Case

1
Case 22

• Jim Pointer, MD, FACEP
• Medical Director
• Alameda County EMS

2
The Call

• You are dispatched to a park where an 18 year
  old female, Anita, has been stung by a yellow
  jacket. She is having a reaction to the sting.

3
History

• The patients boyfriend tells you that Anita has
  a history of allergies to hemoptera stings (smart
  boyfriend) and usually carries an Epi-Pen
• She has one in her purse, but the boyfriend was
  reluctant to use it because the expiration date
  is Dec. 2002 (not-so-smart boyfriend)
• She has no other medical problems, takes only
  birth control pills, and is in good health

4
General Assessment

• A airway is intact, but she has
• perioral edema
• B tachypnea
• C intact
• Vital signs B/P 104/58, HR 162, RR 38,
  Pulse Ox 92 room air

5
Focused Survey

• HEENT facial urticaria, edematous tongue and
  oral mucous membranes
• Lungs bilateral wheezes
• Heart tachycardia
• Abdomen mild generalized tenderness
• Neuro anxious but alert and oriented unable to
  speak in full sentences. GCS 15

6
Focused Survey (cont.)

• Skin extensive wheal flare urticaria
  multiple apparent insect sting lesions on neck,
  face, and upper extremities

7

• What is your assessment of this patient?
• What would be your treatment?

8
In the real case

• 100 O2 by NRM
• IV NS TKO
• Epinephrine 11000, SQ 0.3 cc
• Albuterol nebulizer treatment
• Immediate Transport

9
Questions?

• How much saline?
• What should be the route of the epinephrine?

10
Out-of-Hospital Course

• The patient does not respond to the SQ epi. She
  becomes minimally responsive and the wheezing and
  tachypnea increase.
• Updated vital signs B/P 80/palp, HR 184, RR
  48 shallow, Pulse Ox 90 on O2

11
Further Treatment?

• IV NS, 500 cc as rapidly as possible (why?)
• Epinephrine, IV 110,000 3-5 cc
• Prepare for advanced airway management

12
Hospital Course

• Upon arrival vital signs B/P-128/72, HR 122,
  RR 26 regular, Pulse Ox 98 on O2
• The patient is moving air well and the urticaria
  has partially resolved.
• The ED staff administers an H2 blocker and
  methylprednisolone

13
The Outcome

• The patient is observed for 6 hours in the ED.
  She is discharged with a prescription for
  prednisone and more Epi-Pens.

14
Questions

• What happened physiologically to this patient?
• Did your assessment and treatment affect her
  outcome
• Why and how did your treatment affect her outcome?

15
?2001 DEY B9-508-00 7/01
16
Anaphylaxis Screen, Educate, and Protect to
Improve Patient Outcomes

?2001 DEY B9-508-00 7/01
17
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

18
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)

19
Pathogenesis of Anaphylaxis

• IgE-mediated (Type I hypersensitivity)
• Sensitization stage
• Subsequent anaphylactic response

20
Sensitization Stage
? Antigen (allergen) exposure
Antigen
? Plasma cells produce IgE antibodies
against the allergen
Plasma cell
IgE
Mast cell with fixed IgE antibodies
? IgE antibodies attach to mast cells and
basophils
Granules containing histamine
21
Anaphylactic Reaction
? More of same allergen invades body
Antigen
? Allergen combines with IgE attached to mast
cells and basophils, which triggers degranulatio
n and release of histamine and other chemical
mediators

















































Mast cell granules release contents after antigen
binds with IgE antibodies































.




















































































































































































Histamine and other mediators


22
Common Causes of IgE-mediated Anaphylaxis

• Foods
• Insect venoms
• Latex
• Medications
• Immunotherapy
• Insect venom
• Inhalant allergens

23
Anaphylactoid Reactions

• NonIgE-mediated
• Complement-mediated
• Anaphylatoxins, eg, blood products
• Direct stimulation
• eg, radiocontrast media
• Mechanism unknown
• Exercise
• NSAIDs

24
Myth The Cause ofAnaphylaxis is Always Obvious

• REALITY
• Idiopathic anaphylaxis is common
• Triggers may be hidden
• Foods
• Latex
• Patient may not recall details of exposure,
  clinical course

25
Clinical Manifestations of Anaphylaxis

• Skin Flushing, pruritus, urticaria, angioedema
• Upper respiratory Congestion, rhinorrhea
• Lower respiratory Bronchospasm, throat or chest
  tightness, hoarseness, wheezing, shortness of
  breath, cough

26
Clinical Manifestations of Anaphylaxis

• Gastrointestinal tract
• Oral pruritus
• Cramps, nausea, vomiting, diarrhea
• Cardiovascular system
• Tachycardia, bradycardia, hypotension/shock,
  arrhythmias, ischemia, chest pain

27
Clinical Manifestations of Anaphylaxis
Signs/symptoms Incidence
() Urticaria and angioedema Upper airway
edema Dyspnea and wheezing Flush
Dizziness, syncope, and hypotension Gastrointest
inal symptoms Rhinitis Headache S
ubsternal pain Itch without
rash Seizure Symptom or sign not
reported in all four series
28
Myth Anaphylaxis Always Presents with 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
  not associated with cutaneous signs or symptoms

29
Clinical Course of Anaphylaxis

• Uniphasic
• Biphasic
• Recurrence up to 8 hours later
• Protracted
• Hours to days

30
Myth Prior Episodes Predict Future Reactions

• REALITY
• No predictable pattern
• Severity depends on
• Sensitivity of the individual
• Dose of the allergen

31
Anaphylaxis Fatalities

• Estimated 5001000 deaths annually
• 1 risk
• Risk factors
• Failure to administer epinephrine immediately
• Beta blocker, ?ACEI therapy
• Asthma
• Cardiac disease
• Rapid IV allergen

32
Food-induced Anaphylaxis Incidence

• 3555 of anaphylaxis is caused by food allergy
• 68 of children have food allergy
• 12 of adults have food allergy
• Incidence is increasing
• Accidental food exposures are common and
  unpredictable

33
Food-induced Anaphylaxis Common Triggers

• Children and adults (usually not outgrown)
• Peanuts
• Tree nuts
• Shellfish
• Fish
• Additional triggers in children (commonly
  outgrown)
• Milk
• Egg
• Soy
• Wheat

34
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

35
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

36
Fatal Food-induced Anaphylaxis (Bock SA, et al.
JACI 2001107191193)

• 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

37
Food-induced Anaphylaxis Prevention
I. AVOID ALLERGENS

• Learn to read product labels
• Identify alternative names for ingredients
• Find hidden ingredients
• Avoid high-risk foods (eg, baked goods)
• Avoid sharing food, utensils, or food containers
• Minute amounts can be life-threatening
• Provide educational materials
• FAAN- (www.foodallergy.org)

38
Food-induced Anaphylaxis Prevention
II. RISK MANAGEMENT

• Complete avoidance is impossible
• Must always be prepared to treat a reaction
• Have an emergency action plan
• Keep EpiPen? or EpiPen? Jr on hand at all times
• Train caregivers and teachers on EpiPen? use
• Wear MedicAlert? bracelet

39
Venom-induced Anaphylaxis Incidence

• 0.55 (13 million) Americans are
• sensitive 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 40100 deaths per year

40
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

41
Venom-induced Reactions Common Symptoms

• Normal Local pain, erythema, mild swelling
• Large local Extended swelling, erythema
• Anaphylaxis Usual onset within 1520 minutes
• Cutaneous urticaria, flushing, angioedema
• Respiratory dyspnea, stridor
• Cardiovascular hypotension, dizziness, loss of
  consciousness
• 3060 of patients will experience a systemic
  reaction with subsequent stings

42
Venom-induced Anaphylaxis Prevention
Avoidance Measures What to do What not to
do Have professionals Use scented
products remove hives or nests Wear bright
colors Wear white, smooth- finish clothes,
ankle- Go barefoot high shoes Drink from
open cans Keep outdoor areas free when contents
are not of garbage visible
43
Venom-induced Anaphylaxis Prevention

• Risk Management
• Keep EpiPen? or EpiPen? Jr on hand at all times
• Educate and train on EpiPen? use
• Develop emergency action plan
• Wear a MedicAlert? bracelet
• Consult an allergist to determine need for venom
  immunotherapy

44
Venom-induced Anaphylaxis Immunotherapy

• Medical criteria
• Hx of any systemic reaction in adults
• Hx of life-threatening reaction in children
• Positive venom skin test
• 97 effective
• Can be discontinued in most after 35 years 10
  risk of systemic reaction to subsequent stings

45
Venom-induced Anaphylaxis Immunotherapy

• Risk of anaphylaxis
• 10-15 of patients experience systemic reactions
  during early weeks of treatment
• Sx generally occur within 20 minutes
• Patients at risk asthma, prior reactions, beta
  blocker or ACEI therapy

46
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

47
Latex-induced Anaphylaxis Incidence

• 16 of US population (up to 16 million)
  affected
• 817 incidence among health care workers
• Repeated exposure leads to a higher risk
• Incidence has increased since mid 1980s
• Latex gloves, especially powdered gloves

48
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

49
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

50
Latex-induced Anaphylaxis Prevention
I. AVOIDANCE

• 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

• Banana
• Chestnuts
• Stone fruit

• Kiwi
• Avocado
• Others

51
Latex-induced Anaphylaxis Prevention
II. RISK MANAGEMENT

• Prescribe EpiPen or EpiPen Jr
• Accidental exposure
• Patients at risk
• Educate re EpiPen use
• Develop emergency action plan

52
Other Causes of Anaphylacticand Anaphylactoid
Reactions

• Drugs
• Antibiotics
• Chemotherapeutic agents
• Aspirin, NSAIDs
• Biologicals (vaccines, monoclonal antibodies)
• Radiocontrast media
• Exercise
• Idiopathic

53
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

54
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

55
Diagnosing Anaphylaxis
Allergists can identify specific causes by

• Skin tests/RAST
• Foods
• Insect venoms
• Drugs
• Challenge tests
• Foods
• NSAIDs
• Exercise

56
Treatment of Anaphylaxis

• 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
• Antihistamine (oral or parenteral if oral, use
  liquid or chewable tablet)
• Call 911 proceed to Emergency Room

57
EpiPen?/EpiPen? Jr Directions for Use
58
EpiPen?/EpiPen? Jr Directions for Use
59
EpiPen?/EpiPen? Jr Directions for Use
60
Myth Epinephrine is Dangerous

• REALITY
• 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 cardiac disease

61
Treatment of Anaphylaxis

• Additional measures may include
• Corticosteroids
• Supplemental O2 airway maintenance
• IV fluids, vasopressor therapy
• Repeat epinephrine if Sx persist or increase
  after 10-15 minutes
• Repeat antihistamine H2 blocker if Sx persist
• Observe for a minimum 4 hours
• Arrange follow-up care, provide EpiPen Rx and
  education

62
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

63
Risk Management for Anaphylaxis

• SCREEN
• Atopy
• 10 of children with asthma have food allergy
• 3040 of children with atopic dermatitis have
  food allergy
• Previous reactions
• 75 will have more than one
• 57 will have three or more

64
Screening Patients at Risk

• Did you ever have a severe allergic reaction
• To any food?
• To any medicine?
• To an insect sting?
• To latex?
• That caused breathing trouble? Severe hives and
  swelling? Severe vomiting or diarrhea? Dizziness?
• That required you to go to the hospital?

65
SCREEN, Educate, and Protect Patients at Risk
66
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

67
EpiPen 2-Pak
EpiPen 2-Pak? was launched in April 2001
68
Risk Management for Anaphylaxis

• EDUCATE Draft an Emergency Plan
• Provide specific instructions on when to
  administer EpiPen? or EpiPen? Jr
• Call for help (911) transport patient to
  emergency care facility
• Stay calm keep patient warm
• Specify directions for antihistamine use
• Report EpiPen? administration

69

Screen, Educate, and Protect

• Emergency Health Care Plan
• ALLERGY TO_______________________________________
  ______________________
• Childs
• Name___________________________D.O.B____________
  Teacher___________________
• Asthmatic Yes (High risk for severe
  reaction) No
• Signs of an allergic reaction include
• Systems Symptoms
• MOUTH itching swelling of the
  lips, tongue, or mouth
• THROAT itching and/or a sense of
  tightness in the throat, hoarseness, and hacking
  cough
• SKIN hives, itchy rash,
  and/or swelling about the face or extremities
• GUT nausea, abdominal
  cramps, vomiting, and/or diarrhea
• LUNG shortness of breath,
  repetitive coughing, and/or wheezing
• HEART thready pulse,
  passing-out
• The severity of symptoms can quickly change! All
  above symptoms can potentially progress to a
  life-
• threatening situation!
• ACTION
• 1. If ingestion is suspected
  give______________________________________________
  __
  medication/dose/route
• and________________________
  _____________________________immediately!

Place Childs Picture Here

AAAAI Board of Directors. Position statement
Anaphylaxis in schools and other childcare
settings. J Allergy Clin Immunol
1999102173-176. Reprinted with permission.
70
Myth Anaphylaxis is easy to avoid if you know
what you are allergic to

• REALITY
• Most cases of anaphylaxis are due to accidental
  exposures

71
Risk Management for Anaphylaxis

• PROTECT
• Prescribe self-injectable EpiPen?
• Teach patient proper use of EpiPen?
• Educate family, friends, teachers, caregivers

72
Anaphylaxis

• Screen, educate, and protect
• Immediate treatment
• Saved lives