The Anaphylaxis Response SOP for Crews
Purpose
Anaphylaxis is a severe allergic reaction that can close an airway or drop blood pressure within minutes. The one drug that reverses it, epinephrine, works best given early, and the most common reason it is given late is that the people standing next to the patient spent the first five minutes deciding whether it was serious. This SOP removes that decision for any crew member, including a first-week helper, from the first symptom to the paramedic hand-off.
Scope
Covers: a crew member, or a customer or bystander on your job site, showing signs of a severe allergic reaction after a sting, a bite, a food or a medication. Stings are the field trigger this was written around.
Does not cover: the ordinary local sting reaction and the escalation ladder that tells you which rung you are on (see related: Stinging Insects in Equipment and Eaves); a mass-sting event from a large colony, where getting everyone to shelter comes first (see related: Africanized Bees and Large Colonies); diagnosis or treatment beyond first aid. Nobody improvises medical care past what this procedure and the 911 dispatcher direct. Epinephrine here is the person's own prescribed auto-injector.
Roles and responsibilities
| Role | Owns | Hands off to |
|---|---|---|
| First person to notice | Steps 1 and 2: calls it, calls 911 | The crew lead or second person, for step 3 |
| Second person (if present) | Step 3: fetches the injector; meets the ambulance at the street | The first person, injector in hand |
| Whoever is with the patient | Steps 4 to 7: assists, positions, re-doses, watches | Paramedics at step 8 |
| Crew lead | Step 8 hand-off details; calls the office once EMS has the patient | Office manager |
| Office manager | Step 9: incident record, OSHA log decision, workers' comp report | Owner, for corrective action |
On a one-person job, the lone tech holds every field role and calls 911 on speaker so both hands stay free. Where no clinic or hospital is in near proximity, OSHA requires a person adequately trained in first aid to be available (29 CFR 1910.151(b) in general industry, 29 CFR 1926.50 in construction), which for a field shop means at least one trained person on every crew and every solo tech trained.
Procedure
Call it as anaphylaxis on the signs, not on certainty. After a sting or other exposure, treat it as anaphylaxis if the person has symptoms in two or more body systems (hives or flushing beyond the sting site, swelling of lips, face or tongue, vomiting or cramps) or any one of: trouble breathing, wheeze, throat tightness or hoarseness, faintness or collapse. Acceptance: the call is made within 1 minute of the first symptom away from the sting site. Wrong looks like: "let's give it ten minutes and see," or a person saying they are fine while their voice goes hoarse. Stop rule: if in doubt, it is anaphylaxis; there is no penalty for a 911 call that turns out to be a large local reaction. Hazard: if insects are still active, move the person at a walk to the truck or out of range first; if they are on a ladder or a roof, they come down now with someone steadying the ladder, because faintness at height is a fall.
Call 911 and say three things. Give the job address from the work order (not "the Smith house"), say "suspected anaphylaxis from a sting," and say whether epinephrine is on scene. Put the phone on speaker and keep the line open. Acceptance: dispatcher has the street address and cross street, and the line stays connected. Wrong looks like: a crew member loading the person into the truck to drive them to urgent care. Stop rule: do not drive the person yourself unless the dispatcher tells you to, because a patient who collapses in a moving truck gets nothing from a driver watching the road. Hazard: if you are on a road shoulder or a driveway, the caller stands clear of traffic, and the second person meets the ambulance at the street to wave it in.
Get the person's own epinephrine auto-injector into your hand. Ask "do you carry epinephrine, and where is it?" or use the location on their emergency card. Acceptance: injector in hand within 1 minute of the 911 call. Wrong looks like: the injector is "in my car at the shop," expired, or nobody knows. Stop rule (no injector present): tell the dispatcher immediately, "no epinephrine on scene," go straight to step 5, and follow the dispatcher's instructions. Do not give an antihistamine from the first-aid kit in place of epinephrine; it does not reverse airway swelling or low blood pressure, and the minutes spent on it delay what does. Hazard: do not leave the person alone to search a truck; the second person fetches it, and a lone tech fetches only if the person stays in sight the whole way.
Help the person use the injector. If they can, they inject themselves; you steady the leg and read the device's printed instructions aloud. If they cannot, you inject following those instructions: outer middle thigh, through clothing if needed, held for the time the device states. Note the time to the minute. Acceptance: injection time recorded, and the device shows it fired. Wrong looks like: the injector fired into a thumb or a hand. Stop rule: a misfire into the helper's hand means that person also needs medical care; tell the dispatcher, and use the second injector on the patient if one exists. Hazard: the needle. Keep fingers off the needle end, never recap it, and set the used device aside for the paramedics. Most states' Good Samaritan laws protect a good-faith helper, though their scope varies; this is not legal advice.
Position the person and keep them down. Lay them flat with legs raised. If breathing is hard, let them sit up. If they are vomiting or not responsive, roll them onto their side. Acceptance: positioned within 1 minute of the injection (or of the step 3 stop rule) and not standing or walking. Wrong looks like: the person feels better and stands up to "walk it off." Stop rule: they stay lying or sitting until paramedics move them, because standing suddenly during anaphylaxis can cause collapse. Hazard: check the ground before you lay them down: no ant mound, no wasp traffic, shade if the pavement or roof is hot.
Give a second dose if they are not improving. If symptoms are not getting better, or are getting worse, 5 to 15 minutes after the first dose and a second injector is available, give it the same way, following the device instructions and the dispatcher. Acceptance: second dose time recorded, at least 5 minutes after the first. Wrong looks like: the second injector given 2 minutes after the first because nobody watched the clock. Stop rule: if there is no second injector and symptoms are worsening, tell the dispatcher and follow instructions. Hazard: the same needle rules as step 4.
Never leave them, and watch breathing. One person stays at the patient's side at all times, checking breathing and responsiveness and saying what they see to the dispatcher. Acceptance: continuous attendance until the hand-off, with symptoms noted at least every 5 minutes. Wrong looks like: everyone walking to the street to look for the ambulance. Stop rule: if the person stops breathing normally, start CPR as trained and as the dispatcher directs. Hazard: CPR exposure to saliva or vomit; use a barrier device if you have one and are trained on it.
Hand off to paramedics, and the person goes to the hospital. Tell paramedics the time of the sting, the times of each epinephrine dose, and what symptoms you saw, and give them the used injectors. Acceptance: paramedics have taken over and the person is transported, or has refused transport to the paramedics directly. Wrong looks like: the person feels fine 20 minutes later and wants to finish the job. Stop rule: no return to work that day; symptoms can come back hours later without a new sting, which is why emergency care follows every epinephrine dose. Hazard: the insects are still there; the area stays taped off and nobody resumes work near the nest that day.
Close out the incident. Crew lead calls the office once paramedics have the patient. The office opens the incident record and decides the reporting. Acceptance: record opened the same day. Wrong looks like: "he's fine, no need to write it up." Stop rule: an in-patient hospital admission must be reported to OSHA within 24 hours under 29 CFR 1904.39, which applies to every employer under OSHA's jurisdiction; treatment and release from an emergency room is not an admission. Separately, a covered employer's injury and illness log (29 CFR 1904.7) counts prescription medication as medical treatment beyond first aid, so an epinephrine case belongs on it. Hazard: none at this step; it is done at a desk.
The record this produces
One incident entry per event, opened in the job record and completed by the office:
- Times: exposure, first systemic symptom, 911 call, each epinephrine dose, EMS arrival, transport.
- Steps: each of the nine marked done, done late, or not performed, with the reason for any that failed.
- Outcome: transported or refused; admitted or released (decides the 1904.39 report).
- Reporting: OSHA log entry yes or no, OSHA 24-hour report yes or no, workers' comp claim filed.
- Corrective action: one sentence, owned by a named person.
The owner reads the corrective action; the safety meeting reads the steps.
Worked pass: no injector on scene
Setting. A two-person HVAC crew from a 14-employee shop in Texas, replacing a bathroom fan vent at a soffit. Late August. The helper's emergency card says he has a severe sting allergy and carries epinephrine "in backpack."
| Step | What happened | Result |
|---|---|---|
| 1 | 2:14 pm, helper stung on the neck by a paper wasp from a soffit nest while on the ladder. 2:16, hives on chest and arms, says his throat feels tight. Lead calls it at 2:16 and steadies the ladder while the helper climbs down. | Pass, 2 minutes after the sting and within 1 minute of the systemic symptoms |
| 2 | 2:17, lead calls 911 on speaker, gives the street address and cross street, "suspected anaphylaxis from a wasp sting." | Pass |
| 3 | Helper says the backpack is in his own car at the shop, 25 minutes away. No injector on site. 2:18, lead tells the dispatcher "no epinephrine on scene." The truck kit holds antihistamine tablets; the lead does not use them. | Fail, stop rule taken |
| 4 | Not performed: no injector. | Not performed |
| 5 | 2:18, helper laid flat in the shade of the garage, legs on a toolbox. Wants to sit up as breathing tightens; lead lets him. | Pass, within 1 minute of the stop rule |
| 6 | Not performed: no injector. Lead reports worsening hoarseness at 2:23. | Not performed |
| 7 | Lead stays beside him; the customer waits at the street. Symptoms told to the dispatcher at 2:18, 2:23 and 2:28. | Pass |
| 8 | 2:29, paramedics arrive, 12 minutes after the call, and give epinephrine. Lead gives the sting time and symptom times. Transported. | Pass |
| 9 | Released from the emergency room after observation that evening; not admitted, so no 1904.39 report. Epinephrine was given, so the case goes on the shop's OSHA log. Record opened at 3:05 pm. | Pass |
Every step the crew controlled was done on time. The step that failed was decided weeks earlier, when an injector needed in the first minute was written down as "in backpack." The patient waited 13 minutes for epinephrine: from 2:16, when the reaction was called, to 2:29, when the paramedics gave it.
Corrective action, owned by the operations manager: anyone whose card says they carry epinephrine keeps it on their body, not in a bag, while in the field, and the crew lead confirms it at the morning huddle as part of the truck check. The card's location field now asks "on your body, where?"
References
- OSHA, 29 CFR 1904.7 (medical treatment beyond first aid) and 29 CFR 1904.39 (reporting an in-patient hospitalization within 24 hours)
- OSHA, 29 CFR 1910.151(b) and 29 CFR 1926.50, first-aid availability where medical care is not in near proximity
- American Academy of Allergy, Asthma and Immunology, anaphylaxis and epinephrine auto-injector guidance
- See related: Stinging Insects in Equipment and Eaves; Dealing With a Wasp Nest in Your Work Area; Africanized Bees and Large Colonies