Anaphylaxis and Syncope Communicable Disease Control – Population, Public and Indigenous Health Anaphylaxis and Syncope September 3, 2019

Communicable Disease Control – Population, Public and Indigenous Health Anaphylaxis Anaphylaxis is a potentially life-threatening allergic reaction Very rare (about 1 per 1,000,000 doses) but even so, it should be anticipated with every client Pre-immunization screening can prevent episodes – ask questions about possible allergy to the vaccine or any vaccine component Every immunizer should be familiar with the symptoms of anaphylaxis and be ready to initiate appropriate interventions Most instances begin within 15 minutes after immunization All clients are encouraged to wait for 15 minutes after immunization For clients with any known anaphylactic allergies, extend this recommended wait period to 30 minutes Have clients remain within a short distance and return immediately for assessment if they feel unwell

Anaphylaxis recognition & treatment Communicable Disease Control – Population, Public and Indigenous Health Anaphylaxis recognition & treatment The immunizer must: be able to identify allergic reactions and anaphylaxis, and know how to respond appropriately be able to distinguish between fainting, breath-holding spells, anxiety, and anaphylaxis always have an up-to-date anaphylaxis kit readily available when immunizing

Histamines – do what?? They cause: Communicable Disease Control – Population, Public and Indigenous Health Histamines – do what?? They cause: - Capillary permeability and therefore the escape of plasma into the tissues - Widespread dilatation of arterioles and capillaries (vasodilation) - Bronchial smooth muscle contraction - Over secretion by mucous glands Histamines are mediators of hypersensitivity reactions including anaphylaxis.

… which is why we see these symptoms… Communicable Disease Control – Population, Public and Indigenous Health … which is why we see these symptoms… Respiratory: dyspnea - wheezing - sneezing choking - drooling cyanosis – angioedema - tightness in throat/chest Dermatologic (skin): urticaria - erythema - pruritus flushing - pale/grey - facial swelling tingling of mouth or face followed by a feeling of warmth

... and these symptoms... Vascular Collapse (cardiovascular) Communicable Disease Control – Population, Public and Indigenous Health ... and these symptoms... Vascular Collapse (cardiovascular) rapidly falling blood pressure sweating rapid, thready pulse a feeling of uneasiness, restlessness or anxiety weakness or dizziness throbbing in the ears or a headache Gastrointestinal: nausea, vomiting diarrhea abdominal cramps

Anaphylactic shock intervention Communicable Disease Control – Population, Public and Indigenous Health Anaphylactic shock intervention The Initial Response … Call for help Lie the client on his/her back with feet elevated, if possible Loosen restrictive clothing around the neck Establish an adequate airway Note the time

What would you do? Would you give this child epinephrine? Communicable Disease Control – Population, Public and Indigenous Health What would you do? Would you give this child epinephrine? Why or why not? If in doubt, give!

Prompt administration of epinephrine is essential Communicable Disease Control – Population, Public and Indigenous Health Prompt administration of epinephrine is essential Refer to your local Anaphylaxis Management Guideline and information in your anaphylaxis kit for direction on how to proceed with administration of epiNEPHrine and diphenhydramine hydrochloride (e.g., Benadryl®) Remember: Failure to administer epiNEPHrine promptly is more dangerous than administering it in a situation where anaphylaxis is not truly present!

Syncope post immunization Communicable Disease Control – Population, Public and Indigenous Health Syncope post immunization Fainting is also known as syncope or vasovagal syncope Vasovagal syncope is triggered by a stimulus (anxiety) that causes an exaggerated response in the part of the nervous system that regulates involuntary body functions (like heart rate and blood flow) When a stimulus triggers an exaggerated response, both heart rate and blood pressure drop, quickly reducing blood flow to the brain and leading to loss of consciousness

Syncope post immunization Communicable Disease Control – Population, Public and Indigenous Health Syncope post immunization In about 25% of cases, reduced blood flow can result in jerking movements that resemble seizures These movements are more common when fainting occurs soon after immunization, and disappear when consciousness is regained Clients fainting due to vasovagal syncope recover quickly, usually within seconds or a few minutes

Signs and symptoms of syncope Communicable Disease Control – Population, Public and Indigenous Health Signs and symptoms of syncope Musculoskeletal muscles relaxed weakness incontinence (rare) clonic jerks of limbs and face Respiratory normal or yawning Dermatologic pallor/grey color - sweating

Signs and symptoms of syncope (cont’d) Communicable Disease Control – Population, Public and Indigenous Health Signs and symptoms of syncope (cont’d) Gastrointestinal vomiting nausea Cardiovascular hypotension, slow weak pulse ringing in ears Neurological light headedness, dizziness spots before the eyes dazed unconsciousness

Communicable Disease Control – Population, Public and Indigenous Health Facts about syncope There is a clear incidence peak in age 10 to 19 years, with a smaller peak at age 4-6 years - After the age of 20 years, the incidence decreases with age 57.5% of syncopal episodes occur in females The incidence of fainting is under-reported Most cases occur within 5 minutes of immunization Fainting can result in head trauma if a client falls The goal is to prevent falls!

Tips to prevent syncope Communicable Disease Control – Population, Public and Indigenous Health Tips to prevent syncope Administer vaccine while client is seated Maintain a calm and confident demeanor Observe anxious client until anxiety has resolved after immunization Have clients with a history of fainting lie down prior to administering vaccine Clients with pre-syncopal symptoms (such as dizziness, anxiety, pallor, perspiration, trembling, or cool, clammy skin) should sit or lie down until symptoms resolve

Assisting clients after syncope Communicable Disease Control – Population, Public and Indigenous Health Assisting clients after syncope Assist the client to lay down with feet elevated Ensure the client’s airway is open (ABCs) Monitor for signs of allergic reaction Call for assistance if needed Cover the client with a blanket for warmth if available Wipe the client’s forehead with a damp cool cloth May offer fluids Have the client resume a standing position in stages (sit, stand, walk) Observe the client until the symptoms have resolved

Anxiety spells Signs and Symptoms - Fearful - Pale - Diaphoretic Communicable Disease Control – Population, Public and Indigenous Health Anxiety spells Signs and Symptoms - Fearful - Pale - Diaphoretic - Complains of light headedness, dizziness, numbness, and tingling of face and extremities - Hyperventilation Treatment - Reassurance - Instruct to relax and breathe slowly

Breath holding Occurs in young children when upset Signs and symptoms: Communicable Disease Control – Population, Public and Indigenous Health Breath holding Occurs in young children when upset Signs and symptoms: - Suddenly become quiet but still very agitated - Facial flushing & perioral cyanosis - Often ends with resumption of crying, or a brief period of unconsciousness during which time breathing resumes Treatment - Reassurance

Anaphylaxis and Syncope Knowledge Check Communicable Disease Control – Population, Public and Indigenous Health Anaphylaxis and Syncope Knowledge Check Review Questions 1. What is the incidence of anaphylaxis after immunization? 2. Should you withhold epiNEPHrine if you are not completely sure whether the client is experiencing anaphylaxis? 3. What is the percentage of people who experience jerking movements that resemble seizures after fainting? Note: Answers can be found at the end of the power point.

Communicable Disease Control – Population, Public and Indigenous Health Answer Key Anaphylaxis & Syncope Knowledge Check Answers 1. What is the incidence of anaphylaxis after immunization? Although anaphylaxis is very rare with an incidence of about 1 per 1,000,000 doses, it should be anticipated with every client. 2. Should you withhold epinephrine if you are not completely sure whether the client is experiencing anaphylaxis, but you are pretty certain? No. Prompt administration of epinephrine is essential. Refer to your local Anaphylaxis Guideline and information in your anaphylaxis kit for direction on how to proceed with administration of epinephrine and diphenhydramine hydrochloride (e.g., Benadryl®). Failure to administer epinephrine promptly is more dangerous than administering it in a situation where anaphylaxis is not truly present! 3. What is the percentage of people who experience jerking movements that resemble seizures after fainting? In about 25% of cases, reduced blood flow can result in jerking movements that resemble seizures. These movements are more common when fainting occurs soon after immunization and disappear when consciousness is regained.