Transcript Allergic Reaction and Anaphalaxis June 2014

OBJECTIVES
• Understand and define the terms allergic reaction and
anaphylaxis explaining the difference between a local and
systemic reaction.
• Describe the five categories of stimuli that can cause an allergic
reaction or anaphylaxis
• Explain the importance of managing the Airway, Breathing and
Circulation of a patient who is having an allergic reaction.
• Outline the management steps for a patient with a local or mild
allergic reaction
• Outline the management steps for a patient with a severe
systemic allergic reaction/anaphylaxis
IMMUNE SYSTEM
Two distinct, cooperative systems
 Natural/Innate Immune System is a generalized defense system against any
foreign invaders.
 Everyone is born with a functioning Natural/Innate Immune System
 Learned/Acquired Immune System is gained through both passively and
actively being exposed to a foreign pathogen.
 Everyone develops their own Learned/Acquired Immune system specific
to that individual.
INVADERS “IF YOU’RE NOT WITH US,
YOU ARE AGAINST US!”
• What types of things invade the body triggering the immune
system?
• Pathogens – disease producing agent: a virus or other
microorganism
• Antigens– foreign proteins that trigger the release of
antibodies
• Immunogens – a cell or substance that triggers immune
response
DEFENSE SYSTEMS
Natural Immunity (Everyone has)
 Anatomical Barriers – Skin, mucous membranes
 Inflammation
Acquired Immunity (Specific to the individual)
 Antibodies – bind with the receptor site of an antigen,
disabling it and/or signaling of its existence to other
parts of the defense system to be destroyed
ANATOMICAL SURFACE BARRIERS
• First Line of Defense in Immune Response
Skin
First line of defense against any foreign invader
Mucus Membranes at natural openings
Antibacterial
Serve to protect internal systems with open links to the
outside such as the respiratory and gastrointestinal
systems
PROTECTING INTERNAL SYSTEMS
 GI Tract
 Saliva
 Turbulence of swallowing
 Low pH of stomach
 Natural bacteria of gut
 Airway
 Mechanical ejection of pathogens through coughing
 Mucus membrane sloughing
 Urinary Tract
 Acidic
 Antibacterial mucosa
 Sphincters to inhibit backflow
INFLAMMATION
• Second Line of Defense in Immune Response
General – Non specific to the type of invader
All available foot soldiers called into action – Immune
system is activated and immune cells respond to the
effected site to begin removal of pathogens
INFLAMMATION
• Immune Cells (white blood cells) responding to site of
invasion will take part in a variety of processes:
Destroy and remove unwanted substances
Dispose of invaders
• Wall off infected/injured area
Prevent spread of damage
• Stimulate immune process
Call up more White Blood Cells
• Promote healing
Set stage for repair
TISSUE INJURY: WHAT HAPPENS THAT RESULTS IN
INFLAMMATION?
Causes release of chemical mediators
 Histamine – Kinins – Prostaglandins are examples
Vasodilation of arterioles
 Increased blood flow to area of injury
 Increased heat due to increased blood flow
 Increased metabolic rate– use more glucose
Permeability of capillaries
 Leak fluid into interstitial space between blood vessels and cells
 Shortens diffusion route of oxygen and glucose from blood vessels to cells
 Increased oxygen and nutrients to injured cells
 Increased edema due to extra fluid in interstitial space
 Pressure on pain neurons due to extra fluid in interstitial space
FOUR CARDINAL SIGNS OF INFLAMMATION
Redness
Heat
Swelling
Pain
HOWEVER IF IT GOES OVERBOARD . .
Inflammation causes
Bronchoconstriction
Vasodilation
Increased vascular permeability
Increased gastric motility
Can cause a medical emergency
LEARNED/ ACQUIRED IMMUNE RESPONSE
•
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Third Line of Defense in Immune Response
Elite Group of soldiers - Antibodies
High tech weapons
Specific targets
Takes time to mobilize
Depend on inflammation to begin battle
ANTIBODIES
•
Made by specific white blood cells – B lymphocytes
•
B lymphocytes are specific to the individual person
•
B lymphocytes create antibodies after exposure to
specific antigens to protect the body
•
B lymphocytes also create memory cells to recognize
the antigen if it appears again and call up the
antibodies
ANTIBODIES ACT TO…..
• Directly destroy or neutralize foreign antigen
• Call up white blood cells to assist in
destroying antigen
• Indirectly call up increased inflammation
response
IF THE ANTIGEN APPEARS AGAIN. . .
• Recognized by B memory cells
• Located and identified by antibodies
• White blood cells called in to destroy the antigen
• The antibody response is stronger each time the
antigen appears.
INAPPROPRIATE IMMUNE RESPONSES
Auto Immune Disorders: Body allergic to itself
Arthritis
Lupus
Exaggerated Immune Response
Hypersensitivity
Allergic Reactions
Anaphylaxis
ALLERGENS: WHAT CAN CAUSE AN ALLERGIC
REACTION?
• Antibiotics
• Foreign Proteins
• Foods: eggs, shell fish, MSG
• Insect Stings
• Hormones
• Blood Products
• Preservatives
• X-ray contrast media
SIGNIFICANT ALLERGENS
To cause an allergic reaction an allergen must be:
• Significantly foreign
• Significantly large
• Significantly complex
• Present in significant amounts
ALLERGIES
Hypersensitivity– Mild allergic reaction
 Delayed response to an antigen
 Results does not involve antibodies.
 Commonly results in skin rash.
 Results from exposure to certain drugs or chemicals.
 Allergic to soaps or detergents
ALLERGIC REACTION VS ANAPHYLAXIS
Allergic Reaction
An exaggerated response by the immune system to a
foreign substance/ antigen not always life
threatening
Involves antibodies
Anaphylaxis
An unusual or exaggerated allergic reaction to an
antigen
A life-threatening emergency
ALLERGIC REACTION
Rapid Response
Inflammation Response
Antibodies created
• First response may be mild
• Following responses will be more rapid and
severe
Generalized Reaction
 Mucus membranes swelling
 Skin --hives
 Respiratory Tract -- swelling
 Circulatory System---capillary leaking
 Gastrointestinal– vomiting and diarrhea
ANAPHYLAXIS: SEVERE ALLERGIC REACTION
Most anaphylaxis results from an injected antigen.
Antigen rapidly distributed throughout the body, resulting
in massive inflammation and antibody reactions.
Most common
 Antibiotic injections
 Insect stings.
Affects cardiovascular, respiratory, gastrointestinal
systems and skin
Significant fluid loss through increased capillary
leaking
ANAPHYLACTIC SHOCK
• Caused by widespread
vascular dilation
increased capillary leaking
bronchoconstriction
• Can cause severe
• respiratory distress
• dizziness
• fainting, coma
• respiratory and cardiac arrest
ANAPHYLACTIC SHOCK
• Patient will have:
hives, flushed skin
edema (especially of the tongue, face, and lips)
stridor from the upper airway, and wheezes
altered LOC and cyanosis during later stages.
signs and symptoms of shock
hypotensive
tachycardia
May be deadly due to poor oxygenation
and perfusion
MANAGEMENT: STABLE MILD/MODERATE
ALLERGIC REACTION
V – Vital Signs
O - Oxygen
M – Cardiac Monitor (When available)
I – Intravenous Access (When available) Fluid bolus to raise BP
T – Treatment (medications) and Transport
Consider the need for medications:
Epinephrine: SubQ 1:1000 0.3- 0.5 ml
Diphenhydramine (Benadryl) 25-50 mg IV/IM
Nebulized Duoneb
EPINEPHRINE
•
Used in cases of moderate allergic reactions and anaphylaxis
•
Administered via auto injector (0.3mg IM for adult or 0.15mg IM for peds)
or by ALS providers 0.3mg SQ for adults and 0.01mg/kg for peds.
**Note concentration is 1:1000
•
Serves as a vasoconstrictor to raise blood pressure
•
Serves as a bronchodilator to relieve respiratory distress and stridor
•
Need to monitor vital signs after administration; pulse and blood pressure
will be effected
•
Some patients may carry their own Epi-Pen to use in case of an allergic
reaction
DUONEB
• Consists of 3mg Albuterol and 0.5mg Ipratropium in 3ml normal
saline
• Is used as a bronchodilator for patients who are experiencing
wheezing and/or diminished lung sounds
• Administered with oxygen via a nebulizer at 8-10 LPM
• Requires reassessment of patient vital signs between Duoneb
treatments
• Can be given to patients in severe respiratory distress or
respiratory arrest via a BVM with an inline nebulizer kit
DIPHENHYDRAMINE (BENADRYL)
• Used as an anti-histamine to block the naturally occurring effects
of inflammation involved in the reaction
• Given only by ILS/ALS providers
• Dosages are 50mg IVP or IM for adults; 1mg/kg IVP or IM for peds
• Monitor patient vital signs after administration
USE COMMON SENSE
• Do all patients get all treatments listed in protocol?
• Does everyone with hives and itching need
Epinephrine?
Epinephrine is only administered to patients with
respiratory difficulty and wheezing or signs and
symptoms of shock
• What if no wheezing?
Does this patient require a Duoneb treatment?
• History of cardiac disease?
 Will the Epinephrine have a negative effect on the
patient
6 ‘RIGHTS’ OF MEDICATION USAGE
Before giving any medications be sure
you know:
Right Medication
Right Route
Right Time
Right Patient
Right Dosage
Right Documentation
MANAGEMENT: SEVERE ALLERGIC REACTION
UNSTABLE ANAPHYLAXIS
V – Vital Signs
O - Oxygen
M – Cardiac Monitor (When available)
I – Intravenous Access (When available) Fluid bolus to raise BP
T – Treatment (medications) and Transport
Needs medications!!
Epinephrine: SubQ 1:1000 0.3- 0.5 ml
Diphenhydramine (Benadryl) 25-50 mg IV/IM
Nebulized Duoneb
If patient experiences respiratory arrest or if
respiratory arrest is imminent, ALS providers
should contact Medical Control to administer
Epinephrine 1:10,000 0.3-0.5 mg IV
ONGOING MANAGEMENT
• Reassess critical patients every 5 minutes
• Reassess non-critical patients every 10 minutes
• Monitor lung sounds, O2 saturation, respiratory
rate, and heart rate
• Reevaluate patients skin for signs of redness
and hives
CASE STUDY 1
Dispatch: 1800 to a residence for a 61 year old male
patient with tightness in his chest and trouble
breathing
SCENE SIZE UP
Scene Safety: Private home; no signs of potential
danger, large porch with 4 steps to get onto porch;
Taken to dining room where patient is seated; Note
half eaten dinner roses and a strong odor of garlic
BSI: Gloves
Nature of Illness: Respiratory Distress
Number of Patients: 1
Additional Resources: ALS Intercept (If Applicable)
PRIMARY ASSESSMENT
General Impression: The patient is sitting in an upright position at end of table
Level of Consciousness: Awake, alert and obeys commands.
Airway: Open, clear
Breathing: Respirations fast and shallow; lungs clear
Circulation
Skin: pale, normal in temperature and dry
Pulses: Radial pulse weak and rapid
Bleeding: None
Rapid Head to Toe: Note hives on chest and neck
Priority: Stable
FOCUSED HISTORY
Signs and Symptoms: Began having trouble breathing
while eating dinner
Allergies: none known
Medications: Nitro-patch, Lasix, and Zestril
Past Medical History: Uncomplicated MI 2 years prior,
Hypertension, and Congestive Heart Failure
Last Oral Intake: Eating Shrimp Scampi when trouble
breathing began
Events: No complaints prior to eating; sudden onset
DETAILED PHYSICAL EXAM
Note hives on chest and neck
Breathing short and shallow but lung sounds clear
Vital signs:
Blood Pressure: 118/70
Pulse: 128
Respiratory: 28
O2 Saturation: 91%
Blood Sugar: 91
CRITICAL THINKING
• Is this patient stable or unstable?
• How aggressive do you need to be with him?
• Does he need epinephrine?
• What might happen to this patient if you gave him
epinephrine considering his past history of heart
disease?
MANAGEMENT
Interventions
Oxygen to keep patient O2 Saturation above 94%
Ongoing Assessment
Patient voices relief with oxygen
Repeat Vital Signs:
Blood Pressure: 116/70
Pulse: 110
Respirations: 20
O2 saturation: 100% on Oxygen at 4lpm
CASE STUDY 2
Dispatch: 1100 to a residence for a 38 year old male
patient unresponsive
SCENE SIZE UP
Scene Safety: Private home; no signs of potential
danger, easy access with patient laying in kitchen near
side door
BSI: Gloves
Nature of Illness: Unresponsive
Number of Patients: 1
Additional Resources: ALS Intercept (If Applicable)
PRIMARY ASSESSMENT
General Impression: Patient is prone in kitchen, does not move as you come into
the room
Level of Consciousness: Unresponsive to verbal or painful stimuli
Airway: Open but stridor noted
Breathing: Respirations are labored; poor rise and fall of chest; audible wheezes
Circulation
Skin: pale, cool, and cyanotic
Pulses: No radial pulses with weak carotid pulse
Bleeding: None
Rapid Head to Toe: Large, blotchy hives over most of patients skin
Priority: Acute status; initiate ALS Intercept immediately and correct ABCs
FOCUSED HISTORY
Signs and Symptoms: Was in garage when he found a bee hive;
came into kitchen and collapsed in front of wife, who is able to
assist with your assessment
Allergies: Bee stings, but never had a reaction this bad
Medications: Has an Epi-Pen but wife was unable to locate it
Past Medical History: None
Last Oral Intake: Breakfast 2 hours ago
Events: No complaints prior to collapsing, but wife says it looked
like he couldn’t breathe
DETAILED PHYSICAL EXAM
Hives over most of body
Pupils reactive but sluggish
No purposeful movement with GCS of 3
Vital signs:
Blood Pressure: Unable to obtain via palpation or auscultation
Pulse: 140 felt at carotid
Respirations: 6
Oxygen Saturation: 68%
Blood Sugar: 110
MANAGEMENT
•
Oxygen at 100% via Bag-Valve-Mask
•
Consider need for Spinal Motion Restriction
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(ALS) Initiate Intravenous Access with 0.9NS at wide
open rate
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(ALS/BLS) Duoneb through Inline Nebulizer
•
(ALS/BLS) Administer Epinephrine as appropriate;
ALS consider need to contact medical control for
Epinephrine 1:10,000 IVP
•
(ALS) Benadryl 50mg IVP
Ongoing Assessment
After medication administration, patient is now awake
and anxious; hoarse voice
Repeat Vital Signs:
Blood Pressure: 110/70
Pulse: 110
Respirations: 16
O2 saturation: 94% with Duoneb treatments and Oxygen
at 100% through NRB
REVIEW
•
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•
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TRUE OR FALSE?
1. Every allergic reaction is considered to be
anaphylactic
2. Every patient that has an allergic reaction should
receive epinephrine
3. The skin is a natural barrier against antigens
TRUE OR FALSE?
4. The common signs of inflammation are redness,
heat, swelling, and pain
5. Lupus is an auto-immune disorder
6. Inflammation release causes vasoconstriction
TRUE OR FALSE ?
7. Anaphylaxis is a serious medical condition that could
result in the death of the patient
8. An allergic reaction is an exaggerated response by
the immune system to a foreign substance
TRUE OR FALSE?
9. The 6 ‘Rights’ of medication administration are: Right
Patient, Right Time, Right Medication, Right Dosage,
Right Route, Right Documentation
10. A patient does not need to be reassessed between
administration of Duonebs
TRUE OR FALSE? (ALS)
11.A Patient in respiratory arrest should be treated with
Epinephrine 1:10,000 IVP AFTER contacting Medical
Control
12.Benadryl is a histamine blocker
13.Epinephrine will have no effect on patient heart rate
or blood pressure
ANSWERS
1. False
2. False
3. True
4. True
5. True
6. False
7. True
8. True
9. True
10. False
11. True
12. True
13. False