mass flu clinics
DESCRIPTION
Update for Mass Flu clinic for PHNsTRANSCRIPT
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VIHA Child, Youth and
Family Community Health
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Reserved Titles
Defined scope of practice◦ “Restricted Acts”
◦ With/without an order
Requirements on practice ◦ “additional
education”
◦ CRNBC Certified Practice
RNs now authorized per HPA: RN/NP Regulation to
diagnose and manage conditions (including prevention), e.g. Anaphylaxis
administer certain medications to treat conditions or prevent disease/disorders, e.g. immunization for influenza
No order, transfer of function or delegation required
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HPA - RN/NP Regulation
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CRNBC requires RNs to have “additional education” to administer influenza* without an order (as determined by their employer)
and “strongly recommends” use of evidence-informed clinical decision support tools (“DSTs” or “CDSTs”) to guide practice, e.g. protocols, clinical
practice guidelines, order sets, etc.
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Educational
component ◦ Attend an Influenza
education session or
review Influenza
materials
Clinical ◦ Immunization of
clients >5 years
◦ Observation of 5
immunizations
◦ Be observed doing 5
immunizations
◦ Skills Checklist
Yearly Review
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1. Vaccine Preventable Diseases
◦ The Immune System
◦ Vaccine Development
◦ Types of Immunizing Agents
◦ Vaccine Immune Response
2. Immunization Schedules
◦ Populations Requiring Special Consideration
3. Storage and Handling of Vaccine
4. Client Assessment
◦ Legal and Ethical- Informed Consent
5. Administration
◦ Clinic set up
◦ Injection techniques
◦ Documentation
6. Reactions Following Immunization
7. Common Myths
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An acute onset of respiratory illness with
fever and cough and one or more of the
following:
-Sore throat -Muscle aches
-Joint pain -Fatigue
Fever and other symptoms can last 7-10
days, fever may not be present in the
elderly or children under 5 years of age
Children <5 may have GI symptoms
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Spread: ◦ direct, indirect, droplet
◦ Can survive in environment for hours (door knobs etc)
Incubation: ◦ 1-3 days
Period of communicability◦ 3-5 days from onset of
symptoms, up to 7 days in children
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“stomach flu” – influenza does not usually
cause GI symptoms
Colds – e.g. rhinoviruses
Similar symptoms to RSV
◦ Sneezing, chills, malaise, teary eyes
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Each year:
5 million Canadians (1 in 6) are infected
50,000 will be hospitalized
Estimated up to 7,000 will die from flu and its
complications
1.5 million work-days will be lost
In BC about 1,400 people die from the flu and
pneumonia
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Can damage the lining of the respiratory tract
Secondary infections – viral or bacterial◦ Strep.pneumococcal
Hospitalization for complications
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Influenza A causes:◦ Moderate to severe illness
◦ Epidemics
◦ Pandemics
Influenza B causes:◦ Milder epidemics
Influenza C causes:◦ No disease in humans
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Overall activity was mild
Increased activity presented later in the
season
Influenza A & B detections reported across the
country
Emergence of H1N1
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“Immunization is one of the miracles of this
century. With the exception of safe drinking
water, no other intervention - not even antibiotics
- has had such a major impact on people’s health
and survival” (Plotkin & Plotkin)
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Individual effect:individual is protected against disease
Collective effect:entire population, including those not immunized or not having illness is protected against disease when a critical number of people are immune
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HERD IMMUNITY
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Annual fall administration
Reduces influenza incidence, severity, duration and
shedding of virus
◦ Protects against outbreaks
In elderly and high risk:
- Reduces clinical infection
- Reduce hospitalization/pneumonia
- Reduces mortality
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Influenza A / Brisbane / 59 / 2007 / (H1N1)
This is the type The place where the isolate year subtype
(A or B) the virus was first number
code
isolated
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Frequent Hand Hygiene
Yearly influenza vaccination
Cough etiquette
Stay home when ill
Outbreak control measures in
facilities◦ Standard precautions
◦ Antivirals etc…
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Doesn’t work if hands are greasy or visibly dirty. If hands are visibly soiled, use soap and water, if not available towelettes may be used first
Make sure hands are dry. Use enough product to cover all the surfaces of hands and fingers.
Rub hands together until the product has evaporated.
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Does not replace annual influenza vaccine
Used to control influenza outbreaks among
high risk residents in facilities – given to all
residents during an outbreak
Adjunct to late vaccination of people at high
risk
For unvaccinated people who provide care
for high risk people during an outbreak
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Oseltamivir (Tamiflu®)◦ Neuraminidase inhibitor (stops virus from releasing
particles)
◦ Effective for both influenza A and B
◦ Some strains of Influenza A are resistant
◦ Lab results important to make decision about which
antiviral to use during an outbreak
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Body wide network of
cells and organs
Evolved to defend
against foreign
invaders
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ANTIGEN – any molecule that identifies
as foreign to the immune system and
stimulates the immune system to attack it.
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Protein (Immunoglobulin) produced by
the body in response to stimulation by
an antigen.
Unique contours in antigen binding
sites allow antibody to recognize
matching antigen (“lock and key”)
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Immunity is the ability of the body to defend
itself, particularly against attack by an infectious
agent
There are two types of immunity◦ Acquired (Passive)
◦ Natural (Active)
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I.G.SHORT TERM PROTECTION
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LONGER TERM PROTECTION
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The goal of vaccines is to stimulate the immune
system to produce an immune response similar
to that caused by disease, without causing the
recipient to experience the disease or its
complications.
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The strains of virus that circulate in the community change
frequently because of Antigenic Drift.
It is necessary to update the flu vaccines each year with these
new strains.
This is a killed split virus vaccine
Vaccines consist of 3 different virus subtypes each year.
Currently this is:
◦ A H1N1 strain
◦ A H3N2 strain
◦ B strain
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Influenza viruses can change in two different ways
Not different mechanisms just different degrees of
genetic changes
1. Antigenic “drift”
◦ Small changes that occur continuously over time
2. Antigenic “shift”
◦ Abrupt, major change in virus proteins
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Flu Vaccine Production Timeline
• Decision on which
3 strains
• Manufacturers
purchase hens’
eggs
• Virus strains sent
to manufacturers
• Eggs inoculated
with virus
• Virus multiplies in
eggs
• Virus inactivated
with chemicals
• Egg white removed
/ virus harvested
• Vaccine tested for
purity & potency
• 3 vaccine strains
blended
• Packaging into
syringes /vials
• Licensure and
release
• ShippingImmunization
begins
Jan Feb May June-July Aug Sep Oct
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2009-2010 vaccine:
A/Brisbane/59/2007 (H1N1)-like strain: A/Brisbane/59/2007
IVR-148
A/Brisbane/10/2007 (H3N2)-like strain: A/Uruguay/716/2007
NYMC X-175C
B/Brisbane/60/2008-like strain: B/Brisbane/60/2008
(new strain for 2009-2010)
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Influenza A / Brisbane / 59 / 2007 / (H1N1)
This is the type The place where the isolate year subtype
(A or B) the virus was first number code
isolated
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Contain killed bacteria or viruses and
cannot replicate
Usually no interference from circulating
antibodies
Induces long term memory
Antibody levels fall over time
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Fluviral® ◦ Used for general public◦ Use multi dose vial within 28 days
Vaxigrip®◦ Use multi dose vial within 7 days◦ Preferential use for pregnant women
Influvac®◦ Thimerosal free – only indicated for >
18 years of age and those who are anaphylactic to thimerosal
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Both vaccines have minute quantities of thimerosal
(mercury) used as a preservative
Thimerosal is a safe and effective preservative and
has been used in some vaccines since the 1930s
The mercury is an organic form called ethylmercury
The amount of ethylmercury in vaccines does not
cause neurological problems
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Antibodies develop within 14 days
Immunity depends on age and
immunocompetence
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AGE GROUP DOSE # OF DOSES
6-35 months 0.25ml IM 1 or 2*
3-8 years 0.5 ml IM 1 or 2*
9 years and older 0.5 ml IM 1
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*Previously un-immunized children under 9 years of age require 2
doses of vaccine with an interval of 4 weeks * 2nd dose is not
required if the child has ever received one or more doses of
influenza vaccine from a previous year
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Recommendations for Influenza are published
yearly by the National Advisory Committee on
Immunization (NACI)
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Fall 2009: 65 years and older and residents in
Long Term Care
Early 2010: All other recommended groups under
the age of 65 years
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History of anaphylactic reaction to a previous dose of any type of influenza vaccine
History of anaphylactic reaction to any component of vaccine◦ Fluviral- egg protein, formaldehyde, thimerosal, sodium
deoxycholate, sucrose◦ Vaxigrip- egg protein, neomycin, formaldehyde, thimerosal, sodium
phosphate, sucrose, Triton X -100
History of anaphylaxis to eggs
Infants less than 6 months of age
Hx of Guillain Barre Syndrome (GBS) within 8 weeks of receipt of a previous dose of influenza vaccine
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First seen in 2000/01 influenza season
Consist of bilateral red eyes or facial swelling or
respiratory symptoms within 24 hours or vaccination
Most people do not experience it again
Approx 5 – 34% experience another episode – usually
milder
If mild to moderate ORS usually can safely re-vaccinate
If severe ORS consult physician before vaccinating
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Legal Requirements
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Informed consent is an essential pre-condition
to providing immunization.
It is the professional and legal responsibility of
the provider to obtain informed consent prior to
immunization
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1. Assess capability to give informed consent
2. Determine authority to provide informed consent
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3. Provide Standard Information:
Confirm the voluntary nature of immunization
Advise that consent is obtained for a vaccine series and is valid
until completion of the series or consent is revoked
Provide the vaccine information as outlined in BC Health Files: Benefits of vaccination Risk of not getting vaccinated Eligibility for the vaccine Common and expected adverse events Possible serious or severe adverse events and their frequency Contraindications Disease(s) being prevented
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4. Confirm understanding of Standard Information
5. Provide an opportunity for questions
6. Confirm consent
7. Document consent or refusal
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An elderly client presents at a mass clinic with his daughter. He has never had the Influenza vaccine before. He is worried that it might make him sick, but she wants him to be protected against influenza.
How would you proceed?
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A mom brings her 7 year old child in for a flu shot,
and says she is the foster mom.
How would you proceed?
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Vaccines must be maintained at the appropriate
temperature between 2 to 8 degrees
Pack coolers according to BCCDC section 6 of the
Immunization Manual
Some biological products are
sensitive to light (e.g.:
MMR, epinephrine, PPD)
Return vaccines to fridge as soon as possible upon
return to the health unit
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Ensure cold chain is maintained at all times
Each vaccinating nurse will have a separate small cooler at their work station to store a small amount of vaccine
Vaccine should be protected from freezing by separating it from the ice pack with insulating material
When a dose is drawn up return the vial to the cooler Mark the date of opening on all multi dose vials
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A minimum/maximum thermometer is recommended for monitoring temperature:◦ for large coolers during mass clinics and
◦ for vaccine in all coolers longer than 4 hours
◦ check temperature reading hourly
Provide a protective barrier of insulating material such as a flexible insulating blanket between vaccines and the frozen packs.
Place frozen packs at the top of the cooler
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Consider local testing of packing configurations to
maintain the temperature between 2-8 degrees C.
If vaccines are transported to mass clinics in
numerous coolers, use all the vaccines in one cooler
before opening the next cooler.
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Immunizing station setup includes:
◦ Cooler/ice packs
◦ Sharps container
◦ Easily accessible anaphylaxis kit
◦ Supply of syringes, band aids, alcohol swabs, gauze or cotton
balls, extra needles, alcohol hand sanitizer and a tray or
paper mat
◦ Health Files
◦ Client records, vaccine recording sheets
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All used
safety
syringes
should go
directly into a
sharps
container
after
immunizing a
client.
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Nurses administering vaccine need to follow 7 rights of medication administration:
◦ Right drug
◦ Right client
◦ Right dose
◦ Right time
◦ Right route
◦ Right reason
◦ Right documentation
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Nursing BC Oct. 2006
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Hand washing/cleansers
Check vaccine expiry date
Shake vial well
Cleanse rubber stopper with alcohol/air dry
New disposable syringe & safety needle
Check dose for age
Draw vaccine into syringe immediately before giving
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Use a needle length sufficient to reach the
largest part of the muscle Infants, toddlers, older children = 7/8” – 1”
Adolescents and adults = 1 – 11/2”
The IM site of choice for children > 12 months of
age and for adults
is the deltoid muscle.
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This site is used for IM injections only
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1) Use correct length and size of needle
2) Clean the site with a cotton pad/swab/ball moistened with 70% isopropyl alcohol
3) Insert needle quickly at a 90o angle into the muscle
If client’s muscle mass is small, grasp body of muscle between thumb and fingers before and during the injection
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4) Rapidly inject the biological product
5) Remove the needle in one swift motion,
immediately applying pressure to the injection site
with a dry cotton pad/swab/ball. Continue to apply
pressure for 30 seconds.- Do not massage injection site
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Hold the child on parent’s lap or have the
child stand in front of the seated parent
Parent’s arms embrace the child during the
process
Both legs firmly between the parent’s legs
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Watch BCCDC’s demonstration of IM
injections in the Deltoid Click here
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Define this site by dividing the space between the
trochanter major of the femur and the top of the
knee into 3 parts; draw a horizontal median line
along the outer surface of
the thigh.
The injection site is in the
middle third, just above
the horizontal line.
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Click Here to watch BCCDC's demo IM Injection Vastus Lateralis
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Activate safety needle with thumb
Discard needle & syringe into sharps container
Observe client briefly - ask to stay in observation area for 15 minutes
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To view more videos on landmarking for IM
injections go to www.bccdc.ca
Click on:◦ Vaccines and Immunization
◦ For Health Professionals
◦ Immunization Competency
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For each biological product administered, the minimum data to be recorded is:◦ Name of biological product
◦ Date
◦ Route of administration
◦ Site
◦ Name of biological product manufacturer
◦ Lot number
◦ Name and title of person administering biological product
◦ Any reactions following immunization
◦ Any recommended biological products that were not given (i.e., declined, deferred or contraindicated
◦ Informed consent for immunization obtained.
Vaccine given to children up to 18 years entered into iPHIS
Provide client with record of immunization
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Local
Soreness at the injection site lasting two days
Redness, swelling, itching , warmth, pain on contact
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Systemic
• Fever, malaise,
myalgia
• may occur 6-12 hours
following vaccination
and lasting 1-2 days
• especially in
individuals receiving
vaccine for the 1st time
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Acetaminophen for local reactions and fever
Comfort measures - cool cloth on injection site
Fluids
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An untoward event temporally associated
with immunization that may or may not
have been caused by the vaccine or the
immunization process.
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Carefully review history of anaphylaxis to any antigens or components in the vaccine
Instruct client to remain under observation for 15 minutes
Take precautions for those with previous allergies to the biological product
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Know what to do in the event of anaphylaxis
Know address and location of where you are
Ensure anaphylaxis kits are up to date Protect epinephrine from light and open vial only when ready to
use
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Based on clinical presentation, exposure history
Cutaneous, respiratory symptoms most common
Some cases may be difficult to differentiate
◦ Vasovagal (fainting)
◦ Anxiety
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• Immediate systemic allergic reaction
• Affects body as a whole
• Multiple organ systems may be
involved
• Onset generally acute
• Manifestations vary from mild to fatal
• Incidence: 0.4 to 1.8 reports per
1,000,000 vaccine doses distributed
in Canada
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Fainting (vasovagal episode)
Lack of hives, slow steady pulse rate and cool pale skin
Sometimes accompanied by brief clonic seizure activity.
If unconsciousness persists more than 2 to 3 minutes,
call 911 and proceed with anaphylaxis treatment
Anxiety:
sudden onset.
Pale, cold clammy skin, hyperventilation, rapid pulse
fearful.
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• Skin: Hives at injection site, generalized
urticaria (hives), flushing, pruritus
(itchiness) , angioedema (welts)
• Upper respiratory: Congestion, rhinorrhea
• Lower respiratory: Bronchospasm, throat
or chest tightness, hoarseness, wheezing,
shortness of breath, cough
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• Cardiovascular system:
• Tachycardia, bradycardia,
hypotension/shock, arrhythmias, ischemia,
chest pain
• Gastrointestinal tract:
• Oral pruritus (itchiness)
• Cramps, nausea, vomiting, diarrhea
• Other symptoms:
• Headache, uneasiness, restlessness,
agitation
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• Uniphasic
• Biphasic
• Recurrence up to 8 to 12 hours later
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CALL 911
Administer Epinephrine IMMEDIATELY. There is no contraindication to epinephrine in anaphylaxis
Give epinephrine (1:1000) IM into an unimmunized thigh.
If both thighs were used for immunization:- Give epinephrine IM into deltoid if client is > 12 months old- Give epinephrine SC into upper outer triceps area of the arm(s) if client is < 12 months old
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Repeat epinephrine twice at 5 minute
intervals as needed to a maximum of 3
doses.
- Alternate right and left thigh (or arm)
sites for repeat doses of epinephrine.
Injection can be made through clothing if
necessary
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Dose: 0.01 ml/kg to maximum of 0.5 ml
OR:
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AGE Epinephrine
2 – 6 months 0.07 ml
7 – 12 months 0.10 ml
13 months – 4 years 0.15 ml
5 years 0.20 ml
6 – 9 years 0.30 ml
10 – 13 years 0.40 ml
> 14 years 0.50 ml
Section V, June 2009
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What about Benadryl?
can be used as an adjunct if client not
responding well to epinephrine; OR
to maintain symptom control when client can’t be
transferred to acute care within 30 minutes.
Administer 1 dose of Benadryl IM preferably in a
different site in which epinephrine was given.
Can be given in same muscle mass as vaccine.
Can be given either after the initial or repeat
doses of epinephrine.
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AGE Diphenydramine
hydrochloride
< 2 years 0.25 ml
2 – 4 years 0.50 ml
5 – 11 years 0.50 – 1.0 ml
> 12 1.0 ml
Section V, June 2009
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Position client recumbent position and elevate legs as tolerated symptomatically.
Monitor respiratory effort, pulse and level of consciousness.
If experiencing respiratory difficulty, elevate head and chest slightly.
If airway is impaired, use head tilt, chin lift or jaw thrust.
If vomiting is likely, turn person to side lying position.
Arrange for rapid transport by emergency vehicle to
an emergency department.
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Suggested epinephrine kit contents: BCCDC guidelines for the management of anaphylaxis: Sections 2.3,
10.0 and 11.0
3 - 1 cc syringes and needles (25 – 27 gauge, 1" needle)
1 - 1cc syringe and needle (25 – 27 gauge, 1 ½" needle)
2 - 3 cc syringes and needles (25 – 27 gauge, 1” and 1 ½" needles)
2 – 1cc syringes and needles (25 – 27 gauge, 5/8”) for SC route
extra needles
4 ampules of epinephrine 1:1,000 (within expiration time frame)
2 vials of diphenhydramine hydrochloride 50mg/ml (within expiration time frame)
alcohol swabs
pens/paper Section V, June 2009
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0
Use the “Worksheet for Emergency
Treatment of Anaphylaxis”.
Complete iPHIS Adverse Event form.
Document in the client’s immunization
record/consent card
Recommendation will be made by the
MHO.
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Mr. Smith is 65 years old and comes into your flu clinic for
his flu immunization. Mr. Smith is nervous about getting
his shot as he has never had a flu immunization before.
After administering his flu immunization, you notice that
Mr. Smith’s face becomes flushed and his breathing
becomes wheezy, and states that his mouth feels
“tingly”.
What is happening?
Why do you think this?
What do you do?
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NACI statement on Influenza Vaccination
BCCDC Immunization Program Manual
Canadian Immunization Guide
Vancouver Coastal Health
Fraser Health Authority
Claire Coombs
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