anahalaxis cole.ppt

8/14/2019 anahalaxis cole.ppt

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AnaphylaxisAre we bugging you?

Steve Cole, CCEMT-P

Ada County Paramedics


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Anaphylaxis

Anaphylaxis comes from the Greek andmeans against or without protection.

As opposed to prophylaxis for protection


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Definition of Anaphylaxis

Systemic allergic reaction

Affects body as a whole

Multiple organ systems may be involved

Onset generally acute

Manifestations vary from mild to fatal


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Antigen to Antibody

Relationship Antigen

the foreign protein that when taken into

the body stimulates/formulates specific protective proteins called antibodies.

Antibody a protein produced in the body to response to

a specific antigen (foreign protein) tot destroy orinactivate the antigen. (IgE)


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Histamine

Coronary vasoconstriction Bronchoconstriction Vascular permeability Intestinal smooth muscle contraction

Dysrhythmias: sinus tach, a-fib, AV, andIVCD


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Pathogenesis of Anaphylaxis

IgE-mediated (Type I hypersensitivity)

Sensitization stage

Subsequent anaphylactic response


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Sensitization StageAntigen (allergen)exposure

Plasma cellsproduce IgE antibodiesagainst the allergen

IgE antibodiesattach to mast

cellsand basophils

Mast cell withfixed IgEantibodies

IgE

Granulescontaining

histamine

Antigen

Plasma cell


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Anaphylactic Reaction More of

same allergeninvades body

Antigen

Mast cell granulesrelease contentsafter antigen bindswith IgEantibodies

Histamine and

other mediators

.

Allergen combineswith IgE attached to

mast cells andbasophils,which triggersdegranulation and

releaseof histamine and other

chemical mediators


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Common Causes of IgE-mediatedAnaphylaxis

Foods Insect venoms

Latex Medications Immunotherapy

Insect venom

Inhalant allergens


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Anaphylactoid Reactions

Non IgE-mediated

Complement-mediated

Anaphylatoxins, eg, blood products Direct stimulation

eg, radiocontrast media

Mechanism unknown Exercise

NSAIDs


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Clinical Manifestations ofAnaphylaxis

Skin: Flushing, pruritus,

urticaria, angioedema

Upper respiratory: Congestion,rhinorrhea

Lower respiratory:

Bronchospasm, throat or chest

tightness, hoarseness,wheezing, shortness of breath,

cough


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Clinical Manifestations of

Anaphylaxis Gastrointestinal tract:

Oral pruritus

Cramps, nausea, vomiting,diarrhea

Cardiovascular system:

Tachycardia, bradycardia,

hypotension/shock,arrhythmias, ischemia,chest pain


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Clinical Manifestations of

Anaphylaxis Urticaria Angioedema Upper airway

edema Dyspnea and

wheezing Flush Dizziness, syncope,

and hypotension

Gastrointestinalsymptoms

Rhinitis Headache Substernal pain Itch without rash

Pruritus Seizure


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Clinical Course of Anaphylaxis

Uniphasic

Biphasic

Recurrence up to 8 hours later Different in Peds

Descriptions and perceptions are different

Protracted Hours to days


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Anaphylaxis Fatalities

Estimated 500 1000 deaths annually 1% risk Risk factors:

Failure to administer epinephrine immediately Peanut, Soy & tree nut allergy (foods in general) Beta blocker, ACEI therapy Asthma

Cardiac disease Rapid IV allergen Atopic dermatitis ( eczema)


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Food-induced Anaphylaxis:Incidence

35% 55% of anaphylaxis is caused by food allergy

6% 8% of children have food allergy

1% 2% of adults have food allergy

Incidence is increasing

Accidental food exposures are common and unpredictable


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Food-induced Anaphylaxis:Common Triggers

Children and adults (usually not outgrown):

Peanuts (Beware Atrovent) Tree nuts Shellfish Fish

Additional triggers in children (commonly outgrown):

Milk Egg Soy Wheat


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Food-induced Anaphylaxis:Common Symptoms

Oropharynx: Oral pruritus, swelling of lips and tongue, throat

tightening

GI: Crampy abdominal pain, nausea, vomiting, diarrhea Cutaneous: Urticaria, angioedema

Respiratory: Shortness of breath,

stridor, cough, wheezing


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Food-induced Anaphylaxis:Fatal Reactions

Fatal reactions are on the rise

~150 deaths per year

Usually caused by a known allergy

Patients at risk:

Peanut and tree nut allergy

Asthma

Prior anaphylaxis Failure to treat promptly w/epinephrine

Many cases exhibit biphasic reaction


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Fatal Food-induced Anaphylaxis(Bock SA, et al. JACI 2001;107:191 193)

32 cases of fatal anaphylaxis

Adolescents or young adults

Peanuts, tree nuts caused >90% of Rxn

20 of 21 with complete history had asthma

Most did not have epinephrine available


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Venom-induced Anaphylaxis:Incidence

0.5% 5% (13 million) Americans aresensitive to one or more insect venoms

Incidence is underestimated Incidence increasing due to fire ants and Africanized bees Incidence rising due to more outdoor activities At least 40 100 deaths per year


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Venom-induced Anaphylaxis:Common Culprits

Hymenoptera Bees Wasps

Yellow jackets Hornets Fire ants

Geographical Honeybees, yellow jackets most common in East,

Midwest, and West regions of US Wasps, fire ants most common in Southwest

and Gulf Coast


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Hymenoptera


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Venom-induced Reactions:Common Symptoms

Normal: Local pain, erythema, mild swelling Large local: Extended swelling, erythema

Anaphylaxis: Usual onset within 15 20 minutes Cutaneous: urticaria, flushing, angioedema Respiratory: dyspnea, stridor Cardiovascular: hypotension, dizziness, loss of

consciousness 30% 60% of patients will experience a systemic

reaction with subsequent stings


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Venom-induced Anaphylaxis:PreventionRisk Management

Keep EpiPen or EpiPen Jr on hand at all times

Educate and train on EpiPen use

Develop emergency action plan

Wear a MedicAlert braceletConsult an allergist to determine need for venom immunotherapy


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Venom-induced Anaphylaxis:Immunotherapy

Risk of anaphylaxis10%-15% of patients experience systemicreactions during early weeks of treatmentSx generally occur within 20 minutesPatients at risk: asthma , prior reactions, beta

blocker or ACEI therapy


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Immunotherapy-induced

AnaphylaxisRisk management

Trained physician, equipped facility

Epinephrine immediately available

Monitor closely for 20 30 minutesConsider supply of EpiPen for those at high

risk


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Latex-induced Anaphylaxis:Incidence

1% 6% of US population (up to 16 million) affected

H igh as 67% in patients with spina bifida 6.5% in patients who have undergone multiple surgeries

3% 18% incidence among health care workers Repeated exposure leads to a higher risk

Incidence has increased since mid 1980s

Latex gloves, especially powdered gloves BVM, ETT, IV Tubing and Caths.

Nasal Canulas, NRBs.


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Risk Groups

Patient Risk Groups

Patients with spina bifida and congenitalgenitourinary abnormalities

18-73%

Health care workers (housekeepers, lab workers,dentists, nurses, physicians) 3-17%

Rubber industry workers 11%

Atopic patients (asthma, rhinitis, eczema) 6.8%

Patients who have undergone multiple procedures 6.5%


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Latex-induced Anaphylaxis

Hypoallergenic The "hypoallergenic" label generally means

that gloves are low in chemical contactsensitizers, but "hypoallergenic" does notrefer to latex allergens.


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Latex-induced Anaphylaxis:Triggers

Proteins in natural rubber latex

Component of ~40,000 commonly used items

Rubber bands

Elastic (undergarments)

Hospital and dental equipment

Latex-dipped products are biggest culprits

Balloons, gloves, bandages, hot water bottles


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Reactions to LatexIrritant contact dermatitis

Dry, itchy, irritated hands

Allergic contact dermatitis

Delayed hypersensitivityLatex allergy

Immediate hypersensitivity

Sx: hives, itching, sneezing, rhinitis, dyspnea, cough,

wheezingGreatest risk with mucosal contact

L t i d d A h l i


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Latex-induced Anaphylaxis:Prevention

Use latex-free products

Alert employer/health care providers, schools about need for

latex-free products and equipment Wear MedicAlert bracelet Awareness of cross-sensitivity with foods:

AVOIDANCE

Banana Avocado Chestnuts

Kiwi Stone fruit Others

L t i d d A h l i


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Latex-induced Anaphylaxis:Prevention

Prescribe EpiPen or EpiPen Jr

Accidental exposure

Patients at risk

Go Latex Free at agency

Educate re: EpiPen

use Develop emergency action plan

RISK MANAGEMENT


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Exercise-Induced Anaphylaxis

First reported in 1979 Mechanism of action is unclear

Predisposing factors: ASA , Motrin use Food, including shell fish, cheese, dense fruits,

snails.

Triggered by almost any physical exertion Most common in very athletic children


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Exercise-Induced Anaphylaxis

Four Phases Prodromal phase is characterized by fatigue,

warmth, pruritus, and cutaneous erythema The early phase: urticarial eruption that

progresses from giant hives may includeangioedema of the face, palms, and soles.

Fully established phase: hypotension, syncope,

loss of consciousness, choking, stridor, nausea,and vomiting ( 30 minutes to 4 hours.) Late or postexertional phase, Prolonged urticaria

and headache persisting for 24-74 hours.

Other Causes of Anaphylactic


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Other Causes of Anaphylacticand Anaphylactoid Reactions

Drugs

Antibiotics

Chemotherapeutic agents

Aspirin, NSAIDs

Streptokinaise

Biologicals (vaccines, monoclonal antibodies)

Radiocontrast media (iodine)

Idiopathic


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Diagnosing Anaphylaxis Based on clinical presentation, exposure Hx

Cutaneous, respiratory Sx most common

Some cases may be difficult to diagnose

Vasovagal syncope

Scombroid poisoning

Systemic mastocytosis


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Diagnosing Anaphylaxis Careful history to identify possible causes

Can be confirmed by serum tryptase

Specific for mast cell degranulation Remains elevated for up to 6 hours

Other labs to rule out other diagnoses

Refer to allergist for specific testing


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Diagnosing Anaphylaxis

Skin tests/RAST

Foods Insect venoms Drugs

Challenge tests

Foods NSAIDs Exercise

Allergists can identify specific causes by:


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Use of Epi Pen Immediate treatment with epinephrine

imperative

No contraindications in anaphylaxis Failure or delay associated with fatalities IM may produce more rapid, higher peak

levels vs SC Must be available at all times


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State of Idaho Regs 1994 EMT-B Curriculum

Trained to recognize anaphylaxis Not Authorized to possess EPI-PEN Authorized assist patient in self administration

Assist & Monitor

Effective September 9 th, 2003: EpiPen may now be carried by BLS agencies with medicaldirector approval and QA No Medical Director, may only assist the pt with

their Epi Pen Must undergo upgrade module

About 1-2 hours Skills test


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EpiPen /EpiPen Jr:Directions for Use

E iP /E iP J


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E iP /E iP J


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Treatment of Anaphylaxis


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Simple BLS (O2, position, etc)

Anti Histamines Benadryl (IV 25-50 mg, PO 50 mg adult, 25

mg ped)

Corticosteroids Decadron, Solu-medrol, etc

Treat Hypotension IV fluids Dopamine 5-20 mcg/min

Epi Drip 2-10 mcg/min


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Broncheodiators Albuterol MDI or Neb

Observe for a minimum 8-12 hours Insure F/U with PMD,

Benadryl for 24 hours.

Rebound or persitant S/S Repeat epinephrine if Sx persist or increase after 10-15

minutes

Repeat antihistamine H 2 blocker if Sx persist


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Screening Patients at RiskDid you ever have a severe allergic reaction:

To any food?

To any medicine?

To an insect sting? To latex?

Side effect or allergic reaction?

That caused breathing trouble? Severe hives and swelling? Severe

vomiting or diarrhea? Dizziness?

That required you to go to the hospital?


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Risk Management for Anaphylaxis

EDUCATE

Teach avoidance measures

Accidents are never planned

Stress importance of:

Always having a current EpiPen on hand

Immediate treatment

Emphasize the need for follow-up care


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EpiPen 2-Pak

* EpiPen 2-Pak was launched in April 2001


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Myth: Insect Stings are the most fatal

REALITY :

While any trigger can be fatal, Most common trigger resulting ina fatal

outcome is food allergies, especially in peds.

This is espeecialy true with other risk factors , like Astma Also aggrivated as most kids forget Epi Pen or have the wrong size. Most common fatal food allergies are:

Peanuts Tree Nuts

Myth: Prior Episodes


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Myth: Prior EpisodesPredict Future Reactions

REALITY :

No predictable pattern

Severity depends on:

Sensitivity of the individual Dose of the allergen Anaphylactoid vs Anaphylactic


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Myth: Anaphylaxis Is Rare

REALITY :

Anaphylaxis is underreported

Incidence seems to be increasing

Up to 41 million Americans at risk (Neugut AI et al, 2001)

63,000 new cases per year

(Yocum MW et al, 1999) 5% of adults may have a history of anaphylaxis (various

surveys)

Myth: Anaphylaxis is Easy to Avoid


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Myth: Anaphylaxis is Easy to AvoidIf You Know What You are Allergic

ToREALITY:

Most cases of anaphylaxis are due toaccidental exposures

Clinical studies have found repeatedly that, evenwhen patients attempt strict avoidance of a knownallergen, their efforts are rarely 100% successful.


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Myth: Anaphylaxis is Reported

REALITY :

Most individuals do not inform their personal physician of

an anaphylactic reaction either at the time of the reaction

or during routine exams


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Myth:Epinephrine is DangerousREALITY :

Risks of anaphylaxis far outweigh risks

of epinephrine administration Minimal cardiovascular effects in children

(Simons et al, 1998) Caution when administering epinephrine in

elderly patients or those with known cardiacdisease

Myth: The Cause of Anaphylaxis is


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Myth: The Cause of Anaphylaxis isAlways Obvious

REALITY : Idiopathic anaphylaxis is common

Triggers may be hidden Foods

Latex

Patient may not recall details of exposure, clinical course


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Myth: Anaphylaxis Always Presentswith Cutaneous Manifestations

REALITY : Approximately 10%-20% of anaphylaxis cases will not

present with hives or other cutaneous manifestations

80% of food-induced, fatal anaphylaxis cases were notassociated with cutaneous signs or symptoms

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