Anaphylaxis

Pavlo Razumnyi, MD, International SOS Physician

Allergic reactions
 Allergic reactions
 Allergic reactions can occur at any time and to
anyone

 A natural response of the human body’s immune

system is to react to any foreign substance—in
other words, to defend the body by neutralizing
or getting rid of the foreign material

 Sometimes the immune response is exaggerated;

this exaggerated reaction is called an allergic
reaction
 Allergic reactions
 A wide variety of substances can produce
such reactions

 Foods, medications, insect stings — even

exercise — are common causes

 An allergen can enter the body in four ways:

ingestion, injection, inhalation, or absorption
through the skin or mucous membranes
 Allergic reactions

An allergic reaction may

include

 a runny nose
 mild skin rash
 local/facial swelling
 hives - red, itchy, possibly
raised blotches
on the skin
.
Allergic reactions
Anaphylaxis
 Anaphylaxis
 At the other end of the spectrum, however, is
the life-threatening allergic reaction that is
known as an anaphylactic reaction

 Anaphylactic shock is a life-threatening medical

emergency

 Severe cases may result in complete obstruction

of the airway, cardiovascular collapse, and death
 Anaphylaxis=Anaphylactic
shock

 Anaphylaxis is a severe or life-threatening

allergic reaction in which the blood vessels
dilate, causing a drop in blood pressure, and the
tissues lining the respiratory system swell,
interfering with the airway

 Also called anaphylactic shock

 Anaphylaxis
Signs and Symptoms
 Serious upper airway (laryngeal) edema, lower
airway edema (asthma), or both may develop,
causing stridor and wheezing.
 Rhinitis
 Cardiovascular collapse is the most common
peri-arrest manifestation
 Gastrointestinal signs and symptoms of
anaphylaxis include abdominal pain, vomiting,
and diarrhea
Anaphylaxis
Signs and
Symptoms
 Anaphylaxis
Signs and Symptoms
 Anaphylaxis
Signs and Symptoms
 Anaphylaxis
Signs and Symptoms
 Anaphylaxis
Signs and Symptoms
Allergic reaction/Anaphylaxis
Signs and Symptoms
Anaphylaxis = Anaphylactic
shock
Anaphylaxis
 Allergic Reaction First Aid
If the patient has come in contact with a
substance that is causing an allergic reaction
without signs of respiratory distress or shock:

Maintain an open airway (ABC)

Give oxygen
Arrange for patient transport, and reassess
while waiting for the arrival of EMS personnel
 Anaphylaxis First Aid
Calm and reassure the person

Call emergency medical help

Get the person in a comfortable position and elevate

his or her legs

Check the person's pulse and breathing (ABC) and, if

necessary, administer CPR or other first-aid measures
Anaphylaxis First Aid
 Anaphylaxis First Aid
If the patient has come in contact with a
substance that caused a past allergic reaction and
complains of respiratory distress or shows signs
and symptoms of shock:

 Perform a primary assessment

 Treat all life threats (ABC)
 Be prepared to provide basic life support (BLS) if it is
needed
 Anaphylaxis First Aid
Establish and maintain an open airway. The
patient with an allergic reaction may initially
present with airway or respiratory compromise,
or airway or respiratory compromise may
develop as the reaction progresses

Make sure suction equipment is within arm’s

reach
 Anaphylaxis First Aid
Give oxygen

If you are equipped and allowed to do so,

administer 100% high-flow oxygen

If the patient’s breathing is adequate, apply

oxygen by nonrebreather mask at 10 to 15 L/min
if not already done
 Anaphylaxis First Aid
Remove exposure to the trigger

If the allergic reaction is from a bee sting,

scrape the stinger off the skin with something
firm (such as a fingernail or plastic credit card)

Do not use tweezers. Squeezing the stinger will

release more venom
 Anaphylaxis First Aid
Removal of venom sac. Insect envenomation by bees
(but not wasps) may leave a venom sac attached to
the victim’s skin

At some point during initial assessment, look at the

sting site, and if you see a stinger, immediately scrape
it or any insect parts at the site of the sting, using the
dull edge of a knife

 Avoid compressing or squeezing any insect parts near

the skin because squeezing may increase
envenomation
 Anaphylaxis First Aid
Assist the patient with his or her medication.
Medications may include an epinephrine auto-
injector (EpiPen) or antihistamines

Find out if the patient has a prescribed

epinephrine autoinjector available

After administration, reassess the patient in 2

minutes. Record reassessment findings, and
prepare the patient for transportation
 Anaphylaxis First Aid
Give medications to treat an allergy attack, such
as an epinephrine autoinjector or antihistamines,
if the person has them

If the person has emergency allergy medicine on

hand, help the person take or inject it.

Do not give medicine through the mouth if the

person is having difficulty breathing
 Anaphylaxis First Aid

An anaphylaxis kit

contains an
epinephrine autoinjector

Some kits also contain

a metered-dose inhaler
What to do in an emergency
Anaphylaxis First Aid
 Anaphylaxis First Aid
 Reassess every 5 min. If the patient’s condition
improves, provide supportive care

 Signs that indicate the patient’s condition is worsening

include decreasing mental status, increasing breathing
difficulty, and decreasing blood pressure. Treat for shock

 Be prepared to deliver basic life support (BLS) to begin

cardiopulmonary resuscitation (CPR) and use the
automated external defibrillator (AED), if necessary
 Anaphylaxis First Aid
DO NOT:
Do not assume that any allergy shots the person
has already received will provide complete
protection
Do not place a pillow under the person's head if
they are having trouble breathing. This can block
the airways
Do not give the person anything by mouth if they
are having trouble breathing
Causes of Upper Airway obstruction
 Anaphylaxis First Aid

FA providers may correction of the blocked

airway by using deferent maneuvers

FA providers may place a tube through the nose

or mouth into the airways
Correction of the blocked
Airway
Follow these steps to perform the head tilt-chin lift
maneuver:

place the patient on his or her back and kneel

beside the patient

place one hand on the patient’s forehead and apply firm

pressure backward with your palm

move the patient’s head back as far as possible

place the tips of the fingers of your other hand under the
bony part of the lower jaw near the chin

lift the chin forward to help tilt back the head

Correction of the blocked
Airway
Follow these steps to perform the jaw-thrust maneuver:
Place the patient on his or her back and kneel at the top of
the patient’s head. Place your fingers behind the angles of the
patient’s lower jaw and move the jaw forward with firm
pressure

Tilt the head backward to a neutral or slight sniffing

position. Do not extend the cervical spine in a patient who has
sustained an injury to the head or neck

Use your thumbs to pull down the patient’s lower jaw,

opening the mouth enough to allow breathing through the
mouth and nose
Correction of the blocked Airway
 Look in the mouth
 Remove any blood, vomit, debris
(broken teeth, bone fragments) or
foreign bodies from the mouth,
without pushing them further into the
airway

 If the patient’s mouth is clear,

consider using one of the airway
devices
 Oral Airway
An oral airway has two primary
purposes:

it is used to maintain the patient’s

airway after you have manually
opened the airway

it functions as a pathway through

which you can suction the victim
 Oral Airway
 Oral airways can be used for
unconscious victims who are breathing
or who are in respiratory arrest
(sudden stoppage of breathing)

 An oral airway can be used in any

unconscious victim who does not have
a gag reflex

 Oral airways cannot be used in

conscious victims because they have a
gag reflex
 Oral Airway

Select the proper size airway by

measuring from the victim’s earlobe
to the corner of the mouth

Open the victim’s mouth with one

hand after manually opening the
patient’s airway with a head tilt-chin
lift or jaw-thrust maneuver
 Oral Airway
 Hold the airway upside down with your
other hand

 Insert the airway into the patient’s

mouth and guide the tip of the airway
along the roof of the patient’s mouth,
advancing it until you feel resistance

 Rotate the airway 180° until the flange

comes to rest on the victim’s teeth or lips
Assessing and Managing an Allergic
Reaction
Assessing and Managing an Allergic
Reaction
Assessing and Managing an Allergic
Reaction
Assessing and Managing an Allergic
Reaction
Assessing and Managing an Allergic
Reaction
Assessing and Managing an Allergic
Reaction
Assessing and Managing an Allergic
Reaction
Assessing and Managing an Allergic
Reaction
Assessing and Managing an Allergic
Reaction
Assessing and Managing an Allergic
Reaction
Anaphylaxis
 Prevention

 Avoid triggers such as

foods and medicines that
have caused an allergic
reaction in the past.

 Ask detailed questions

about ingredients when
you are eating away from
home. Also carefully
examine ingredient label
 Prevention

 People who know that

they have had serious
allergic reactions should
wear a medical ID tag
 Prevention

 If you have a history of serious allergic reactions,

carry emergency medicines (such as a chewable
antihistamine and injectable epinephrine or a bee
sting kit) according to your provider's instructions

 Do not use your injectable epinephrine on anyone

else. They may have a condition (such as a heart
problem) that could be worsened by this drug
Thank You
 Treatments and drugs
 During an anaphylactic attack, an emergency medical
team may perform cardiopulmonary resuscitation (CPR)
if you stop breathing or your heart stops beating. You
may be given medications including:

 Epinephrine (adrenaline) to reduce your body's allergic

response
 Oxygen, to help compensate for restricted breathing
 Intravenous (IV) antihistamines and cortisone to reduce
inflammation of your air passages and improve breathing
 A beta-agonist (such as albuterol) to relieve breathing
symptoms
 Treatments and drugs
 Oxygen. Administer oxygen at high flow rates.

 Epinephrine
• Administer epinephrine by IM injection early to all
patients with signs of a systemic reaction, especially
hypotension, airway swelling, or definite difficulty
breathing.

• Use an IM dose of 0.3 to 0.5 mg (1:1000) repeated

every 15 to 20 minutes if there is no clinical
improvement
 Treatments and drugs
 Administer IV epinephrine if anaphylaxis appears to
be severe with immediate life-threatening
manifestations

 Use epinephrine (1:10 000) 0.1 mg IV slowly over 5

minutes. Epinephrine may be diluted to a 1:10 000
solution before infusion

 An IV infusion at rates of 1 to 4 µg/min may prevent

the need to repeat epinephrine injections frequently
Treatments and drugs
 Treatments and drugs
Patients who are taking ß-blockers have
increased incidence and severity of
anaphylaxis and can develop a paradoxical
response to epinephrine

 Consider glucagon as well as ipratropium for

these patients
 Treatments and drugs
Aggressive fluid resuscitation. Give isotonic crystalloid
(eg, normal saline) if hypotension is present and does
not respond rapidly to epinephrine. A rapid infusion of
1 to 2 L or even 4 L may be needed initially

Antihistamines. Administer antihistamines slowly IV or

IM (eg, 25 to 50 mg of diphenhydramine)

H2 blockers. Administer H2 blockers such as

cimetidine (300 mg orally, IM, or IV)
 Inhaled ß-adrenergic agents
 Provide inhaled albuterol if bronchospasm is a major
feature

 Inhaled ipratropium may be especially useful for

treatment of bronchospasm in patients receiving ß-
blockers

 Note that some patients treated for near-fatal asthma

actually had anaphylaxis, so they received repeated
doses of conventional bronchodilators rather than
epinephrine
 Treatments and drugs

Corticosteroids Infuse high-dose IV

corticosteroids early in the course of therapy.
Beneficial effects are delayed at least 4 to 6
hours
 Potential Therapies
 Vasopressin. There are case reports that vasopressin
may benefit severely hypotensive patients.

 Atropine. Case reports suggest that when relative or

severe bradycardia is present, there may be a role for
administration of atropine.

 Glucagon. For patients who are unresponsive to

epinephrine, especially those receiving ß-blockers,
glucagon may be effective. This agent is short-acting;
give 1 to 2 mg every 5 minutes IM or IV. Nausea,
vomiting, and hyperglycemia are common side effects
 Observation
Symptoms may recur in some patients (up to
20%) within 1 to 8 hours (biphasic response).
Biphasic responses have been reported to
occur up to 36 hours after the initial reaction.
A patient who remains symptom-free for 4
hours after treatment may be discharged.
Severity of reaction or other problems,
however, may necessitate longer periods of
observation.
 Airway Obstruction
Early elective intubation is recommended
for patients observed to develop hoarseness,
lingual edema, stridor, or oropharyngeal
swelling.
Patients with angioedema pose a particularly
worrisome problem because they are at high
risk for rapid deterioration
 Patients can deteriorate over a brief
period of time ( to 3 hours), with
progressive development of stridor,
dysphonia or aphonia, laryngeal edema,
massive lingual swelling, facial and neck
swelling, and hypoxemia. This may
occur when patients have a delayed
presentation to the hospital or fail to
respond to therapy
 At this point use of either the laryngeal
mask airway or the Combitube will be
ineffective, and endotracheal intubation and
cricothyrotomy may be difficult or impossible.
Attempts at endotracheal intubation may
only further increase laryngeal edema or
cause trauma to the airway
Thank You