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A Protocol for Training

Revised April, 2013

Oregon Health Authority – Public Health Division

Page 1

Oregon Health Authority Epinephrine Training Protocol Authorized for use by the Oregon Health Authority, Public Health Division If you need more information on Epinephrine and/or its use,

please contact:

Leslie Huntington 503-931-0659 Leslie.D.Huntington@state.or.us.

For additional copies or if you need this document in an

alternate format, contact:

Dan Nielsen 971-673-1230 FAX: (503) 872-6738 daniel.m.nielsen@state.or.us Page 2 Oregon Health Authority Epinephrine Training Protocol CREDITS Astrid Newell, MD and the late Beth Epstein, MD, of the Oregon Department of Human Services, Public Health Division, for the development of the original training protocol and the Oregon Administrative Rules (OARs) regarding the use of epinephrine by the general public.

Jan Sanderson, RN, BSN, of the Multnomah Educational Service District (MESD), for the development of the original Power Point.

Jeanne Fratto, RN, BS, of the MESD for the revisions and updates to subsequent versions of the epinephrine training materials and editing assistance with the 2013 revisions.

Ritu Sahni, MD, and Mellony Bernal of the Oregon Health Authority Public Health Dvision, for the 2012 revisions to the OARs.

Leslie Huntington, BS, Paramedic, of the Oregon Health Authority-Emergency Medical Services and Trauma Systems Office for the 2013 revisions of the training protocol and creation of the new Power Point presentation.

Kathleen Mahaffy-Dietrich, RN, BSN, MPA, of the MESD for her editing assistance with the 2013 revisions.

Page 3 Oregon Health Authority Epinephrine Training Protocol I. INTRODUCTION Anaphylaxis is a severe, potentially fatal allergic reaction. It is characteristically unexpected and rapid in onset. Immediate injection of epinephrine is the single factor most likely to save a life under these circumstances. Several hundreds of deaths each year are attributed to insect stings and food allergies.

In 1981 legislation was passed by the state of Oregon to provide a means of authorizing certain individuals to administer lifesaving treatment to people suffering severe insect sting reactions when a physician is not immediately available. In 1989 the Legislature expanded the scope of the original statute by providing for the availability of the same assistance to people having a severe allergic response to other allergens. The statute underwent minor revisions again in 1997 and 2012.

These bills were introduced at the request of the Oregon Medical Association. This legislation is intended to address situations where medical help often is not immediately available: school settings, camps, forests, recreational areas, etc. The following protocol for training is intended as an administrative document outlining the specific applications of the law, describing the scope of the statute, people to be trained, and proposing the content of that training.

II. BACKGROUND A. An explanation of the law and rules According to the law (ORS 433.805-830), a person who meets the prescribed qualifications may obtain a prescription for pre-measured doses of epinephrine.

The epinephrine may be administered in an emergency situation to a person suffering from a severe allergic response when a licensed health care provider is not immediately available.

The Oregon Administrative Rules supporting this law (OAR 333-055-000 to 333stipulate those who complete the training prescribed by the Oregon Health Authority, Public Health Division, receive a statement of completion signed by the licensed health care professional conducting the training. This statement of completion includes an authorization for a prescription to obtain an emergency supply of epinephrine auto injectors for one adult and one child.

In order for the prescription to be filled, the authorization must be signed by the nurse practitioner or physician responsible for the oversight of the training. This prescription may be filled up to four times in a three-year period. The training and Page 4 Oregon Health Authority Epinephrine Training Protocol subsequent authorization will expire three years after the date of the class as identified on the form. The individual must complete retraining in order to receive a new statement of completion and authorization.

B. Who can be trained?

In order to qualify for this training, a person must be 18 years of age or older and must ―have, or reasonably expect to have, responsibility for or contact with at least one other person as a result of the eligible person’s occupational or volunteer status.‖ Individuals who are likely to fall under the definition of the law include public or private school employees, camp counselors or camp employees, youth organization staff or volunteers, forest rangers and foremen of forest workers, public or private employers/employees with demonstrated exposure to risk.

In addition to taking the required training course described above, trainees are strongly encouraged to obtain and maintain current training in approved first aid and CPR courses that are offered through organizations such as Medic First Aid, the American Heart Association or the American Red Cross.

C. The training program

The training program must be conducted by either:

1. A physician licensed to practice in Oregon; or,

2. A nurse practitioner licensed to practice in Oregon; or,

3. A registered nurse, as delegated by a licensed physician or nurse practitioner;


4. A paramedic, as delegated by an EMS medical director defined in OAR 333No other personnel are qualified to conduct these trainings under this law.

The training must include the following subjects:

1. Recognition of the symptoms of systemic allergic response (anaphylactic reaction) to insect stings and other allergens;

2. Familiarity with factors likely to cause systemic allergic response;

3. Proper administration of an injection of epinephrine; and,

4. Necessary follow-up treatment.

Page 5 Oregon Health Authority Epinephrine Training Protocol The Oregon Health Authority, Public Health Division, is responsible for approving this training program as well as adopting the rules necessary for administering the law.

–  –  –


As stated in the definition above, anaphylaxis is a life-threatening condition and is almost always unexpected. It can start within minutes of exposure to an allergen.

The reaction may be delayed by several hours. Death often occurs as a result of swelling and constriction of the airway and the significant drop in blood pressure.

Once someone is having an anaphylactic reaction, the most important factor in whether they live or die is how quickly they receive an injection of epinephrine.

Because epinephrine must be given promptly at the first signs of anaphylaxis, the decision to treat must be based on recognition of the symptoms.

–  –  –

Although anaphylactic reactions typically result in multiple symptoms (e.g., hives, difficulty breathing and loss of normal blood pressure), reactions may vary substantially from person to person with possibly only one symptom being present.

Previous history of anaphylactic reactions and known exposure to potential allergens should increase the suspicion that the above signs or symptoms represent an anaphylactic reaction. Because reactions vary little from time to time in the same individual, obtain a description of previous reactions, if possible.

An anaphylactic reaction to an insect sting or other allergen usually occurs quickly;

death has been reported to occur within minutes after a sting. Highly food-sensitive individuals may react within seconds to several minutes after exposure to allergens. An anaphylactic reaction occasionally can occur from up to one to two hours after exposure.

It is common for people who are having an anaphylactic reaction to be in an Page 7 Oregon Health Authority Epinephrine Training Protocol increased state of anxiety. This is especially so if they have a history of a previous severe reaction.


If your staff, students or clients will be facing possible exposure to insect stings (in school settings, camps, tour groups, or outdoor settings such as forests, etc.),

and/or may be remote from medical assistance, you should:

Make EVERY EFFORT to identify beforehand who in the group has a history of allergic reactions (to insects, foods, etc.). This information should be obtained from the student, parent and/or physician as appropriate.

Obtain signed forms allowing emergency treatment.

Know how to access emergency medical help, including:

Location of nearest hospital;

Location of nearest Emergency Medical Services (EMS) response unit; and Determine ahead of time how you will call for help (e.g., cell phone, radio).

If a person has had an anaphylactic reaction in the past, it is possible that his or her next exposure to the allergen (for instance to bee stings or peanuts) may cause a more severe reaction.


A. Overview of the causes of anaphylaxis

The most common identifiable causes of anaphylaxis are:

Insect stings or bites (e.g., yellow jackets, wasps);

Foods (e.g., nuts, shellfish, eggs, milk);


Latex (e.g., balloons, duct or adhesive tape); and Physical exercise.

It is important to know that in a high percentage of cases, no specific cause of anaphylaxis is found.

Page 8 Oregon Health Authority Epinephrine Training Protocol Severe reactions can occur in someone with no history of previous allergic reaction. While anyone may experience anaphylaxis, individuals with a history of previous severe reaction, and those with asthma are most at risk for life-threatening anaphylaxis.

Severe life-threatening allergic response to various allergens occurs in only a small percentage of the general population. It is estimated between 1 and 2 percent of the population will experience anaphylaxis in their lifetime. (Mustafa, 2012, Epidemiology section, para.2).

When severe allergic reactions occur, immediate administration of injectable epinephrine is vital. Often the person suffering the reaction is unable to selfadminister epinephrine or is unequipped for the situation. Recognizing the signs of anaphylaxis quickly and administering epinephrine are critical actions you will learn in this training.

B. Insect stings

1. Epidemiology/likely culprits Fatal or serious reactions to insect stings are confined almost entirely to bees, wasps, hornets and yellow jackets.

Insects are more likely to sting during late summer and fall when it is dry and few flowers are still in bloom. Venom is more potent during this time of the year and stinging insects are easier to arouse.

Bees are more likely to sting on warm bright days, particularly following a rain.

The yellow jacket is the most frequent cause of an allergic reaction in the Pacific Northwest.

Patients are seldom able to identify the offending insect. When possible, an attempt at identification should be made once the reaction is treated so the sensitive person can avoid future exposure and his or her doctor can be informed.

–  –  –

3. What is not an anaphylactic reaction to an insect sting?

a. Normal reactions to stings A sting in a nonallergic person produces localized, sharp pain that varies in duration following the insertion of the stinger.

Within minutes, a small reddened area appears at the sting site and may enlarge to about the size of a quarter with hardening and redness.

Varying levels of pain and itching may accompany the redness, heat and swelling.

This response usually lasts about 24 hours, although a sting on the hand or foot may produce swelling that lasts for several days.

This reaction does not generally require professional medical attention.

Treatment includes washing the area and removing the stinger.

The individual with no history of allergic reactions should be observed for one-half hour after the sting.

If a child will return home later, then the parent or guardian should be notified of the sting.

If the sting occurs around the eye, nose, or throat the reaction may be more severe because even minimal swelling may cause obstruction. These types of stings need immediate medical attention. Stings around eyes are particularly serious and should be evaluated by a physician because long-term eye damage is a possibility.

–  –  –

c. Toxic reactions to multiple stings Toxic reactions are the result of multiple stings (usually 10 or more) — for instance when a person steps on a yellow jacket nest. Call 9-1-1 immediately.

The evaluation and treatment should be the same as you would for anaphylaxis.

C. Foods

1. Epidemiology/likely culprits Nearly any food can trigger an allergic reaction at any age. Food allergies are most common in children, and appear to be increasing in frequency.

Approximately 8 percent of children in the U.S. have a food allergy (Gupta, 2011, Results section).

–  –  –

* Peanuts are the most common cause of anaphylaxis in children, and is the food most frequently causing fatal reactions (Sicherer 2007) ** Shellfish are the most frequent food causing anaphylaxis in adults.

2. Avoiding food allergens Avoid exposure to known allergens;

Inform food preparation personnel of individuals with known food allergies;

Lunch ―swapping‖ or sharing (for instance, among children in a school setting) should be avoided;

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