Dana V. Wallace, MD Assistant Clinical Professor Nova Southeastern University Davie, Florida [email protected].

Dana V. Wallace, MDDana V. Wallace, MDAssistant Clinical ProfessorAssistant Clinical Professor

Nova Southeastern UniversityNova Southeastern UniversityDavie, FloridaDavie, Florida

[email protected]@gmail.com

ANAPHYLAXIS IN THE OFFICEANAPHYLAXIS IN THE OFFICEALLERGIST ALLERGIST and Staffand Staff BE PREPARED BE PREPARED

Templates and Forms Templates and Forms

ARE IMPORTANT!ARE IMPORTANT!

Templates & Forms for SITTemplates & Forms for SIT Cox, L., H. Nelson, et al. Cox, L., H. Nelson, et al. "Allergen "Allergen

immunotherapy: a practice parameter third immunotherapy: a practice parameter third update." update." J Allergy Clin ImmunolJ Allergy Clin Immunol 127127(1 Suppl): (1 Suppl): S1-55.S1-55.– http://www.jacionline.org/article/PIIS00916749100150

34/addons

[jacionline][jacionline] www.acaai.orgwww.acaai.org

– (ACAAI > Members > Practice Resources > Skin (ACAAI > Members > Practice Resources > Skin Testing & Immunotherapy)Testing & Immunotherapy)

Kalier, M., Lockey, R., edsKalier, M., Lockey, R., eds. Clinical Allergy and . Clinical Allergy and Immunology SeriesImmunology Series, 4, 4thth Edition Edition

www.drdanawallace.comwww.drdanawallace.com

Discussing SCIT Treatment OptionDiscussing SCIT Treatment Optionwww.drdanawallace.com

SLIT Patient Info (Part 1)SLIT Patient Info (Part 1)

SLIT Patient Info (Part 2)SLIT Patient Info (Part 2)

SLIT Patient Info (Part 3)SLIT Patient Info (Part 3)

SLIT Side EffectsSLIT Side Effects

Allergy Immunotherapy Allergy Immunotherapy Consent process should discuss:Consent process should discuss:

Treatment and alternativesTreatment and alternatives Potential benefitPotential benefit Potential risks, giving frequency of adverse Potential risks, giving frequency of adverse

events, including deathevents, including death Cost associated and coverage optionsCost associated and coverage options Anticipated duration of TxAnticipated duration of Tx Office policies that affect Tx, e.g. waiting Office policies that affect Tx, e.g. waiting

time, missed AIstime, missed AIs

Based on 2011 Immunotherapy PP

Consent to Allergen Consent to Allergen ImmunotherapyImmunotherapywww.acaai.org

CONSENT FORMS TO CONSIDERCONSENT FORMS TO CONSIDER

Allergy testing & immunotherapyAllergy testing & immunotherapy Permission to treat a minorPermission to treat a minor Consent to take allergy vaccine out of Consent to take allergy vaccine out of

office to another MD for administrationoffice to another MD for administration Consent from remote MD agreeing to Consent from remote MD agreeing to

administer AIadminister AI Privacy form to authorize info to specific Privacy form to authorize info to specific

people- e.g. child custody people- e.g. child custody

www.drdanawallace.com

Consent to take Allergen Extract Consent to take Allergen Extract Sets to another officeSets to another office

www.acaai.org

Cross-reacting AllergensCross-reacting Allergens jacionline

Recommended Documentation SCIT Recommended Documentation SCIT Prescription (Rx) Forms Prescription (Rx) Forms

Purpose:Purpose: – To define the contents of the allergen immunotherapy To define the contents of the allergen immunotherapy

extract in enough detail that it could be precisely extract in enough detail that it could be precisely duplicatedduplicated

Patient information: Patient information: – Name, chart number (if applicable), birth date, Name, chart number (if applicable), birth date,

telephone number (home/mobile), email, & picturetelephone number (home/mobile), email, & picture   Preparation information: Preparation information:

– Name of person (& signature) preparing the allergen Name of person (& signature) preparing the allergen immunotherapy extract & date preparedimmunotherapy extract & date prepared

– Vial name, by allergens included (e.g., Trees, Grass or Vial name, by allergens included (e.g., Trees, Grass or abbreviations (e.g., T, G, with legend)abbreviations (e.g., T, G, with legend)

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Recommended Documentation SCIT Recommended Documentation SCIT Prescription (Rx) Forms Prescription (Rx) Forms

Allergen immunotherapy extract content information Allergen immunotherapy extract content information for for eacheach allergen: allergen:– Common name or genus and speciesCommon name or genus and species

– Concentration of available manufacturer’s extract Concentration of available manufacturer’s extract

– Volume of manufacturer’s extract to add to achieve the Volume of manufacturer’s extract to add to achieve the projected effective concentrationprojected effective concentration

• Calculate by dividing the projected effective concentration Calculate by dividing the projected effective concentration by the concentration of available manufacturer’s extract by the concentration of available manufacturer’s extract times the total volume times the total volume

– Extract manufacturer & lot number, expiration dateExtract manufacturer & lot number, expiration date

– Same detail for all mixes Same detail for all mixes

Vial expiration date should not exceed of any of the Vial expiration date should not exceed of any of the individual components individual components

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SCIT Prescription FormSCIT Prescription Form jacionline

SCIT Prescription Form-completedSCIT Prescription Form-completedjacionline

IMMUNOTHERAPYRX FORM

MODIFIED BY DANA WALLACE,MD

Name: Jane Doe Chart #: 3341 Bottle Name: A

DOB: 8/29/1948 Bottle #: 177

Maintenance Concentrate Content Rx Total Vials 4

Allergen, Concentration Available, Manufacturer, Lot # , Expiration date

Projected Effective

Concentration available

Volume in ml extract to add

Remake if same Lot

1 Australian Pine 1:10 C 1C00061 8/19/03 1/100 1/10 0.50

2 Bald Cypress 1:10 C 2D00061 1/8/04 1/100 1/10 0.50

3 Bayberry 1:10 C 1J00041 1/8/04 1/100 1/10 0.50

4 Mulberry, Red 1:10 C 1J44691 3/24/03 1/100 1/10 0.50

5 Baccharia 1:20 G 225-40-2A19 10/2/03 1/100 1/10 0.50

6 Dog Fennel 1:10 C 1L3291 7/14/03 1/100 1/10 0.50

7 Pigweed, Spiny 1:10 C 0M00081 8/4/03 1/100 1/10 0.50

8 Ragweed, Short 1:10 C 1L00191 2/4/03 1/100 1/10 0.50

9 Sheep Sorrel 1:10 C 1G00191 5/1/03 1/100 1/10 0.50

10 Yellow Dock 1:10 C 0M00431 7/14/03 1/100 1/10 0.50

11 None 0 1/10 0.00

12 None 0 1/10 0.00

A=ALK 5.00C=Center 0.00

5 G+Greer 5HS=Hollister Steer

0.5 injected 1ml injectedMite Pteronysinus 1200 AU/ml 600AU/mlMites Farinae 4000 AU/ml 2000 AU/ml Date and Signature Cat 5000 BAU/ml 2500 BAU/mlOther Animals 1:100/ml 1:200/mlStandardized Grassed 8000 BAU/ml 4000 BAU/mlPollens 1:100/ml 1:200/mlMolds 1:50/ml 1:100/ml

High Protease:Dust Mites, Molds, Cockroach Low Protease: Pollens. Cat, Dog

Do not mix high with low protease allergens May mix low with low, high with high

Ragweed may be mixed in either group. Keep venomous insects separate

Remakes Date, initals & Date, initals & Date, initals & Date, initals &

Bottle Color/Vial Dilutions Volume:Volume Expiration Expiration Expiration Expiration

Brown 1:10,000,000 4 wks

Peach 1:1,000,000 4wksPink 1:100,000 4wksSilver 1:10,000 4wksGreen 1:1,1000 6wks

Blue 1/100 6mths

Yellow 1/10 6mthsRed Full Strength Earliest expiring constituent

Jane Doe Vial A

Dana V. Wallace MD 2699 Stirling Road Suite B305 Ft. Lauderdale,FL 33312 954-963-5363 fax 963-7099Revised 9/02

1/100

5

1/10 Australian Pine 1:10 C 1C00061 8/19/03

Bald Cypress 1:10 C 2D00061 1/8/04

Bayberry 1:10 C 1J 00041 1/8/04

Mulberry, Red 1:10 C 1J 44691 3/24/03

Dog Fennel 1:10 C 1L3291 7/14/03

Baccharia 1:20 G 225-40-2A19 10/2/03

Pigweed, Spiny 1:10 C 0M00081 8/4/03

Ragweed, Short 1:10 C 1L00191 2/4/03

Sheep Sorrel 1:10 C 1G00191 5/1/03

Yellow Dock 1:10 C 0M00431 7/14/03

None

None

1/100

1/100

1/100

1/100

1/100

1/100

1/100

1/100

1/100

1/10

1/10

1/10

1/10

1/10

1/10

1/10

1/10

1/10

1/10

1/10

5

Projected Effective ConcetrationAnitgen

Total ExtractDiluent

Total Volume

Factor is volume to be injected X 10

www.acaai.org (ACAAI > Members > Practice Resources > Skin Testing & Immunotherapy)

Labels for allergen Labels for allergen immunotherapy extracts immunotherapy extracts

Each vial must have Each vial must have appropriate patient appropriate patient identifiersidentifiers, e.g., name, number, DOB, picture, e.g., name, number, DOB, picture

Contents, e.g, T, G, M, Df, D, etc.Contents, e.g, T, G, M, Df, D, etc. The dilution from the maintenance concentrate The dilution from the maintenance concentrate

(vol/vol) using color, numbers, letters(vol/vol) using color, numbers, letters Expiration date of individual vialExpiration date of individual vial

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Allergy Extract Vial Dilution & LabelingAllergy Extract Vial Dilution & Labelingwww.acaai.org

Allergy Extract Vial Dilution & LabelingAllergy Extract Vial Dilution & Labelingwww.acaai.org

Vial LabelsVial Labels www.acaai.org

Weekly Build-up TherapyWeekly Build-up Therapy jacionline

Cluster SCIT ScheduleCluster SCIT Schedule jacionline

SCIT Rush Immunotherapy ScheduleSCIT Rush Immunotherapy Schedulewww.acaai.org

SLIT Proposed SchedulesSLIT Proposed Schedules

SCIT Administration RecordSCIT Administration Record List info in separate columnsList info in separate columns

– Date of injectionDate of injection– Arm administeredArm administered– Delivered volume in mmDelivered volume in mm– Currently on antihistamine (desirable)Currently on antihistamine (desirable)

Projected build-up scheduleProjected build-up schedule Description of any reaction (details may Description of any reaction (details may

appear on separate sheetappear on separate sheet Peak flow- pre and post SCIT may be Peak flow- pre and post SCIT may be

includedincluded

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IImmmmuunnootthheerraappyy VVaacccciinnee AAddmmiinniissttrraattiioonn FFoorrmm

Best Baseline Peak Flow: ___________________

Date Time Health screen abnormal1

Anti-histamine

taken?2

Peak

Flow

Arm Vial Number

or Dilution

Delivered

Volume

Reaction 3

Arm Vial Number

or Dilution

Delivered

Volume

Reaction Injector

Initials

1. ___/____/____ _______ Y N Y N ___________ R L ________ ________ ____________ R L ________ ________ _________ _______

2. ___/____/____ _______ Y N Y N ___________ R L ________ ________ ____________ R L ________ ________ _________ _______ 3. ___/____/____ _______ Y N Y N ___________ R L ________ ________ ____________ R L ________ ________ _________ _______ 4. ___/____/____ _______ Y N Y N ___________ R L ________ ________ ____________ R L ________ ________ _________ _______ 5. ___/____/____ _______ Y N Y N ___________ R L ________ ________ ____________ R L ________ ________ _________ _______ 6. ___/____/____ _______ Y N Y N ___________ R L ________ ________ ____________ R L ________ ________ _________ _______ 7. ___/____/____ _______ Y N Y N ___________ R L ________ ________ ____________ R L ________ ________ _________ _______ 8. ___/____/____ _______ Y N Y N ___________ R L ________ ________ ____________ R L ________ ________ _________ _______ 9. ___/____/____ _______ Y N Y N ___________ R L ________ ________ ____________ R L ________ ________ _________ _______ 10. ___/____/____ _______ Y N Y N ___________ R L ________ ________ ____________ R L ________ ________ _________ _______ 11. ___/____/____ _______ Y N Y N ___________ R L ________ ________ ____________ R L ________ ________ _________ _______ 12. ___/____/____ _______ Y N Y N ___________ R L ________ ________ ____________ R L ________ ________ _________ _______ 13. ___/____/____ _______ Y N Y N ___________ R L ________ ________ ____________ R L ________ ________ _________ _______ 14. ___/____/____ _______ Y N Y N ___________ R L ________ ________ ____________ R L ________ ________ _________ _______ 15. ___/____/____ _______ Y N Y N ___________ R L ________ ________ ____________ R L ________ ________ _________ _______ 16. ___/____/____ _______ Y N Y N ___________ R L ________ ________ ____________ R L ________ ________ _________ _______ 17. ___/____/____ _______ Y N Y N ___________ R L ________ ________ ____________ R L ________ ________ _________ _______ 18. ___/____/____ _______ Y N Y N ___________ R L ________ ________ ____________ R L ________ ________ _________ _______ 19. ___/____/____ _______ Y N Y N ___________ R L ________ ________ ____________ R L ________ ________ _________ _______ 20. ___/____/____ _______ Y N Y N ___________ R L ________ ________ ____________ R L _______ ________ _________ _______ 21. ___/____/____ _______ Y N Y N ___________ R L ________ ________ ____________ R L _______ ________ _________ _______ 22. ___/____/____ _______ Y N Y N ___________ R L ________ ________ ____________ R L _______ ________ _________ _______ 23. ___/____/____ _______ Y N Y N ___________ R L ________ ________ ____________ R L _______ ________ _________ _______ 24. ___/____/____ _______ Y N Y N ___________ R L ________ ________ ____________ R L _______ ________ _________ _______

1. Health screen refers to either a written or verbal interview of the patient prior to the administration of the allergy injection regarding: the presence of increased allergy or asthma symptoms or symptoms of respiratory tract infection, beta-blocker use, change in health status (including pregnancy) or adverse reaction to previous injection. A yes answer to this health screen may require further evaluation (see health screen record on back page). 2. Antihistamine use: to improve consistency in interpretation of reactions it should be noted if the patient has taken an antihistamine on injection days. Physician may also request that an antihistamines be taken consistently on injection days: recommended: Y N 3. Reaction: refers to either immediate or delayed systemic or local reactions. Local reactions (noted as LR) can be reported in millimeters as the longest diameter of wheal and erythema.. The details of the symptoms and treatment of a systemic reaction (noted as SSRR) would be recorded elsewhere in the medical record. Guidelines for dose reduction after a systemic reaction on a separate instruction sheet.

Date to reorder: __/__/__

Vaccine Name Abbreviations* Tree: T Mold: M Grass: G Cat: C Weed: W Dog: D Ragweed: R Cockroach: Cr Mixture: Mx Dust Mite: Dm

SCHEDULE Vial 5 Vial 4 Vial 3 Vial 2 Vial 1

Injector signature

Initials

Patient Name: Date of Birth: Patient Number: Telephone Number: Diagnosis:

Prescribing Physician: Address: Telephone: Fax:

Dilution Color

Vial number

1:10,000 (v/v) Silver

5

1:1000 (v/v) Green

4

1:100 (v/v) Blue

3

1:10 (v/v) Yellow

2

Maintenance 1:1 (v/v) Red

1 Expiration date(s)

____/____/____ ____/____/____ ____/____/____ ____/____/____ ____/____/____

Vial A: Extract name* Vial B: Extract name

Vaccine A: vaccine contents* Vaccine B: _______________

ALLERGY INJECTION

ADMIN. FORM

www.acaai.org (ACAAI > Members > Practice Resources > Skin Testing & Immunotherapy)

SCIT Administration RecordSCIT Administration Recordwww.acaai.org

Health Screen Form (Pre SCIT)Health Screen Form (Pre SCIT)

Patient identifiers, date, baseline peak flow & BP, Patient identifiers, date, baseline peak flow & BP, if advised to use antihistamines with SCITif advised to use antihistamines with SCIT

Records status of: Records status of: – Asthma control, consider standardized instrument and Asthma control, consider standardized instrument and

Peak Flow pre and postPeak Flow pre and post

– Beta-blocker useBeta-blocker use

– Pregnancy or other recent health care status, including Pregnancy or other recent health care status, including recent infection or allergy/asthma flarerecent infection or allergy/asthma flare

– Previous adverse reaction to SCITPrevious adverse reaction to SCIT

– Consider BP measurementConsider BP measurement

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Health Screen FormHealth Screen Form jacionline

PRE-INJECTION

HEALTH SCREEN

Immunotherapy Pre-Injection Questionnaire

Patient Name:____________________________________ Date:____________________ This questionnaire is designed to optimize safety precautions already in place for your allergen immunotherapy injections (allergy shots). Please review and answer the following questions. The nursing staff will review your responses and notify your physician if they have any questions or concerns whether you should receive your injection(s) today. If you are pregnant or have been diagnosed with a new medical condition, please notify the staff. (Please circle the appropriate answer.) 1. Have you had increased asthma symptoms (chest tightness, increased cough, wheezing, or

felt short of breath) in the past week? Yes No

2. Have you had increased allergy symptoms (itching eyes or nose, sneezing, runny nose,

post-nasal drip, or throat-clearing) in the past week? Yes No

3. Have you had a cold, respiratory tract infection, or flu-like symptoms

in the past two weeks? Yes No

4. Did you have any problems (such as increased allergy or asthma symptoms, hives, or

generalized itching or redness) within 12 hours of receiving your last injection? Yes No

5. Are you on any new medications? Any new eyedrops? Please specify.___________________

Staff intervention/office visit:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Staff Signature:_________________________________________________________________ www.acaai.org

Preparing your office staff for Preparing your office staff for ANAPHYLAXISANAPHYLAXIS

ANAPHYLAXIS CARTANAPHYLAXIS CART

Supplies and Equipment for Anaphylaxis Treatment in office

“NECESSARY” Stethoscope and Stethoscope and

sphygmomanometersphygmomanometer *Epinephrine 1:1000*Epinephrine 1:1000 OxygenOxygen IV FluidsIV Fluids Tourniquets, syringes, Tourniquets, syringes,

hypodermic needles, hypodermic needles, large-bore needles large-bore needles

“CONSIDER HAVING”” One-way valve facemaskOne-way valve facemask Diphenhydramine inj.Diphenhydramine inj. Corticosteroids inj.Corticosteroids inj.

“MAYBE” Vasopressor (Dopamine)Vasopressor (Dopamine) GlucagonGlucagon Automatic defibrillatorAutomatic defibrillator Oral airwayOral airway

* Required 2011 JTF Anaphylaxis PP

ANAPHPYLAXIS CART INVENTORY AND UPDATE LIST

2005

ANAPHYLAXIS CART

Algorithm for Tx Treatment Recording Sheet Pulse Oximeter Stethoscope Twin Jet Nebulizer Ambu Bag- Child (450 ml) (2)

Adult (1500ml) (2) (Disposable, latex-free)

Sphygmomanometer & cuffs: child, Adult regular, and oversized

Laryngoscopes Adult and Pediatric (optional)

Defibrillator with heart monitor (Optional)

IV ADMINISTRATION DRUGS IV Pole Epinephrine 1:1000 1cc ampules (10) 1000cc .9 Normal Saline (4 bags)

Hydroxyethyl starch (Hespan) 500 ml bag (2) Epinephrine 1:10,000 10cc pre-mixed syringes (2)

(Optional) 3-Way Stopcock (2) Epinephrine 1:1000 30 cc multidose vials (1)

Micro drip IV set (2) 60 gtt/ml

Benadryl (diphenhydramine) IV 1 ml ampule, 50 mg/ml (2)

Macro drip IV (2) 10-15 gtt/ml Benadryl liquid 12.5 mg/ml (4 oz) & 25 mg tablets (10) Extension tubing (2) Zyrtec (Cetirizine) 5mg/ml (4 oz), 5 mg (5) & 10 mg (5)

tablets T-Connector (2) Zantac(ranitidine HCL) IV 2 ml vial, 25 mg/ml (2) Catheters #22, 20, 18 (2 each) Zantac(ranitidine HCL) PO 1 oz, 15 mg/ml & 150 mg

tablets Butterfly Needles #21, #19 (3 each) Albuterol 2.5 mg unit dose (3) or Xopenex 1.25 mg (3)

and .63 mg (3) inhalant solution Syringes 1cc, 5cc, 10cc, 20cc, 50cc (5 each) Atrovent Inhalant solution .083% unit doses (2) Needles # 16, #18, #20, #22 (5 each) Aminophylline IV, 500 mg vial , 50 mg/cc(1) Tourniquet (2) Prednisolone Syrup 15 mg/tsp 4 oz Cushioned IV Boards (2) Solu-Medrol 1 ml vial, 40 mg/ml (3)

4x4 cotton sponges (10) Medrol 4 mg tablets # 20

1” tape Synthetic (Transpore) Atropine (ipratropium bromide) 4 ml vial, 0.5 mg/ml (2) Alcohol Swabs (10) Dopamine 10cc vial, 40 mg/ml (2) Latex Free Gloves- 1 box M, L Glucagon 1 mg vial (3 vials) Saline 30 cc, 10 cc (5 each) NaHCO3 50 mEq/50 ml (Optional) (2) D5W 250 ml (4), 500 ml (1), 30 ml (2) Calcijex IV calcium 1 mg/ampule (Optional)

Valium IV 10 ml vial (Optional)

AIRWAY OXYGEN DELIVERY Face mask-infant, toddler, child, adult O2 E-Tank with wheeled carrier Oral Airways-6 cm, 7cm, 8cm, 9 cm, 10cm Gas regulator Endotracheal tubes 3.5, 5,6,7, 8, 9, 10

(optional) Tank wrench

Scalpel, disposable (2) Pediatric oxygen mask Adult oxygen mask Nasal canula

Extension tubing Note (#) number of units to order Check and restock monthly and after each use:

Year_______

Month Initial Month Initial Month Initial Month Initial

Jan. April July Oct.

Feb. May Aug. Nov.

March June Sept. Dec.

Practice Name Practice Address

Practice Phone Number

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ANAPHYLAXIS TREATMENT

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Drug Start Strength Add Final dilution or max

A=adult, C=child Method of Delivery Frequency Adult

(A) Child < 12 (C) Dose/kg ***

X wt in KG = Dose

Epinephrine Aqueous (Epi)

1:1000 1ml=1mg= 1000mcg

1:1000 Max .3 mg C

IM lateral thigh

Q ≤ 5 min 0.2-0.5 mg (ml) 0.01mg (ml) /kg max 0 .3 mg

X _____ =___ mg (ml)

Auto Injector (Epi-Pen or TwinJect)

1:1000 1ml=1mg

1:1000 IM lateral thigh

Q ≤5 min SR, .3 mg JR , 0.15 mg <15 kg .15 mg

Epi Infusion 1st choice after IM

1:1000 1ml=1mg

250 ml D5W 1:250,000=4.0μg/ml IV infusion continual 1-4 μg/min=.25-1.0 ml/min (15-60 microdrops/minute)

0.1 μg/kg/min X_____

_______ 1 μg=.25ml

μg/ min

Epi IV (or IO) after cardiac arrest, if not responding to infusion or Tracheal (T)

1:1000 1-3ml=1-3mg 1:1000

9-27 ml Saline None

1:10,000 1:1000, .3 max C

IV #1 slow push Over 3 minutes Flush T with 10 ml saline A, 5ml C

3-5 minutes rapid

10-30 ml T: .3-.5ml of 1:1000

.1ml/kg (0.01 mg/ kg ) max 0.3 mg=3ml T: .05-.1 ml/kg

X_____ X_____

=______ =______

ml ml

Epi IV after cardiac arrest, if not responding to above

1:1000 3-5ml=3-5 mg

27-45 ml Saline

1:10,000 IV #2 Over 3 minutes

3-5 minutes 10-30 ml

1ml/kg (0.1 mg/kg) max 30 ml

X______ X_______

=______ =______

ml ml

Epi IV high dose infusion after cardiac arrest, if not responding to above

1:1000 1mg= 1 ml

250 ml D5W 1:250,000=4.0μg/ml Max 10 μg/min A, C

IV infusion continual 4-10 μg/min=1.0-2.5ml/min (60-150 microdrops/minute)

0.1 μg/kg/min and ↑ up to 10 μg/min

X_______ _______ 1 μg=.25ml

μg/ min

Diphenhydramine (Benadryl) IV/IM/PO

50 mg/ml IV/IM 12.5 mg/5ml PO

Or 25 mg PO tablet/capsule

Max 24 hr A=400 mg C=300 mg

IM/IV PO

repeat 1x PRN then q 6 hr

25-50 mg 1 mg /kg or 2 mg /kg

X______ X______

=______ =_____

mg mg

Cetirizine (Zyrtec) PO 5 mg/5ml or 5 mg, 10 mg tablet

PO 10 mg PO-A

2.5-10 mg PO-C mg

Ranitidine HCl (Zantac) IV/IM/PO

25 mg/ml IV/IM 75 mg/5 ml or 150 mg tablet PO

20 ml D5W for IV

IV over 5 minutes PO

Q 6 hr

50 mg IV/IM 150 mg PO

1 mg/kg IV/IM 2 mg/kg PO

X______ X______

=______ =______

mg mg

Albuterol 2.5 mg in 3 ml .083% Nebulized Q 20 min 2.5 mg 1.25-2.5 mg 1.25-2.5 mg Levalbuterol (Xopenex) .63-1.25 mg in 3

ml Nebulized Q 20 min 1.25 mg 0.63-1.25 mg 0.63-1.25 mg

Ipratropium bromide (Atrovent)

.02% in 2.5 ml vial May add to Albuterol or Xopenex

Nebulized Q 6 hr 500 mcg= 1 vial

250-500 mcg = ½-1 vial

250-500 = ½-1 vial

mcg

Aminophylline (optional)

500 mg/10 ml Add to 100 ml Saline, micro drip

IV over 30 minutes 5 mg/kg 5 mg/kg X______ =______ mg

Normal Saline 1000 ml bags 1-2 L needed in adult

IV infusion over first 60 minutes

Continue, but reduce after BP stable

20-30 ml/kg 25% first 10 minutes

30 ml/kg X______ =______ ml

Hydroxyethyl starch Hespan (2nd choice)

500 ml IV infusion over first 60 minutes

500 ml 30 ml/kg X______ =______ ml

Methylprednisolone (Solu-Medrol)

40 mg/ml Max 2 mg/kg/24 hr IV push Q 6 hours 1 mg/kg 1 mg/kg X______ =______ mg

Prednisolone (Pediapred) 5 mg/5 ml PO ? repeat X1 in 6 hrs 25-50 mg 0.5 mg/kg X______ =______ mg Methylprednisolone 4 mg PO ? repeat X1 in 6 hrs 20-40 mg 0.4 mg/kg X______ =______ mg Atropine 0.5 mg/ml Max 2 mg A

Max 1 mg C Subcut. Q 10 min. .3-.5 mg 0.02 mg X______ =______ mg

Glucagon (Side effects= N and V)

1 mg/ml = 1000 μg/ml

If Infusion use D5W or Saline

Max 1 mg C IV over 5 min Follow with Infusion 5-15 μg/minute

1-5 mg 20-30 μg/kg (1 mg max)

X_____ =______ mg

NaHCO3 50 mEq/50 ml 2nd dose ½ first dose IV Q 10 min 50-100 mEq 1 mEq/kg X______ =______ mEq Dopamine 400 mg 500 ml D5W 800 μg/ml IV infusion to ↑ BP 2-20 μg/kg/minute 2-20 μg/kg/minute X______ =______ μg/min

Patient Name_______________________Patient Name_______________________ TABLE OF ANAPHYLAXIS DRUGSTABLE OF ANAPHYLAXIS DRUGS

www.drdanawallace.com

Anaphylaxis Simple TX PlanAnaphylaxis Simple TX PlanTreatment of Anaphylaxis in the Physicians Office

Assess airway breathing, circulation, and orientation

Inject epinephrine, 0.3 mg intramuscularly, in the vastus lateralis (lateral thigh)

Activate emergency medical services (call 911 or local rescue squad)[Might delay, depending upon severity of reaction. DW]

Place patient in recumbent position and elevate the lower extremities, as tolerated

Establish and maintain airway Administer oxygen

Establish an intravenous line for venous access and fluidreplacement; keep open with normal saline [Might delay, depending upon severity of reaction. DW]

Consider administration of nebulized albuterol, 2.5-5 mg in 3 mL of saline; repeat as necessary

Consider administration of ancillary medications, such as H1, [H2]antihistamine, [and] or a systemic corticosteroid

Modified from Cox, et. al. AAAAI/ACAAI JTF Report on omalizumab-associated anaphylaxis. J Allergy Clin Immunol. 2007 Dec;120(6):1373-7.

POST AN ANAPHYLAXIS PROTOCOL POST AN ANAPHYLAXIS PROTOCOL AND/OR ALGORITHM (in visible location )AND/OR ALGORITHM (in visible location )

Allergen Immunotherapy Systemic Reation/Anaphylaxis Treatment Record

Name:________________________ Date________________________________ Date of Birth__________________ Prescribing Physician__________________ Allergens: Tree-Grass-Weed-Mites-Cockroach-Animal Dander-Mold-Hymenoptera Prior systemic rxn:__________ Hx of asthma?_____________ Date/time of injection:_________________ Date/time of rxn:____________________ Dilution (Vial #): ________________ New? Yes No History of the systemic reaction (SR): Immediate measures: __Assess airway, breathing, circulation, and orientation __Epinephrine IM into thigh __Activate EMS (call 911 or local rescue squad) Y/N Time called:______AM/PM __Management algorithm reviewed (as needed) Signs & Symptoms: Respiratory: Skin : Eye/Nasal: Vascular Other: Shortness of breath Hives Runny nose Hypotension Difficulty swallowing Wheezing Angioedema Red eyes Chest discomfort Abdominal pain, nausea, diarrhea Cough Generalized itch Congestion Dizziness Diaphoresis Stridor Flushing Sneezing Headache Time

Resp. rate/ PEFR Pulse/ O2 Saturation

BP

Intervention, Medications, Exam Comments

Time (AM/PM)/ Condition upon release:_____________________________________________________ Patient instructions:______________________________________________________________________ Follow-up call to patient: Time________ Comments:___________________________________________ Clinical impression: True SR Questionable SR No SR Comments:_________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

Dosage adjustment?: ____________________________________________________________________ Signatures_______________________________ RN ___________________________________MD/DO

ANAPHYLAXIS TX RECORD

www.acaai.org

WAO Grading System for SCIT Systemic WAO Grading System for SCIT Systemic Reactions: Reactions: GRADE 1- one organ systemGRADE 1- one organ system

42

WAO Grading System for SCIT Systemic WAO Grading System for SCIT Systemic Reactions: Reactions: GRADE 2GRADE 2

Symptoms/signs of more than one organ system presentSymptoms/signs of more than one organ system presentoror

Lower respiratoryLower respiratory Asthma: cough, wheezing, SOB (e.g. < than 40% PEF or FEV1 Asthma: cough, wheezing, SOB (e.g. < than 40% PEF or FEV1

, responding to inhaled bronchodilator), responding to inhaled bronchodilator)oror

GastrointestinalGastrointestinal Abdominal cramps, vomiting, or diarrheaAbdominal cramps, vomiting, or diarrhea

OrOr

OtherOther: uterine cramps: uterine cramps

Patients may describe a feeling of doomPatients may describe a feeling of doom

Might include any of the symptoms listed in grade 1

WAO Grading System for SCIT Systemic WAO Grading System for SCIT Systemic Reactions: Reactions: GRADE 3GRADE 3

Lower respiratoryLower respiratory Asthma (e.g. 40% PEF or FEV1 Asthma (e.g. 40% PEF or FEV1 ))

oror

Upper respiratoryUpper respiratory Laryngeal, uvula, or tongue edema with or Laryngeal, uvula, or tongue edema with or

without stridorwithout stridor

Note: Might include any of the symptoms listed in grade 1 and 2Patients may describe a feeling of doom

WAO Grading System for SCIT Systemic WAO Grading System for SCIT Systemic Reactions: Reactions: GRADE 4GRADE 4

Lower or upper respiratoryLower or upper respiratory– Respiratory failure with or without loss of Respiratory failure with or without loss of

consciousnessconsciousness

oror

CardiovascularCardiovascular– Hypotension with or without loss of Hypotension with or without loss of

consciousnessconsciousness

Note: Might include any of the symptoms listed in grade 1, 2, and 3Adults may describe a feeling of doom

WAO Grading System for SCIT Systemic WAO Grading System for SCIT Systemic Reactions: Reactions: GRADE 5GRADE 5

DeathDeath

[We [We

MustMust

Prevent]Prevent]

Thank You DANA WALLACE, MDdrdanawallace@gmail.comwww.drdanawallace.comMEDICALPROFESSIONAL (USER NAME)Allergy (PASSWORD)