Pros and cons of administering epinephrine to campers who are experiencing anaphylactic shock.

As summer quickly approaches, staff training becomes a number one priority. An important component of training is emergency and first aid situations that might arise at camp. Will your staff be trained to deal with anaphylactic reactions?

Seven million Americans suffer from food allergies. Each year, approximately 30,000 people in the United States go to the emergency room for anaphylaxis (Baily 2003). Anaphylaxis is a severe and potentially life-threatening allergic reaction. It can affect various areas of the body including the skin, respiratory tract, gastrointestinal tract, and cardiovascular system (Allergy Center 2003). Anaphylaxis can happen at any time to those with or without a history of reactions. While many people experience only mild irritation, some people can experience an allergic reaction, including potentially life-threatening symptoms (AAAAI 1998). Therefore, early recognition and prompt treatment, particularly in a camp or wilderness setting, is essential to preserve life.

Symptoms of anaphylaxis usually begin quickly after an exposure, minutes after a sting or bite and within thirty to sixty minutes following ingestion or exposure to an allergen. Some of the signs and symptoms are:

* Hives

* Total body itching and swelling

* Difficulty breathing

* Swelling of the mouth and throat area

* Vomiting, cramping, and diarrhea

Swelling of the bronchial tissues in the lungs can cause a person to choke or lose consciousness (WMA 2000). In such cases of anaphylactic shock, it is imperative that treatment be administered immediately.

With anaphylaxis incidents increasing in camp and outdoor settings, how are we preparing staff of these programs in regards to administering epinephrine or other rescue medications? What are the ethical issues that camp directors and staff face in these emergencies? Which camp staff and administrators should be prepared to recognize and enable emergency response to participants experiencing an anaphylaxis incident?

Without prompt attention, anaphylactic shock can be fatal. Epinephrine is a form of adrenaline and is an effective treatment for an anaphylactic reaction. It works rapidly, reducing the swelling in the chest and airways to ease breathing. (WMA 2000). Epinephrine is available via prescriptions and can be purchased in vials and kits. However, the most popular way is to purchase it as an EpiPen[R] or EpiPen[R] Jr (FAAN 2003).

Doctors can prescribe epinephrine in most cases to patients for self-administration of their allergic reaction. Although prescribed to the individual, many that are suffering from a reaction cannot self-administer. This leaves a camp director or counselor to help out in this emergency and stressful situation.

The Need for Proper Training

Widespread prescription of epinephrine is common, and the risks in using this medication are minimal. However, the camp administration should work with its medical personnel in providing the training needed for the staff selected to assist in giving the medication in an emergency situation.

For example, Sicherer, Forman, and Noone (2000) conducted a research study to determine the ability of families with children with food allergies and pediatricians to properly administer self-injectable epinephrine. They concluded that a substantial portion of parents with children and teenagers with food allergies were unable to demonstrate correctly the use of their self-injectable epinephrine. Furthermore, a large number did not carry the medication with them at all times. The study also found that pediatricians are not familiar with the self-injectable epinephrine and may fail to accurately review their use with patients. As a result, most injection instruction is given by nurses or pharmacists.

According to, Anderson, Krenzelock, Mrvos (2002) accidental injections with epinephrine auto injectors occur. Some people have accidentally injected epinephrine into their thumbs when trying to determine how to operate the syringe or when trying to understand why it did not work correctly. This often occurs because the syringe is not applied to the skin at the correct angle. Jamming the mechanism can also be dangerous. Epinephrine can shut off the whole blood supply by constricting the blood vessels at the base of the finger or thumb. The result is likely to be gangrene. Therefore, camp administrators need to develop an anaphylaxis emergency plan and identify which staff need instruction in the use and administration of epinephrine!

Who Can Administer Rescue Medications?

However, at this point an ethical issue emerges as many states have laws that do not cover the camp staff in using this drug to treat an anaphylactic reaction. Depending on the camp location, different states are reviewing guidelines to determine who should treat and administer various rescue medications. For example, in a newsletter discussed on the Wilderness Medical Associates Web page (2003), Dr. David E. Johnson explains that multi-dose vials that are used by many outdoor programs raise some concerns about non-licensed practitioners drawing up and administering this medication to another person. Johnson advocates a need for more training and institutional authorization. In 1998, only eight states across the nation allowed all of its Emergency Medical Technician's (EMT) to carry and administer epinephrine to a patient suffering from anaphylaxis. Thanks in part to the Food Allergy & Anaphylaxis Network, today we have thirty-six states that have enacted legislative measures regarding epinephrine (foodallergy.org 2003).

The Food Allergy Network urges officials to take all reactions seriously. In a recent case, a child went to the school nurse three times in a day after eating candy that may have contained nuts. After the third time, the nurse called for an EMT. The child died while waiting for the EMT to arrive (Kritz 2003).

Camp directors and staff are doing the best they can to manage anaphylaxis incidents with inadequate information. Better information offers better treatment; which could mean saving lives and a safe camp experience.

Many camps, outdoor programs, and schools are trying to take as many steps as possible to keep people safe. Schools are getting bus drivers, teachers, and administrators trained in administering EpiPens[R]. Outdoor adventure programs are now requiring their instructors to have Wilderness First Aid Certification. More camp trip leaders are being trained to deal with anaphylaxis reactions and to distinguish when to give epinephrine and when not to.

New Policies and Procedures

In response to the need for universal training and the ability to administer epinephrine, schools and related programs are benefiting from new policy and procedures. For example, a letter from the Director of Emergency Medical Services (2000) states that in 1999, Governor Pataki of New York signed the Epinephrine Auto-Injector Device Law. The law permits the possession and use of epinephrine auto-injectors by non-certified and non-licensed personnel, as well as health care providers certified at the level that would not normally allow for administration of medication. This law's intent was to make rapid intervention available to those who suffer an anaphylaxis reaction and may not have access to advanced emergency medical care, while avoiding undue deaths.

In the summer of 2000, children's camps began to participate in this program. Camps have been encouraged to notify their local EMS provider if they elect participation in the program because the health provider will train the camp staff using a Department of Health approved curriculum. Massachusetts, unlike New York, is moving toward universal access via regulation instead of legislation (AAFA 2003).

According to the Department of Justice:

   Children cannot be excluded on the sole basis that they have been
   identified as having severe allergies to bee stings or certain
   foods. A center needs to be prepared to take appropriate steps in
   the event of an allergic reaction, such as administering a
   medicine called "epinephrine" that will be provided in advance
   by the child's parents or guardians (FindLaw 2003, [paragraph] 4).

The Department of Justice also advises this policy on giving medication:

   In some circumstances, it may be necessary to give medication to a
   child with a disability in order to make programs accessible to
   that child. While some state laws may differ, generally speaking,
   as long as reasonable care is used in following the doctors,
   parents, or guardians written instructions about administering
   medication, centers should not be held liable for any resulting
   problems (FindLaw 2003, [paragraph] 4).

Anaphylaxis is a true emergency that gives you literally minutes to save a person's life. Although there are many dangers associated with administering epinephrine, camp directors will need to weigh the pros and cons. Dr. Scott Sicherer, an assistant professor of pediatrics at Mountain Sinai School of Medicine and the Jaffe Food Allergy Institute in New York City says "when in doubt, opt for the medication erring on the side of giving epinephrine is better than not giving it (Kritz 2003)." In most cases, the epinephrine fully prevents or reverses an anaphylactic reaction.

Speed is of the essence, which is why having epinephrine around at all times, is so very crucial. Other medications are also being developed. For example, doctors at New York's Mount Sinai School of Medicine are developing a medication called "anti-IgE therapy" that would prevent allergic reactions to foods. This medication is expected to be available to the public in about two years (Baily 2003). In the meantime, epinephrine continues to be the best protection against anaphylaxis.

While the controversy still continues between organizations, lawmakers, and the medical community, many camp directors and staff still feel that the laws and policies under which they work restrict their actions. For now, camps and outdoor program administrators and staff will continue to deal with anaphylaxis the best way they can.

In the future, camp directors and re-searchers must work together in developing more research studies in relation to administering epinephrine and other rescue medications in treating anaphylaxis in the camp setting. Together we can provide the campers and staff in our camps with the care and attention they deserve.

The information provided herein is not intended as a substitute for professional and medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.

References

American Academy of Allergy, Asthma and Immunology, (AAAAI). (1998, July 6). AAAAI states that intervention by allergist can help prevent insect sting fatalities. Retrieved October 12, 2003. From www.aaaai.org/media/newsreleases/1998/98-07/1980706.html.

Asthma and Allergy Foundation of America, (AAFA). (2003). www.aafa.org.

Asthma & Allergy Information & Research. Anaphylaxis-life threatening allergy. Retrieved October 12, 2003, from www.users.globalnet.co.uk/~aair/anaphylaxis.htm.

Anderson, B.D., Krenselok, E.P., Mrvos, R. (2002). Accidental injection of epinephrine from autoinjector: invasive treatment not always required. Southern Medical Journal. 95(3) p. 318-320. Retrieved October 10, 2003, from Academic Search Elite, database.

Allergy Center, Epinephrine. (2002). Retrieved October 12, 2003, from health.yahoo.com/health/centers/allergy/507.html. Baily, C., (2003). Fatal foods. Scholastic Choices, 18(6). Retrieved September 9, 2003, from MASUltra, school edition, database.

Day, J.H., Ellis, A. K. (2003). Diagnosis and management of anaphylaxis. Medical Association Journal. 169(4), p. 307- 312. Retrieved September 19, 2003, from Academic Search Elite, database.

Department of Justice. (1997, October). Commonly asked questions about child care centers and the Americans with Disabilities Act. Retrieved October 17, 2003, findlaw for legal professionals via http://library.lp.findlaw.com/articles/file.

Food Allergy Initiative. Epinephrine. Retrieved October 12, 2003, from www.foodallergyinitiative.org/section_sectionhome.cfm.

Food Allergy and Anaphylaxis Network, (FAAN). Information about anaphylaxis. Retrieved October 12, 2003, from www.foodallergy.org/anaphylaxis.html.

InteliHealth. (2001, December 3) Despite deaths, study shows EMTs not authorized to administer epinephrine in most states. Retrieved October 20, 2003, from www.intelihealth.com/IH/htih/sih0001/8124/21291/341309.html.

Isaac, J., (1998). The Outward Bound wilderness first-aid handbook. (Rev.ed). Guilford, CA: The Lyons Press. January 3, 2002 Meeting, AFAA meeting. (2002). Retrieved October 17, 2003, from http://affa.home.att.net/meeting/20020103.html.

Johnson, D.E., (N.D.) EpiPens[R] alternative clarifications. Retrieved October 12, 2003, from www.wildmed.com/medical_topics/epi_pens.html.

Kritz, F., (2003, October 12). Treating asthma, allergies at school, some kids can't get needed medications. Newsweek. Retrieved October 12, 2003, from www.msnbc.com/news/314037.

Sicherer, S.H., Forman, J.A., Noone, S.A. (2000). Use assessment of self administered epinephrine among foodallergic children and pediatricians. 108(2) p. 537. Retrieved October 10, 2003, Academic Search Elite, database.

Wilderness Medical Associates, emergency training for outdoors. (2000). Wilderness Medicine Lecture Notes. Bryant Pound, ME.

Gabriel Castillo is a program supervisor, Department of Parks and Recreation Village of Glendale Heights, in Illinois and holds an M.S. degree in Outdoor Pursuits Administration at the George Williams College of Aurora University.

Rita Yerkes is dean of the School of Experiential Leadership at the George Williams College of Aurora University, Williams Bay, Wisconsin.

Originally published in the 2006 May/June issue of Camping Magazine.