Updated 8/2018

1. Treatment of Students with Adrenal Crisis This training was created for teachers and staff associated with students diagnosed with adrenal insufficiency and suffering from an adrenal crisis. Updated 8/2018

2. Credits Thank you to the following people and organizations for contributing to the creation of this training protocol: • Oregon Department of Education School Nurse Advisory Group • Adrenal Insufficiency United

3. Objectives As a result of this training, participants will be able to: • Identify the dangers associated with adrenal insufficiency. • Recognize the symptoms of adrenal crisis and common factors that lead to adrenal crisis. • Provide examples of the types of medications that are available for treating adrenal crisis. • Demonstrate proper administration of injectable medications that treats adrenal crisis. • Explain the importance of follow-up treatment.

4. State Law • In 2015 the Oregon legislature amended ORS 433.800 – 433.830 (laws pertaining to the training of lifesaving treatments). • The Oregon Administrative Rules supporting this law (OAR 333-055-0000 to 333-055-0035) were then amended and adopted by the Oregon Health Authority (OHA), Public Health Division in February 2016.

5. Training Recipients • The training should be provided on behalf of students with a known diagnosis of adrenal insufficiency that places them at risk for adrenal crisis. • The person to be trained must be 18 years of age or older and must have, or reasonably expect to have, responsibility for or contact with a student diagnosed with adrenal insufficiency described above. Individuals who are likely to fall under the definition of the law include public or private school employees and school volunteers. • The Oregon Administrative Rule states that school personnel must be retrained every three years on adrenal crisis, but the OHA recommends retraining every year to maintain competency.

6. School Health Management Plan • For children in school, parents or guardians of children with adrenal insufficiency must notify school personnel of their child’s medical needs to initiate a health management plan (may be included in a 504 Plan or Individualized Education Plan (IEP)). • This plan should document agreements among the parents or guardian, school personnel, and the student's medical provider about providing a safe and supportive learning environment for the child with adrenal insufficiency. • A school nurse is usually the lead staff for implementation of a health management plan.

7. Adrenal Insufficiency • Adrenal insufficiency is a chronic medical condition in which the adrenal glands do not produce enough of the necessary hormones (cortisol and aldosterone) to respond to stressors such as illness and injury. • These hormones help to maintain and regulate key functions in the body such as blood pressure; metabolism (how the body uses food for energy); the immune system; and how the body responds to stress.

8. Adrenal Insufficiency • Adrenal insufficiency is caused by congenital conditions, cancers, tumors and many other conditions that affect the pituitary gland, adrenal gland or other endocrine organs. • Addison's disease, the common term for primary adrenal insufficiency, occurs when the adrenal glands are damaged and cannot produce enough cortisol. • Much like a diabetic student who needs insulin, a student with adrenal insufficiency is missing a hormone vital to life and must take replacement medications on a daily basis.

9. Adrenal Glands • The adrenal glands are located on the top of the kidneys • The adrenal glands are made up of two parts, the cortex and the medulla

10. Adrenal Insufficiency vs. Adrenal Crisis Adrenal Insufficiency: • Chronic condition • Adrenal glands fail to produce specific stress hormones • The student will take daily medications Adrenal Crisis: • Acute • This is an exacerbation of a students adrenal insufficiency which can be caused by: • Illness • Injury • Stress • Missing daily medications

11. Adrenal Crisis Triggers • Illnesses such as a cold or the flu • An injury, such as a twisted ankle or a broken bone • Exposure to stressful situations; i.e. a fire-drill • Missing or stopping daily steroid medications Staff should refer to the School Health Management Plan for each student that suffers from adrenal insufficiency and become familiar with what triggers their adrenal crisis and how it presents.

12. Adrenal Crisis Adrenal crisis is a sudden, severe worsening of symptoms which may include: Red cheeks (not attributed with recess or PE class) Dizziness Loss of appetite Dark rings under the eyes Changes in emotional behaviors- student may seem upset, angry or more tearful than normal Fainting or passing out Fever (over 100°F) • Severe pain in the lower back, abdomen or legs • Muscle weakness or cramping • Trouble focusing • Lethargy • Stomach ache • Nausea and/or vomiting • Diarrhea • Dehydration • Low blood pressure • Headache

13. Medications There are many medications that a student can be prescribed to treat adrenal insufficiency. • Routine Daily Medications • Stress Dose

14. Stress Dose • When a person who does NOT suffer from adrenal insufficiency suffers significant physical or emotional stress, they produce up to 10X the normal amount of hormones needed in response to the event. • Patients with Adrenal Insufficiency cannot produce these hormones and must be given an extra dose of medication (on top of their daily prescribed dose) when their body experiences physical or emotional stress. • This is called a “STRESS DOSE.” Depending on the severity of the event, a stress dose may be given orally or via injection.

15. Stress Dose • Your student’s School Health Management Plan will have: • instructions for oral stress dosing for minor illnessor injury • instructions for emergency injection for serious illness or injury.

16. Adrenal Crisis • Each student is different and will deteriorate differently. This is related to their age, physical condition and the specific stress event. • One third of adrenal crises occur outside of the home. • Vomiting and diarrhea account for most adrenal crisis events because it interferes with the absorption of their daily, prescribed medication.

17. Adrenal Crisis • If the student is unconscious, very lethargic or hard to keep awake, they are at risk for adrenal crisis. • If the student has suffered a traumatic injury such as a broken bone, they are at risk for adrenal crisis. • Be sure you have reviewed your student’s School Health Management Plan for the instructions on when to give the student an injection.

18. Injectable Medications When there is a suspected adrenal crisis, additional doses of oral medication may be necessary, or an injectable medication, such as Solu-Cortef or Solu-Medrol may be required. Injectable medications are given intra-muscularly, which means that it is injected into a large muscle, such as the thigh. Remember to consult the student’s School Health Management Plan for the appropriate medication and administration.

19. Treatment • WHEN IN DOUBT, INJECT! • The lack of Cortisol (stress hormone) during adrenal crisis puts the student at risk of disability and death. • Even if the student is not in crisis, administering the medication will not have any adverse effects.

20. Medication Access and Storage Plans should be in place to assure that medication is readily available and in close proximity of the student. Consideration of transportation activities such as field trips or other off facility functions must be taken into account when planning emergency measures for possible treatment of adrenal crisis. Depending on the age of the child and school policies, it may be advisable for students to carry their own medication during these special activities and trained personnel must accompany the child.

21. Treatment If you determine that the student is suffering from an adrenal crisis: • Instruct someone to call 911 and the student’s parents. • If the student is still conscious, keep talking to them and reassure them that you are there to help. Keep them calm. • Get the injection ready • Administer the injection and wait with the student until help arrives. • The injection will not produce an immediate effect. • Give the empty vial to the Emergency Medical Responders when they arrive.

22. Equipment Needed • Gloves • Medication • Syringe and injection needle • Alcohol swab • Cotton ball or tissue • Sharps container

23. Preparing for Administration 1. Assemble medication and check the expiration date. Consider location where medication is to be injected. 2. Wash hands 3. Put on gloves

24. Injection site

25. Preparing Medication “Act-o-Vial” Make sure that the medication is clear and not expired. 4. Press down on the plastic activator (cap) and force the diluent (liquid) into the lower chamber of powdered medication. The rubber stopper separating the two will fall into the lower chamber. • Gently mix the solution by turning the vial upside down several times. DO NOT SHAKE. *The solution will initially appear cloudy, then clear. If the solution does not clear, do not administer the medication to the student and wait for rescue personnel to arrive. • Remove the plastic tab covering the center of the stopper (small circular disc on the plastic cap).

26. Drawing Up the Medication 7. Wipe the top of the Act-o-Vial with an alcohol swab. • Take the cap off of the syringe • Insert the needle squarely through the center of the top rubber stopper, just until the tip of the needle is visible in the vial. • Invert the vial and withdraw the prescribed dose. • Reassure the student. Always be cautious when handling needles.

27. Administering Medications 12. Uncover the area to be injected (lateral thigh). 13. Use an alcohol swab to cleanse the injection site on the skin. 14. Hold the syringe like a dart.

28. Administering Medications 15. Using the thumb and first two fingers, spread the skin while pushing down lightly.

29. Administering Medications 16. Dart the needle into the injection site, going straight into the tissue at a 90-degree angle. 17. Depress the syringe plunger, administering the drug into the student.

30. Administering Medications 18. Withdraw the syringe quickly and discard into a sharps container. • Use a cotton ball or tissue and massage the injection site gently. • Reassure the student • Notify parent/guardian. 22. Clean up and dispose of waste safely.

31. After Administration of an Injection • Do not leave the student unattended. • Advise the 911 dispatcher of the type of medication given. • Turn the student on their side and monitor their breathing. • If the student’s condition worsens, advise the 911 dispatchers of the change in status. • Document

32. Scenario #1 • A student with diagnosed adrenal insufficiency suffers a broken wrist after falling from a jungle gym on a sunny day. She is crying in pain and states her stomach hurts. • What would you do?

33. Scenario #1 Answer • Call 911 and call the student’s parents. • Reassure the student that you are there to help and keep them calm. • Retrieve the student’s stress dose of medication and administer the medication per prescriber orders and Health Management Plan. • Stay with the student and place them on their side while waiting for EMS to arrive. • Monitor the student’s breathing and level of consciousness. • If the student’s condition changes, alert 911 dispatchers.

34. Scenario #2 • A student with known adrenal insufficiency suffers a skinned knee while running from a bee. The child complains of pain to the knee, but is happy that the bee “went away.” The child is alert and has no other complaints. • What would you do?

35. Scenario #2 Answer • The child is not suffering from an adrenal crisis at this time. • Treat the student for the skinned knee and monitor them. • If no other symptoms arise, the student is not at risk for adrenal crisis. • Notify the student’s parents of what happened so that they can continue to monitor their child later. • Attempt to keep the student relaxed throughout the rest of the day, by not adding any additional stress and by avoiding emotional triggers.

36. Review • Students who are diagnosed with adrenal insufficiency are unable to produce the hormones needed when responding to specific emotional or physical stressors such as: • A broken limb • A fire drill • The flu • Students will need a “STRESS DOSE” of medication when they are suffering from an adrenal crisis.

37. Summary Adrenal crisis is a sudden, severe worsening of symptoms which may include: Red cheeks (not attributed with recess or PE class) Loss of appetite Dark rings under the eyes Changes in emotional behaviors- student may seem upset, angry or more tearful than normal Fainting or passing out Fever (over 100°F) Dizziness • Severe pain in the lower back, abdomen or legs • Muscle weakness or cramping • Trouble focusing • Lethargy • Stomach ache • Nausea and/or vomiting • Diarrhea • Dehydration • Low blood pressure • Headache

38. Summary Review and be familiar with the student’s School Health Management Plan for: • the student’s baseline activity level, attitude and behavior. • the specific emotional or physical stressors that might trigger an adrenal crisis. • the student’s past history with adrenal crisis. • the medication and administration route that is prescribed to the student from their provider to use during an adrenal crisis.

39. Summary When in doubt, INJECT the student with their STRESS DOSE! • The lack of Cortisol (stress hormone) during adrenal crisis puts the student at risk of disability and death. • Even if the student is not in crisis, administering the medication will not have any adverse effects.