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Anaphylaxis
Anaphylaxis comes from the Greek and means against or without protection.
As opposed to prophylaxis for protection
Definition of Anaphylaxis
Systemic allergic reaction
Affects body as a whole Multiple organ systems may be involved
Antibody
a protein produced in the body to response to a specific antigen (foreign protein) tot destroy or inactivate the antigen. (IgE)
Histamine
Coronary vasoconstriction Bronchoconstriction Vascular permeability Intestinal smooth muscle contraction Dysrhythmias: sinus tach, a-fib, AV, and IVCD
Pathogenesis of Anaphylaxis
IgE-mediated (Type I hypersensitivity)
Sensitization stage
Sensitization Stage
Antigen
Plasma cell
IgE Mast cell with fixed IgE antibodies Granules containing histamine
Anaphylactic Reaction
More of same allergen invades body
Antigen
Allergen combines with IgE attached to . mast cells and basophils, which triggers degranulation and release of histamine and other chemical mediators
Mast cell granules release contents after antigen binds with IgE antibodies
Anaphylactoid Reactions
NonIgE-mediated
Direct stimulation
eg, radiocontrast media Mechanism unknown
Exercise
NSAIDs
Seizure
Protracted
Hours to days
Anaphylaxis Fatalities
Estimated 5001000 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)
Incidence is increasing
Accidental food exposures are common and unpredictable
Peanuts (Beware Atrovent) Tree nuts Shellfish Fish Milk Egg Soy Wheat
Patients at risk:
Peanut and tree nut allergy Asthma Prior anaphylaxis
Geographical
Honeybees, yellow jackets most common in East, Midwest, and West regions of US Wasps, fire ants most common in Southwest and Gulf Coast
Hymenoptera
Immunotherapy-induced Anaphylaxis
Risk management
Trained physician, equipped facility Epinephrine immediately available Monitor closely for 2030 minutes Consider supply of EpiPen for those at high risk
Latex gloves, especially powdered gloves BVM, ETT, IV Tubing and Caths. Nasal Canulas, NRBs.
Risk Groups
Patient Risk Groups
Patients with spina bifida and congenital genitourinary abnormalities
18-73%
Health care workers (housekeepers, lab workers, dentists, nurses, physicians) Rubber industry workers Atopic patients (asthma, rhinitis, eczema)
Patients who have undergone multiple procedures
3-17%
11%
6.8%
6.5%
Latex-induced Anaphylaxis
Hypoallergenic The "hypoallergenic" label generally means that gloves are low in chemical contact sensitizers, but "hypoallergenic" does not refer to latex allergens.
Reactions to Latex
Irritant contact dermatitis Dry, itchy, irritated hands Allergic contact dermatitis Delayed hypersensitivity
Latex allergy
Immediate hypersensitivity Sx: hives, itching, sneezing, rhinitis, dyspnea, cough, wheezing Greatest risk with mucosal contact
Accidental exposure
Patients at risk
Go Latex Free at agency Educate re: EpiPen use Develop emergency action plan
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
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 include angioedema 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.
Idiopathic
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
Diagnosing Anaphylaxis
Careful history to identify possible causes Can be confirmed by serum tryptase
Diagnosing Anaphylaxis
Allergists can identify specific causes by:
Skin tests/RAST Foods Insect venoms
Effective September 9th, 2003: EpiPen may now be carried by BLS agencies with medical director approval and QA
No Medical Director, may only assist the pt with their Epi Pen
Treatment of Anaphylaxis
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
Treatment of Anaphylaxis
Broncheodiators
Albuterol MDI or Neb
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?
EpiPen
2-Pak
Tree Nuts
Severity depends on: Sensitivity of the individual Dose of the allergen Anaphylactoid vs Anaphylactic
Myth: Anaphylaxis is Easy to Avoid If You Know What You are Allergic To
REALITY:
Most cases of anaphylaxis are due to accidental exposures Clinical studies have found repeatedly that, even when patients attempt strict avoidance of a known allergen, their efforts are rarely 100% successful.