthcare professional is an ALS indicator. Any patient who receives an EpiPen (pre or post EMS arrival) should be transported (mode of transport depends on clinical findings and symptoms) and evaluated in a hospital.