Anaphylaxis

Are we bugging you?

Steve Cole, CCEMT-P Ada County Paramedics

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

Onset generally acute Manifestations vary from mild to fatal

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 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

Subsequent anaphylactic response

 Antigen (allergen) exposure

Sensitization Stage
Antigen

Plasma cells produce IgE antibodies against the allergen

Plasma cell

IgE Mast cell with fixed IgE antibodies Granules containing histamine

IgE antibodies attach to mast cells and basophils

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

Histamine and other mediators

Common Causes of IgE-mediated Anaphylaxis

Foods Insect venoms Latex Medications Immunotherapy Insect venom Inhalant allergens

Anaphylactoid Reactions
NonIgE-mediated

Complement-mediated Anaphylatoxins, eg, blood products

Direct stimulation
eg, radiocontrast media Mechanism unknown

Exercise
NSAIDs

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

Clinical Manifestations of Anaphylaxis

Gastrointestinal tract:

Oral pruritus Cramps, nausea, vomiting, diarrhea

Cardiovascular system:

Tachycardia, bradycardia, hypotension/shock, arrhythmias, ischemia, chest pain

Clinical Manifestations of Anaphylaxis

Urticaria Angioedema Upper airway edema Dyspnea and wheezing Flush Dizziness, syncope, and hypotension Gastrointestinal symptoms Rhinitis Headache Substernal pain Itch without rash
Pruritus

Seizure

Clinical Course of Anaphylaxis

Uniphasic
Biphasic

Recurrence up to 8 hours later

Different in Peds
Descriptions and perceptions are different

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)

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

Food-induced Anaphylaxis: Common Triggers

Children and adults (usually not outgrown):

Peanuts (Beware Atrovent) Tree nuts Shellfish Fish Milk Egg Soy Wheat

Additional triggers in children (commonly outgrown):

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

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

Fatal Food-induced Anaphylaxis

(Bock SA, et al. JACI 2001;107:191193)

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

Venom-induced Anaphylaxis: Incidence

0.5%5% (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

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

Hymenoptera

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

30%60% of patients will experience a systemic reaction with subsequent stings

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

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

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

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-induced Anaphylaxis: Incidence

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

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.

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

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

Latex-induced Anaphylaxis: Prevention

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 Avocado Chestnuts

Kiwi Stone fruit Others

Latex-induced Anaphylaxis: Prevention

RISK MANAGEMENT
Prescribe EpiPen or EpiPen Jr

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.

Other Causes of Anaphylactic and Anaphylactoid Reactions

Drugs
Antibiotics Chemotherapeutic agents Aspirin, NSAIDs Streptokinaise Biologicals (vaccines, monoclonal antibodies)

Radiocontrast media (iodine)

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

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

Diagnosing Anaphylaxis
Allergists can identify specific causes by:
Skin tests/RAST Foods Insect venoms

Drugs Challenge tests Foods NSAIDs Exercise

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

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 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

Must undergo upgrade module

About 1-2 hours Skills test

EpiPen/EpiPen Jr: Directions for Use

EpiPen/EpiPen Jr: Directions for Use

EpiPen/EpiPen Jr: Directions for Use

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

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 H2 blocker if Sx persist

Screening Patients at Risk

Did 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?

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

 EpiPen

2-Pak

* EpiPen 2-Pak was launched in April 2001

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 Predict Future Reactions

REALITY:
No predictable pattern

Severity depends on: Sensitivity of the individual Dose of the allergen Anaphylactoid vs Anaphylactic

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 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.

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

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

Myth: The Cause of Anaphylaxis is Always Obvious

REALITY:
Idiopathic anaphylaxis is common Triggers may be hidden
Foods
Latex

Patient may not recall details of exposure, clinical course

Myth: Prior Episodes Predict Future Reactions

REALITY:
No predictable pattern

Severity depends on: Sensitivity of the individual Dose of the allergen

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