HOMELESS HEALTHCARE

Rev. S.Brandt 2003

-Everyone should have access to comprehensive, quality, and affordable health care.

So many struggle to pay the rent and a serious illness or disability can start a downward spiral into homelessness, beginning with a lost job, depletion of savings to pay for care, and eventual eviction.

Homelessness severely impacts health and well-being. The rates of acute health problems are extremely high among people experiencing homelessness.

With the exception of obesity, strokes, and cancer, people experiencing homelessness are far more likely to suffer from every category of severe health problem.
Conditions which require regular, uninterrupted treatment, such as tuberculosis, HIV/AIDS, diabetes, hypertension, addictive disorders, and mental disorders, are extremely difficult to treat or control among those without adequate housing.
Housing is the first form of treatment for people experiencing homelessness with medical problems, preventing many illnesses and making it possible for those who remain ill to recover. Lack of affordable housing makes it more difficult for people to recover.
Children without housing experience numerous health problems that impact their development.

Children without a home are in fair or poor health twice as often as other children, and have higher rates of asthma, ear infections, stomach problems, and speech problems (Better Homes Fund, 1999).
They also experience more mental health problems, such as anxiety, depression, and withdrawal. They are twice as likely to experience hunger, and four times as likely to have delayed development.

Universal access to affordable, high-quality and comprehensive health care is essential in the fight to end homelessness.

Approximately 20-25% of the single adult homeless population suffers from some form of severe and persistent mental illness (Koegel et al., 1996). However, only 5% of the estimated 4 million people who have a serious mental illness are homeless at any given point in time (Federal Task Force on Homelessness and Severe Mental Illness, 1992).

Despite the disproportionate number of mentally ill people among the homeless population, the growth in homelessness is not attributable to the release of seriously mentally ill people from institutions. Most patients were released from mental hospitals in the 1950s and 1960s, yet vast increases in homelessness did not occur until the 1980s, when incomes and housing options for those living on the margins began to diminish rapidly (see “Why Are People Homeless?,” NCH Fact Sheet #1). However, a new wave of deinstitutionalization and the denial of services or premature and unplanned discharge brought about by managed care arrangements may be contributing to the continued presence of seriously mentally ill persons within the homeless population.

Mental disorders prevent people from carrying out essential aspects of daily life, such as self-care, household management and interpersonal relationships. Homeless people with mental disorders remain homeless for longer periods of time and have less contact with family and friends. They encounter more barriers to employment, tend to be in poorer physical health, and have more contact with the legal system than homeless people who do not suffer from mental disorder. All people with mental disorders, including those who are homeless, require ongoing access to a full range of treatment and rehabilitation services to lessen the impairment and disruption produced by their condition. However, most people with mental disorder do not need hospitalization, and even fewer require long-term institutional care. According to the Federal Task Force on Homelessness and Severe Mental Illness, only 5-7% of homeless persons with mental illness need to be institutionalized; most can live in the community with the appropriate supportive housing options (Federal Task Force on Homelessness and Severe Mental Illness, 1992). Unfortunately, there are not enough community-based treatment services, nor enough appropriate, affordable housing, to accommodate the number of people disabled by mental disorders in the U.S.

Homeless persons with mental disorders are willing to use services that are easy to enter and that meet their perceived needs (Oakley and Dennis, 1996). Findings also reveal that persons with mental disorder and persons with addictive disorders share many of the same treatment needs, including carefully designed client engagement and case management, housing options, and long-term follow-up and support services. Studies also emphasize the importance of service integration, outreach and engagement; the use of case management to negotiate care systems; the need for a range of supportive housing and treatment options that are responsive to consumer preferences; and the importance of meaningful daily activity. When combined with supportive services, meaningful daily activity in the community (including work), and access to therapy, appropriate housing can provide the framework necessary to end homelessness for many individuals.

Low-income people with mental disorders are at increased risk of homelessness. A variety of approaches must be employed to help them obtain and retain stable housing to prevent homelessness.

Welfare benefit levels must be increased so that disabled people are not forced to live in poverty. In [US] 69 metropolitan areas, the entire maximum welfare does not cover the Fair Market Rent for a one-bedroom apartment (Kaufman, 1997). In most states, even if the welfare does cover the rent, only a few dollars remain for other expenses. Benefit levels have not kept up with increases in the cost of rent and therefore do not provide disabled individuals with adequate allowances for housing.

Finally, the commitment to making deinstitutionalization work as it was intended must be renewed. People with mental illness must be able to live as independently as possible with the help of expanded comprehensive, community-based mental health services and other supports. It is crucial that polices be proactive rather than reactive. Services such as crisis intervention, landlord-tenant intervention, continuous treatment teams and appropriate discharge planning in jails and inpatient facilities must be made available in all communities.

Poor health is closely associated with homelessness. For families struggling to pay the rent, a serious illness or disability can start a downward spiral into homelessness, beginning with a lost job, depletion of savings to pay for care, and eventual eviction.

Thirteen percent of homeless patients surveyed in a national study published in the 1980s stated that poor physical health was a factor in their becoming homeless. Of those patients, half said health was a “major factor” and 15% stated that it was the “single most important” factor (Wright and Weber, 1987). The problem has become much worse in the last decade, as the number of uninsured Americans continues to increase. In 1997, 43.4 million people in the United States lacked health insurance, and nearly one-third of persons living in poverty had no health insurance of any kind (U.S. Bureau of the Census, 1998). The coverage held by many others would not carry them through a catastrophic illness. A recent analysis of Health Care for the Homeless (HCH) projects found that the number of uninsured persons seeking treatment is increasing: overall, HCH programs report a 35% increase in the numbers of patients who are uninsured (O’Connell, J., Lozier, J., and Gingles, K., 1997).

The rates of both chronic and acute health problems are extremely high among the homeless population. With the exception of obesity, strokes, and cancer, homeless people are far more likely to suffer from every category of chronic health problem. Conditions which require regular, uninterrupted treatment, such as tuberculosis, HIV/AIDS, diabetes, hypertension, addictive disorders, and mental disorders, are extremely difficult to treat or control among those without adequate housing.

Many homeless people have multiple health problems. For example, frostbite, leg ulcers and upper respiratory infections are frequent, often the direct result of homelessness. Homeless people are also at greater risk of trauma resulting from muggings, beatings, and rape. Homelessness precludes good nutrition, good personal hygiene, and basic first aid, adding to the complex health needs of homeless people. In addition, some homeless people with mental disorders may use drugs or alcohol to self-medicate, and those with addictive disorders are also often at risk of HIV and other communicable diseases.

Homeless children also experience numerous health problems. A recent study of the health status of homeless children in New York City found that 61% of homeless children had not received their proper immunizations (compared to 23% of all New York City two-year-olds); 38% of homeless children in the City’s shelter system have asthma (an asthma rate four times that for all New York City children and the highest prevalence rate of any child population in the United States); and that homeless children suffer from middle ear infections at a rate that is 50% greater than the national average (Redlener and Johnson, 1999). These illnesses have potentially devastating consequences if not treated early.

Lack of affordable housing also impacts efforts to provide health care to homeless persons: housing is the first form of treatment for homeless people with medical problems, preventing many illnesses and making it possible for those who remain ill to recover.

Universal access to affordable, high-quality and comprehensive health care is also essential in the fight to end homelessness. A health insurance system could reduce homelessness and, more significantly, help to prevent future episodes of homelessness, as well as ease the pain — and even prevent unnecessary deaths — of those on the streets. A universal health system would also reduce the fiscal impact and social cost of communicable diseases and other illnesses

Lack of affordable housing is a critical problem facing a growing number of people living with Acquired Immunodeficiency Syndrome (AIDS) and other illnesses caused by the Human Immunodeficiency Virus (HIV). People with HIV/AIDS may lose their jobs because of discrimination or because of the fatigue and periodic hospitalization caused by HIV-related illnesses. They may also find their incomes drained by the costs of health care.

Tragically, individuals with HIV/AIDS may die before they are able to receive housing assistance. Efforts to build HIV/AIDS housing often encounter chronic funding shortfalls, bureaucratic indifference, and the stigma and fear of AIDS. Projects to create HIV/AIDS housing may fail because of local opposition by neighborhood or community groups.

Studies indicate that the prevalence of HIV among homeless people is between 3-20%, with some subgroups’ having much higher burdens of disease:

In a survey of the Heatlh Care for the Homeless program, a plurality of projects reported that HIV/AIDS is increasing among the homeless population (O’Connell, J., Lozier, J., and Gingles, K., 1997).

36% of people with AIDS have been homeless since learning that they had HIV or AIDS (Robbins and Nelson, 1996).

A Los Angeles study found that two-thirds of people with AIDS had been homeless (Shelter Partnership, 1997).

Up to 50% of persons living with HIV/AIDS are expected to need housing assistance of some kind during their lifetimes (Robbins and Nelson, 1996).
Many homeless adolescents find that exchanging sex for food, clothing, and shelter is their only chance of survival on the streets. In turn, homeless youth are at a greater risk of contracting AIDS or HIV-related illnesses. HIV prevalence studies anonymously performed in four cities found a median HIV-positive rate of 2.3% for homeless persons under age 25 (Robertson, 1996).

To address the special considerations and challenges that primary care providers may face in caring for homeless individuals with HIV, the Health Care for the Homeless Clinicians’ Network is undertaking a project focusing on HIV and homelessness. The following information is taken from the Network’s September 1999 newsletter, Healing Hands.
HIV infection exacerbated by homelessness deserves special attention for the following reasons:

High morbidity and mortality: HIV-infected homeless persons are believed to be sicker than their domiciled counterparts. For example, they tend to have higher rates and more advanced forms of TB, and higher incidence of other illnesses such as Bartonella. Another study has demonstrated that more homeless people die of AIDS than other HIV-infected populations.

Barriers to care: Homeless people with HIV may face many barriers to optimal care. Injection drug use and lack of insurance, common among homeless people, have been shown to negatively affect health care utilization, level of medical care and health status.

Challenges to adherence: Adherence to complex medical regimens may be more difficult if one does not have stable housing or access to basic subsistence needs such as food. As it is believed that decreased adherence is the single best predictor of protease inhibitor failure and the primary cause of medication resistance, this problem has grave personal and public health implications.

Homeless persons with HIV/AIDS need safe, affordable housing and supportive, appropriate health care. Emergency housing grants should be available for persons with HIV-related illnesses who are in danger of losing their homes, and housing assistance should be available for those already on the streets. Federal assistance must be provided through adequate funding of targeted housing and health programs, and through the enforcement of anti-discrimination laws.

Cold Weather Tips

It can get very cold in Calgary. Winter temperature paired with wind can cause severe injuries and even death. Frostbite injuries can lead to amputations. Hypothermia, the most serious of cold weather complications can lead to brain damage and then death. Most susceptible to these cold weather problems are the elderly, children, the homeless, outdoor workers and sport enthusiasts. I would like to offer a few tips to prevent the cold weather in becoming a life-threatening event.
· Wear a hat – up to 40% of body heat loss can occur through the head
· Wear gloves or mittens
· Wear a scarf to protect the chin, lips and cheeks – all are extremely susceptible to cold weather injuries.
· Drink warm fluids, but no alcohol. Alcohol promotes other cold weather injuries.
· If you start to sweat, cool off a little. Wet clothes will also encourage other cold weather injuries.
· Wear clothes in layers
o Inner Layer (closest to the skin) – should have “wicking” properties to move any moisture away from the skin [cotton] o Middle Layer – should be the insulating layer to prevent loss of your body heat while keeping the cold outside air away
o Outer Layer – should be the “windbreaking” layer to reduce the chances of cold air reaching the insulating layer
· Always be on the lookout for signs of frostbite and hypothermia. In case of serious cold weather injury, urge you to seek immediate medical attention.
Frostbite

The months of December, January and February are the coldest months of winter and it’s difficult to avoid the cold weather. Frostbite is defined as damage of the skin from exposure to cold weather. I remind everyone that extremely cold weather can lead to serious complications, the worst being amputation. Injuries from frostbite are extremely common yet extremely preventable.
Frostbite mostly affects areas where the circulation is poor. Since cold weather will cause the body to take preventive measures by constricting (making smaller) the blood vessel, this opens the door to frostbite injuries.
Look for the 4 “P”s of frostbite.
1. Pink – affected areas will be reddish in colour. This is the first sign of frostbite
2. Pain – affected areas will become painful
3. Patches – white, waxy feeling patches show up – skin is dying
4. Pricklies – the areas will then feel numb
Tips to prevent frostbite.
· Get to a warm area before frostbite sets in. If it’s too cold outside, consider staying indoors.
· Keep extra mittens and gloves in the car, house or school bag.
· Wear larger sized mittens over your gloves.
· Wear a scarf to protect the chin, lips and cheeks. They are all extremely susceptible to frostbite.
· Wear two pairs of socks – wool if possible
· Keep feet warm and dry
· Do not drink alcohol. Alcohol narrows blood vessels, which promotes frostbite and then hypothermia
Should frostbite set-in…
· Do not rub or massage affected areas. It may cause more damage.
· NOT HOT – warm up the area slowly. Use a warm compresses or your own body heat to re-warm the area. Underarms are a good place.
· If toes or feet are frostbitten, try not to walk on them.
· Seek immediate medical attention if you see white or grey coloured patches or if the area is numb.
Always be on the lookout for the four “P”s of frostbite and hypothermia . In case of serious cold weather injury, you are urged to seek immediate medical attention.
Hypothermia

Whenever the body’s normal temperature becomes too low, hypothermia (hypo=low and thermia=temperature) occurs and will starve the brain of much needed oxygen. During the hot or cold weather months .I remind you that finding warmth can be the key to survival. Hypothermia can occur even during the hot days of July. Swimming in cold water for a long period of time can induce hypothermia even in the hottest months of the year.
Who is at Risk?
There are three groups that are most susceptible to hypothermia.
· The elderly – with inadequate clothing, food (food sustains normal body temperature) or heat
· Babies – sleeping in cold rooms or inappropriate clothing for the outdoors
· Homeless – lack of shelter, proper clothing and food
· Sport Enthusiasts – hikers, skiers
· Workers – people who work outdoors

Signs of Hypothermia
Look for these signs from people affected by cold temperatures;
· A person who mumbles
· A person who stumbles
· A person who fumbles objects
For infants look for cold reddish skin and low energy – always have a thermometer at home.
Tips to prevent Hypothermia
· Wear clothes in layers
o Inner Layer (closest to the skin) – should have “wicking” properties to move any moisture away from the skin
o Middle Layer – should be the insulating layer to prevent loss of your body heat while keeping the cold outside air away
o Outer Layer – should be the “windbreaking” layer toreduce the chances of cold air reaching the insulating layer
· Drink warm fluids, but no alcohol. Alcohol promotes other cold weather injuries.
· If you start to sweat, cool off a little. Wet clothes will also encourage other cold weather injuries
· Wear a hat – up to 40% of body heat loss can occur through the head
· Wear gloves or mittens or both!
· Wear a scarf to protect the chin, lips and cheeks – all are extremely susceptible to cold weather injuries.
· When going on a trip leave the itinerary with a responsible person
· If hiking use a map and hand-held Global Positioning Satellite (GPS) device which can be purchased for as little as $150.00 CAN
What to do in case of Hypothermia
· Remove wet clothing that promotes hypothermia.
· Get to a warm place as soon as possible. Use several layers of blankets heated in your home dryer if possible.
· If the person is alert, give warm beverages. Never give alcoholic beverages.
Seek immediate medical attention. Always be on the lookout for signs of frostbite and hypothermia. In case of serious cold weather injury, I urge you to seek immediate medical attention.

Street health Definitions

Alcoholism: A primary chronic disease influenced by genetic predisposition, psychosocial, environmental and cultural factors. The alcoholic who chooses to drink does so because of a complex interaction between these factors.

Alcoholics Anonymous: AA is a community program designed to encourage abstinence from alcohol using group support. The group is composed of previous alcoholics. It involves following 12 Steps that are written in the “Big Book.”

Anti-social personality disorder: A psychiatric condition in which the rights of others or socially accepted behaviour are violated.

Ascites: Fluid that accumulates in the abdomen when the liver fails.

Asterixis: (liver flap) a motor disturbance marked by intermittent lapses of an assumed posture often due liver or kidney failure.

b

Bartonella Quintana: An organism which often causes endocarditis in the homeless who suffer from alcoholism. It is often misdiagnosed as Chlamydia.

c

CAGE: A questionnaire used to screen for alcohol abuse. Two positive answers for males and one positive answer for females indicate alcohol abuse with 85% sensitivity and 89% specificity.
C: Have you ever tried to Cut down on your drinking?
A: Have you ever felt Annoyed by others telling you to cut down?
G: Have you ever felt Guilty about your drinking
E: Have you ever had to have an Eye-opener in the morning?

Cellulitis: Occurs when bacteria infect the skin. Any form of skin breakdown will facilitate the development of cellulitis. Untreated cellulitis may lead to lymphatic damage and edema.

Cheeking: A medical slang term to describe patients who hide their medications in their cheek or under their tongue to prevent swallowing them.

Cirrhosis: Endstage liver disease.

Cocaine: A short acting sympathomimetic drug. It is snorted if it is in the form cocaine hydrochloride (a.k.a. Free base). It is smoked if it is in the form of an alkaloid base (crack).

Conduct disorder: A psychiatric condition seen in childhood in which the rights of others or age-appropriate socially accepted behaviour are violated.

d

Direct observed therapy: DOS is a program designed to ensure anti-TB medications are taken daily. The patient has a contract with a nearby pharmacy/clinic. When they arrive at the pharmacy/clinic each day they are given a liquid form of their medication. The liquid form is used to prevent “cheeking.” DOS is also used for the treatment of HIV/AIDS.

e

Encephalopathy: Any degenerative brain disease

Endocarditis: occurs when a microbe infects the endocardium. Right sided endocarditis involves the tricuspid valve and is frequently caused by intravenous drug use or by central venous lines.

Esophagous: musculomembranous passage extending from the pharynx to the stomach (ie. the swallowing tube)

f

Frostbite: is cold, hard, anesthetic, frozen tissue. The tissue has severe cellular water loss and ischemia. Frostbite may progress to neuropathy and gangrene. It may also contribute to the acquisition of peripheral vascular disease in the homeless.

g

h

Hepatitis: Inflammation of the liver, due usually to alcohol or viral infection but also sometimes secondary to toxic agents. (Stedman’s Medical Dictionary, 2000).

Detection of hepatitis B antigens and/or on the finding of the antibodies against these antigens is a sign of infection.

Detection of hepatitis C antigens and/or detection of hepatitis C antibodies are signs of infection.

Hepatomegaly: Large liver

Heroine: An opiod that is synthesized from morphine. It is an analgesic that causes euphoria. It is usually injected intravenously. However, due to the recent increase in potency, more users are smoking and snorting.

Homelessness: A consequence of globalization, urbanization, political and religious strife, financial restraint and physical disability including psychiatric disease and drug/alcohol addiction.

i

Immersion foot: May develop after 10-12 hours of cold liquid exposure. Factors that encourage its development and complications include vasoconstrictor drugs, cognitive dysfunction, peripheral neuropathy, peripheral vascular disease and tobacco use. Weight baring pain, cold sensitivity and hyperhidrosis may persist for years.

Impetigo: The homeless are vulnerable to bullous and non-bullous impetigo. It also occurs when breaks in the skin allow bacteria to enter. However, the skin does not have to break to develop impetigo. Complicated impetigo may result in cellulitis.

j

Jaundice (icterus): yellowing of the skin, sclera, mucous membranes due to hyperbilirubinemia

Junk: A slang term for heroine. Other street names include black tar, china white, dog food, dreamer, dust, H, horse, scag, and smack.

k

Klebsiella: An organism which usually causes pneumonia in homeless alcoholics.

l

Liver Disease: A complex disease that involves different hepatic physiological dysfunctions (i.e. hepatocellular dysfunction, cholestasis and/or the vascular system). It may also involve systemic disease.

m

Mental Disorder: Clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and is associated with present distress or disability or with significantly increased risk of suffering death, pain, disability or an important loss of freedom.

Methadone: A heroin substitute because it has a longer half-life and less sedation. It is used to prevent withdrawal symptoms. Doctors must obtain a special license to prescribe methadone.

n

NSAID: Non-steroidal anti-inflammatory. Example: ibuprofen

o

Onychomycosis: A nail infection that is usually due to trichophyton rubrum. It may also develop secondary to tinea pedis.

p

Pancreatitis: Inflammation of the pancreas. (Stedman’s Medical Dictionary, 2000).

Pediculosis corporis: More commonly known as “body lice.” Lice live in the seams of clothing next to the host’s skin, particularly in the collar and waistband. There, they can then penetrate the host’s skin to feed on their blood.

Peptic Ulcer: An ulcer of the alimentary mucosa, usually in the stomach or duodenum, exposed to acid gastric secretion.’ (Stedman’s Medical Dictionary, 2000).

Pitted keratolysis: A non-inflammatory gram positive bacterial infection of the plantar surfaces. The lesions are discrete, shallow erosions located on the soles and beneath toes. Symptoms include hyperhidrosis, maceration and foul odour.

Pneumococcus: The most prevalent organism in homeless alcoholics, accounting for almost 50% of cases of pneumonia where organisms were isolated.

q

Quadruple therapy: Consists of Isoniazid (INH), Rifampin, Ethambutol, and Pyrazynamide for the treatment of tuberculosis. Vitamin B6 is added to this regimen to prevent INH toxicity.

r

s

Scabies: The organism sarcoptes scabiei is transmitted via skin to skin contact. Crowded homeless shelters are conducive to their transmission. Like lice, scabies is treated with permethrin cream 5% coupled with an anti-pruritic agent. Secondary bacterial infections are common.

Spider nevi: red skin lesion in the shape of a spider that may appear in liver disease

SSRI: Selective serotonin reuptake inhibitor. The long- term medication used for anxiety disorder.

Staph saprophyticus: An organism which usually causes UTI’s in young females.

t

Tinea pedis: Also known as “athlete’s foot or ringworm foot.” It is not an invasive disease. It is a superficial fungal infection affecting the feet. Bacterial infection may develop secondary to tinea pedis. This may result in cellulitis, lymphangitis, pyoderma, gangrene or systemic infections.

u

v

Varices: Dilated veins in the esophagous that appear because of portal hypertension (sever form of liver failure).

Verrucae (or warts): Common, contagious, epithelial tumors caused by at least 60 types of human papillomavirus. Any site of trauma is vulnerable for infection. In an immune compromised host (ex. HIV) multiple warts often appear and treatment in these cases is futile.

w

x

y

Youth: The definition is variable and is dependant on location. In Canada, after age 24, youth are no longer eligible for adolescent social services.

z

Anaphalaxis
Description
Anaphylaxis is an immediate, often life-threatening hypersensitive reaction. It is an acute clinical complex that may include any or all of these signs and symptoms: generalized erythema, pruritis, urticaria, angioedema, nausea, vomiting, abdominal cramps, diarrhea, bronchial constriction, laryngeal edema and cardiac arrhythmia, with or without cardiovascular collapse.
Subjective
Past Hx: Patient may report personal or family hx of allergies, such as hay fever, asthma, eczema, drug reactions or anaphylaxis. (Check for medic alert bracelet.)
Onset: Determine the time interval between exposure and onset of symptoms (most acute anaphylactic reactions occur within one hour); the faster the onset of symptoms, generally the more severe the reaction, although delayed reactions are possible.
Drug Hx: Determine current drug usage: what drugs and time of last doses.
Medical Hx: Is there cardiac or pulmonary dx, pregnancy.
Mental Status: Patient may report anxiety, agitation, decreased mental status.
Objective
Vital Signs: Check for tachycardia, arrhythmia, hypotension or tachypnea.
HEENT: Look for angioedema, rhinorrhea, sneezing.
Neck: Listen for stridor.
Lungs: Auscultate for wheezing or decreased breath sounds.
Abdomen: Note tenderness, diarrhea, emesis or hyperactive bowel sounds.
Extremities: Note if extremities are cold, clammy or cyanotic; if patient fell, check for fx, abrasions, or lacerations.
Skin: Examine carefully for erythema or urticaria.
Assessment
Local reaction: Skin changes only.
Generalized non-life-threatening reaction: Pruritus, urticaria, nausea, vomiting, dizziness.
Generalized life-threatening reaction: Severe wheezing or asthma, dysphagia with tongue swelling, hoarseness with laryngeal edema, hypotension, syncope, seizures, shock, coma, cardiac arrest.
Consult/Refer with MD: All cases of anaphylaxis.
Plan
1. Treatment is dictated by reaction severity. Institute care as soon as possible; time is critical. Remain with the patient, and provide reassurance.
2. For severe reactions, place patient supine (side-lying, if vomiting or increased secretions).
3. Assess ABC’s and keep airway open, monitor VS, provide oxygen 4-6 L / min PRN.
4. Administer epinephrine (1:1000 solution) 0.3cc to 0.5cc SC; PRN repeat doses q 10-15 mins X 3 doses maximum for life-threatening reactions.
5. Administer Benadryl® 25 to 50 mg PO or IM for non-life threatening reactions and consider epinephrine PRN.
6. For local reactions, apply ice and elevate the limb. Consider Benadryl®.
7. In some settings, be prepared to start IV lines, implement endotracheal intubation and administer medications IV (including corticosteriods and vasopressors).
Disposition
1. Most patients with non-life threatening reactions will respond to Benadryl® (and epinephrine PRN). They should be counseled to avoid the allergen, consider use of a medic alert bracelet, and notify their primary care provider of their reaction and treatment. They should be observed until stable, minimum four hours. Counsel these patients to immediately seek emergency care if any symptoms return in the next 24 hours.
2. Patients with more extensive reactions should be closely monitored and transported to an emergency unit or their primary care provider for further evaluation and care.
3. Fully document all reactions and file a VAERS report if due to vaccine injection. Label patient’s chart clearly with allergy alert.
4. All patients with severe allergic reactions require extensive patient counseling that is fully documented in their medical record. Issue patients an EpiPen® and instruct them to wear a medic alert bracelet or carry a wallet card. Refer all patients with a generalized life-threatening reaction to an allergist for further evaluation and/or desensitization therapy. Provide reassurance and address their questions, anxiety and fears.
5. Restock emergency supplies PRN.
6. Review and revise PRN clinic guidelines for preventing and responding to allergic and injection reactions.
References
Mackan M. Managing the patient with anaphylaxis, part 1: Mechanisms and manifestations. Emergency Medicine 1995 Feb; 27(2):68-70, 72-74, 79 passim.