1. Allergic Reactions & Anaphylaxis EMS Professions Temple College

2. Incidence l In USA - 400 to 800 deaths/year l Parenterally administered penicillin accounts for 100 to 500 deaths per year l Hymenoptera stings account for 40 to 100 deaths per year l Risk factors: beta-blockers, adrenal insufficiency

3. Causes of Deaths l Laryngeal edema and acute bronchospasm with respiratory failure account for >70% l Circulatory collapse accounts for 25% l Other <5% - ?brain ?MI

4. Allergic Reaction l  Physiologic response to antigens –Oversensitive response = allergic –Occurs after sensitization to antigen l Antigen binds with Antibody –Less severe result in inflammatory response –Type I reaction involves antibodies attached to mast cells or basophils = most severe form

5. Anaphylaxis l Systemic reaction of multiple organ systems to antigen-induced IgE-mediated immunulogic mediator release in previously sensitized individual

6. Allergic Reaction l Antigen –Induces antibody formation –Examples »Drugs (antibiotics) »Foods (nuts, shellfish) »Insect venoms »Animal serum »Incompatible blood types

7. Anaphylaxis l Antigens enter body by: –Injection –Ingestion –Inhalation –Absorption

8. Anaphylaxis Pathophysiology l Antigen enters body l Antibodies produced l Attach to surface of mast or basophil cells l Mast cells become sensitized

9. Anaphylaxis Pathophysiology l Mast cells –In all subcutaneous/submucosal tissues, –Including conjunctiva, upper/lower respiratory tracts, and gut l Basophils –Circulate in blood

10. Anaphylaxis Pathophysiology l Antigen reenters body l Attaches to antibodies on mast or basophil cells l Mast cell degranulates, releases –Histamine –Leukotrienes –Slow reacting substance of anaphylaxis (SRS-A) –Eosinophil chemotactic factor (ECF)

11. Histamine l Three histamine receptor types: –H1 –H2 –H3

12. Histamine l Acts on H1 receptors to cause –Smooth muscle contraction –Increased vascular permeability –Prostaglandin generation

13. Histamine l Acts on H2 receptors to cause –Increased vascular permeability –Gastric acid secretion –Stimulation of suppressor lymphocytes –Decreased PMN enzyme release –Release of more histamine from mast cells and basophils

14. Histamine l Acts on H3 receptors to cause –Inhibition of central, peripheral nervous system neurotransmitter release –Inhibition of further histamine formation, release

15. Vasodilation l Decreased peripheral vascular resistance l Hypotension l Tachycardia l Peripheral hypoperfusion

16. Increased Capillary Permeability l Tissue edema, urticaria (hives), itching l Laryngeal edema –Airway obstruction –Respiratory distress –Stridor l Fluid leakage from vascular space –Hypovolemic shock

17. Urticaria

18. Smooth Muscle Spasm l Bronchospasm –Respiratory distress –“Tight Chest” –Wheezing l GI Tract Spasm –Nausea, vomiting –Cramping, diarrhea l Bladder Spasm –Urinary urgency –Urinary incontinence

19. Anaphylactic Reaction l Leukotrienes –Potent bronchoconstrictors,  vascular permeability & possibly coronary vasoconstriction –Slower onset than histamine –Effects last longer than histamine

20. Allergic Reactions l Generally classified into 3 groups: –Mild allergic reaction –Moderate allergic reaction –Severe allergic reaction (anaphylaxis)

21. Mild Allergic Reaction l Characteristics –Urticaria (hives), itchy –Erythema (redness) –Rhinitis –Conjunctivitis –Mild bronchoconstriction –Usually localized (look on abdomen, chest, back) l No SOB or hypotension/hypoperfusion l Often self-treated at home

22. Moderate Allergic Reaction l Characteristics –Mild signs/symptoms with any of following: »Dyspnea, possibly with wheezes »Angioneurotic edema »Systemic, not localized l No hypotension/hypoperfusion

23. Severe Allergic Reaction (Anaphylaxis) l Characteristics –Mild and/or moderate signs/symptoms plus –Shock / hypoperfusion

24. Clinical Manifestation l Dependent on: –Degree of hypersensitivity –Quantity, route, rate of antigen exposure –Pattern of mediator release –Target organ sensitivity and responsiveness

25. Clinical Manifestation l Severity varies from mild to fatal l Most reactions are respiratory, dermatologic l Less severe early findings may progress to life- threatening over a short time l Initial signs/symptoms do NOT necessarily correlate with severity, progression, duration of response l Generally, quicker symptoms = more severe reactions

26. Clinical Manifestation l First manifestations involve skin –Warmth and tingling of the face, mouth, upper chest, palms and/or soles, or site of exposure –Erythema –Pruritus is universal feature, erythema –May be accompanied by generalized flushing, urticaria, nonpruritic angioedema

27. Clinical Manifestation l May progress to involvement of respiratory system –cough –chest tightness –dyspnea –wheezing –throat tightness –dysphagia –hoarseness

28. Clinical Manifestation l Other Signs and Symptoms –lightheadedness or syncope caused by hypotension or dysrhythmia –nasal congestion and sneezing –ocular itching and tearing –cramping abdominal pain with nausea,vomiting, or diarrhea –bowel or bladder incontinence –decreased level of consciousness

29. Clinical Manifestation l Physical Exam findings may include –urticaria, angioedema, rhinitis, conjunctivitis –tachypnea, tachycardia, hypotension –laryngeal stridor, hypersalivation, hoarseness, angioedema

30. Insect Sting Hypersensitivity l Hymenoptera - yellow jackets, honeybees, hornets, wasps, bumble bees l 90%: Local hives, pruritus l 10%: Massive local reaction, including swelling beyond two joints of extremity l 1%: Systemic reaction l 10%: have worse reaction on second sting l 28%: have recurrent systemic reaction

31. Management l Treatment depends upon severity of reaction and signs/symptoms of its presentation

32. Management l Optimal management requires –High index of suspicion (suspect, treat within minutes) –Early diagnosis –Pharmaceutical intervention –Observation –Disposition

33. Patient Self-Management l Benadryl 50 mg p.o. l At any sign of anaphylaxis, self-administer subcutaneous epinephrine (Epi-Pen®, Ana- Kit®) l If short of breath or wheezing, use aerosolized epinephrine (Primatene Mist, Medihaler-Epi)

34. Mild Allergic Reaction l Often self-treated at home l Diphenhydramine 25 - 50mg PO or IM –IV is acceptable but should include transport l If stinger present, flick it away with credit card or fingernail l May consider (if available and indicated): –cimetidine or ranitidine –prednisone –inhaled beta-agonists

35. Moderate Allergic Reaction l High flow oxygen l IV NS –Titrated to systolic BP 90 mm Hg l ECG monitor l Beta agonists –Nebulized albuterol, isoetharine, terbutaline –SQ terbutaline or epinephrine 1:1000 or IV aminophylline if severe bronchoconstriction l Diphenhydramine 25-50 mg IM or IV l Methylprednisolone 125 mg IV l Transport

36. Anaphylaxis l Airway and Breathing –High concentration oxygen –Ventilations, ETT, alternative airway prn –Consider inhaled beta agonists l Circulation –Large bore IV NS X 2 –Quickly titrate fluids to perfusion with bolus therapy –ECG monitor l Treat as pre-arrest patient

37. Anaphylaxis l Epinephrine 0.5 - 1.0 mg 1:10,000 IV prn –Hypotension unresponsive to fluids and epinephrine  consider dopamine ~10 mcg/kg/min –Bronconstriction unresponsive to Epi  consider aminophylline l Diphenhydramine 50 mg IV l Methylprednisolone 125 mg IV l Consider MAST if unresponsive to fluids l Rapid transport

38. Disposition l Regardless of response to therapy, all patients with systemic features must be observed for 6 to 8 hours

39. Latex Allergies l Due to a growing number of persons experiencing latex allergies, EMS providers should be prepared to treat patients with such allergies –Have latex free equipment –Use the patient’s latex free supplies

40. Case Presentation #1 l You are dispatched to an electronics manufacturing plant to see a 28-year-old woman. The woman believes she is having an allergic reaction. Security officers will meet you at the front gate and escort you to the patient. What specific information would you like at this point?

41. Case Presentation #1 l You find this patient in an office area sitting at her desk. From a distance, you notice she is awake and speaking clearly. She does not appear to have any breathing difficulty. She states she had just returned from lunch and began to feel hot and light headed. Her friend pointed out that the patient’s arms and neck are very red, and that her face appears “puffy”.

42. Case Presentation #1 l The patient states she is allergic to peanuts but has not eaten any. She went to a health food café where she had grilled chicken and steamed vegetables. She has no other past history and takes no medications. Her last allergic rx was similar to this. Vitals are: BP-116/70; Pulse-100; RR-20; Lung sounds-clear and equal. No difficulty swallowing, redness to her arms, chest, neck and face. Would you like to perform any other procedures/exams/testing or obtain other history before treating?

43. Case Presentation #1 So, what is your complete treatment plan for this patient?

44. Case Presentation #2 39 year-old male found at home in respiratory arrest with a bradycardic carotid pulse. His wife states he was helping a friend paint when he was apparently stung by a bee. He walked into the house, saying “I don’t feel good,” and collapsed.

45. Case Presentation #2 l PMH: depression, gastritis, seasonal allergies l Medications: Ritalin, Zantac, Prozac, Claritin l No known drug allergies l No prior reactions to hymenoptera What therapies would you like to begin for this man?

46. Case Presentation #2 l You have done the following: –intubated orotracheally –administered intravenous epinephrine, 0.5 mg & diphenhydramine 50 mg –started 2 large-bore IVs of NS and given 500 cc fluid l At this point, the patient no longer has a pulse

47. Case Presentation #2 l You begin CPR and give the following: –Dopamine drip at 10 mcg/kg/min –Epinephrine, 1:10,000, 1 mg IV q 3-5 min l You now note the following: –ECG: Idioventricular rhythm –Lung Sounds: difficult to hear –Obvious facial edema Can you think of any ideas for further treatment?

48. How to avoid future stings 1. Don’t “smell like a rose” - avoid scented soaps and fragrances 2. Wear garments that fit close to the body. Insects can become trapped in loose-fitting clothing and will sting defensively. 3. Wear shoes outdoors at all times, in addition to long pants and long-sleeved shirts.

49. How to avoid future stings brown 4. Wear clothing in colors not attractive to bees: white, red, grey. Avoid floral designs and brown clothing, which may mimic the color of the bee’s natural predator, the brown bear. 5. Wasp or hornet nests or beehives near the home should be destroyed by a professional exterminator.

50. How to avoid future stings 6. Stay away from insect feeding grounds: flower beds, fields of clover, garbage, orchards with ripe fruit. 7. Avoid outdoor picnics.