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Anaphylaxis:
Recognition and Response Essentials
in the School
Bernard S. Zeffren, MD
Objectives in Anaphylaxis
Education
• What is it?
• Who is at risk?
• Where and when can it happen?
• How do we know it is anaphylaxis?
• What should we do?
• Why is follow-up needed?
Proposed Definition-2006
• Anaphylaxis is a serious allergic reaction that is rapid in onset
and may cause death.
Sampson HA et al. J Allergy Clin Immunol 2006;117:391-7
Anaphylaxis is highly likely when any one of
the following three criteria are fulfilled:
1.
Acute onset (usually in minutes to within an hour) of symptoms
involving the skin (pallor, hives, flushing, or swelling) PLUS any
of: abdominal symptoms (colicky discomfort/nausea/vomiting/
diarrhea), respiratory compromise (chest tightness/shortness of
breath/wheezing/rapid or shallow breathing), or signs of reduced
blood pressure (lightheadedness/passing out).
2.
Symptoms involving two or more of the typical organ systems
(skin, GI, respiratory, cardiovascular) that occur rapidly after
exposure to a likely allergen for that patient.
3.
Reduced BP following exposure to a known allergen for that
patient. (My personal opinion is this provision should read “Acute onset of any of the typical symptoms
following…”)
Sampson HA et al. J Allergy Clin Immunol 2006;117:391-7
Be aware:
• Many deaths in anaphylaxis, especially from food allergy, are due to
obstruction of airflow in the upper and/or lower respiratory tract that
results in respiratory failure.
• If you wait to administer injectable epinephrine until the patient goes
into shock, you have waited too long!
• Treat with epinephrine long before signs and symptoms of
respiratory and/or cardiovascular collapse occur!
• Epinephrine can stop/reverse ALL the symptoms of anaphylaxis
within 2-5 minutes if given early enough.
• Shoot first, ask questions later, then give oral antihistamines.
• Epi Epi Epi Epi Epi Epi Epi !!!
(NOT Benadryl !)
Epidemiology of Anaphylaxis
How many people are at risk for
fatal anaphylaxis?
•
We do not know for sure how many are at risk.
•
Best guess from available data is under 1%.
Incidence of Anaphylaxis in U.S.
• A medical record review in a Minnesota community found
an incidence of 21 per 100,000 person years, with an
occurrence rate of 30 per 100,000 person years, and a
fatality rate of less than 1%.
• A record review of children and adolescents in a national
HMO found an incidence of anaphylaxis of 10.5 per
100,000 person years.
Yocum MW et al. J Allergy Clin Immunol 1999;104:452-6
Reported Incidence of Anaphylaxis:
Increase in England: 1995-1999
(the effect of good P.R.)
Food
Unspecified
Serum
Medicinal Substance
Overall
1400
1202
1200
1096
# Patients
1000
840
800
600
400
200
229
158
113
1
558
513
501
312 366
153
406
390
183
235
9
10
3
1996-7
1997-8
1998-9
0
1995-6
Wilson R. BMJ 2000; 321:1021-2 ( comment on Sheikh A, Alves B. BMJ 2000;320:1441)
Physiology of Anaphylaxis
Physiology of Anaphylaxis
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2683407
• A lock-and-key specific antibody/antigen interaction.
• Antibodies are typically IgE bound to IgE receptor molecules on the
surfaces of mast cells in affected tissues and basophils in circulation.
• Activation of these cells causes release of preformed mediators from
secretory granules that include histamine, tryptase, carboxypeptidase
A, and proteoglycans. These then cascade into multiple physiologic
effects.
• These overlapping and synergistic physiologic effects on skin, GI
tract, heart, blood vessels, and lungs contribute to the overall
pathophysiology of anaphylaxis.
• Symptoms variably present as any combination of generalized
urticaria and angioedema, bronchospasm, and other respiratory
symptoms, hypotension, syncope, and other cardiovascular
symptoms, and nausea, cramping, and other gastrointestinal
symptoms.
• Biphasic or protracted anaphylaxis may occur.
Triggers of Anaphylaxis
Triggers of Anaphylaxis: Overview
•
•
The most commonly identified triggers are:
-
Foods
-
Insect stings
-
Medications
Many patients with symptoms consistent with anaphylaxis
who are referred to allergists have no specific cause found
after extensive evaluation.
Lieberman P. Ann Allergy Asthma Immunol 2006;97:39-43
Overview of Anaphylactic Triggers
35
35
30
25
20
20
20
20
% of Cases
15
10
5
3
5
0
Food
Golden. Anaphylaxis, 2004
Drug/Bio
Insect
Sting
Idiopathic
Exercise
Allergen
Vaccines
Triggers of Anaphylaxis: Food
•
•
•
•
•
•
•
•
Peanuts
Tree nuts
Seafood
Eggs
Milk
Soy
Wheat
Other
Triggers of Anaphylaxis:
Insect Stings and (rarely) Bites
• Fire ants (most common here in Central FL)
• Yellow Jackets, Hornets, Wasps
• Honey Bees
• Scorpions
• Deer & horse flies
• Mosquitoes (?)
Iatrogenic Triggers of Anaphylaxis
• Diagnostic agents (technically anaphylactoid…)
– Intravenous contrast media
– Has nothing to do with iodine per se, and no relation to shellfish
• Medications
–
Antibiotics
–
Aspirin and other NSAIDs
• Biological response modifiers
–
Anti-venoms
–
Monoclonal antibodies
• Blood transfusions
• Allergen immunotherapy
Joint Task Force on Practice Parameters: AAAAI, ACAAI, and JCAAI.
J Allergy Clin Immunol 2005;115:S483-523
Triggers of Anaphylaxis: Latex
• Some groups are at increased risk
– Healthcare workers
– Children with spina bifida
– Patients with multiple surgeries
• Increased incidence during the 1990’s was due largely to
implementation of universal precautions.
• Incidence has decreased since latex-free and non-powdered
gloves have become more widely available
Kelly KJ et al, J Allergy Clin Immunol 1994;93:813-6
Triggers of Anaphylaxis: Physical
• Exercise- and Food/Exercise- induced
– Food or medication are sometimes co-triggers with exertion
• Fish, wheat , celery, peanut and multiple others
• Cold-induced
• Heat-induced
Burgess B. EMedHome.com
Signs and Symptoms
Most Frequent Signs and
Symptoms of Anaphylaxis
Manifestation
Percent
Urticaria/angioedema
88
Upper airway edema
56
Dyspnea/wheeze
47
Flushing
46
Hypotension
Gastrointestinal
10-33
30
Symptoms/Signs of Anaphylaxis:
The patient’s perspective
General: a feeling of impending doom, a sudden sense
that “things aren’t right”, or panic
Oral: pruritus of lips, tongue, and palate; edema of lips
and tongue; metallic taste in mouth
Cutaneous: flushing or pallor, pruritus, urticaria,
angioedema, morbilliform rash, and pilor erecti;
Symptoms/Signs of Anaphylaxis:
The patient’s perspective (cont’d)
Gastrointestinal: nausea, abdominal pain (colicky),
vomiting, diarrhea
Cardiovascular: feeling of faintness, syncope,
chest pain, dysrhythmia, hypotension
Symptoms/Signs of Anaphylaxis:
The patient’s perspective (cont’d)
Respiratory
• Nose: pruritus, congestion, rhinorrhea, and
sneezing
• Laryngeal: pruritus and “tightness” in the throat,
dysphagia, dysphonia and hoarseness/stridor, dry
“staccato” cough
• Lungs: shortness of breath, dyspnea, chest
tightness, cough, and wheezing
Diagnosis
Anaphylaxis: In Search of the Culprit,
Allergy Test Results are PART of the
Answer
• An allergy test that is (+) for a particular allergen-specific
IgE is just an indication of sensitization, not an absolute
indicator of a cause of anaphylaxis, nor even evidence for
the presence of allergic disease.
• One MUST correlate test results with timing of exposure of
the suspected trigger AND presence/absence of the
symptoms of anaphylaxis
Treatment
Accidents Are Never Planned
Emergency medications (injectable epinephrine)
and
A treatment plan
Both must be immediately available and
accessible at all times!
When in Doubt,
Inject Epinephrine!
Anaphylaxis Emergency Action Plan
An Anaphylaxis Emergency Action Plan should include:
– What symptoms to look for
– What medications to use
– What dose of medication
– Where medications are kept
– What others should do
– Anaphylaxis emergency practice drills
For Patients and Providers
• Anaphylaxis Tool Kit
• Wallet Card
• Emergency Action Plan
• Educational Material
– www.aaaai.org
– www.foodallergy.org
Simons FER. J Allergy Clin Immunol 2006;117:367-77
Simons FER. J Allergy Clin Immunol 2006;117:367-77
Treatment
(Epi Epi Epi Epi - not Benadryl - Shoot first ask questions later)
•
Epinephrine is the drug of choice for all anaphylactic
episodes.
•
Flexibility in dosing needed to treat effectively.
- Many patients require more than a single injection.
- Different doses for children and adults.
•
Early and aggressive use to maintain airway, blood
pressure, and cardiac output.
Outdated Epinephrine Loses Efficacy
•
As time passes, percent of labeled dose and epinephrine
bioavailability are reduced.
•
Improper storage and exposure to sunlight and heat
increase degradation.
•
Degradation often occurs without a color change in the
epinephrine solution.
Simons FER et al. J Allergy Clin Immunol 2000;105:1025-30
Inadequate Knowledge of
Epinephrine Usage
• Healthcare professionals and patients have inadequate
knowledge about outpatient use.
- 76% of physicians are unaware that two EpiPen dose
formulations exist!
- Only 55% of patients at risk have in-date auto-injectors
on hand!
- Only 30%-40% know how to use auto-injectors correctly!
Grouhi M et al. J Allergy Clin Immunol 1999; 104:190-3; Sicherer SH et al. Pediatrics 2000; 105:359-62;
Huang SW. J Allergy Clin Immunol 1998;102:525-6
Auto-injectable Epinephrine Device
Demonstration
• EpiPen
• Auvi-Q
• Twinject (generic epinephrine injector)
Injectable Epinephrine in Schools - The New
Florida Legislation
• http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Stat
ute&URL=1000-1099/1002/Sections/1002.20.html
• Students may carry injectable epinephrine to use in emergencies at
school and at all school-related activities.
• Schools may acquire their own supply of injectable epinephrine.
• Schools/districts (pub. and priv.) shall adopt policies developed by a
licensed physician regarding administration of injectable epinephrine.
• School districts/employees are not liable for any injuries from proper
use of injectable epinephrine used within the auspices of these
policies
(i)
Epinephrine use and supply:
1. A student who has experienced or is at risk for life-threatening allergic reactions may carry an
epinephrine auto-injector and self-administer epinephrine by auto-injector while in school, participating in
school-sponsored activities, or in transit to or from school or school-sponsored activities if the school
has been provided with parental and physician authorization. The State Board of Education, in
cooperation with the Department of Health, shall adopt rules for such use of epinephrine auto-injectors
that shall include provisions to protect the safety of all students from the misuse or abuse of autoinjectors. A school district, county health department, public-private partner, and their employees and
volunteers shall be indemnified by the parent of a student authorized to carry an epinephrine auto-injector
for any and all liability with respect to the student’s use of an epinephrine auto-injector pursuant to this
paragraph.
2. A public school may purchase from a wholesale distributor as defined in s. 499.003 and maintain in a
locked, secure location on its premises a supply of epinephrine auto-injectors for use if a student is
having an anaphylactic reaction. The participating school district shall adopt a protocol developed by a
licensed physician for the administration by school personnel who are trained to recognize an
anaphylactic reaction and to administer an epinephrine auto-injection. The supply of epinephrine autoinjectors may be provided to and used by a student authorized to self-administer epinephrine by autoinjector under subparagraph 1. or trained school personnel.
3. The school district and its employees and agents, including the physician who provides the standing
protocol for school epinephrine auto-injectors, are not liable for any injury arising from the use of an
epinephrine auto-injector administered by trained school personnel who follow the adopted protocol and
whose professional opinion is that the student is having an anaphylactic reaction:
a. Unless the trained school personnel’s action is willful and wanton;
b. Notwithstanding that the parents or guardians of the student to whom the epinephrine is
administered have not been provided notice or have not signed a statement acknowledging that the
school district is not liable; and
c. Regardless of whether authorization has been given by the student’s parents or guardians or
by the student’s physician, physician’s assistant, or advanced registered nurse practitioner.
Anaphylaxis
• Who is at risk? Anyone, especially those allergic to foods
such as peanut, tree nut, seafood, finned fish, milk, or egg; or
to insect stings or bites, natural rubber latex, or medications.
• When can it happen? Anytime, usually within minutes after
the patient comes in contact with their trigger.
• How do we know? Several symptoms occur at the same
time, such as itching, hives, flushing, difficulty breathing,
vomiting, diarrhea, dizziness, confusion, or shock.
Simons FER. J Allergy Clin Immunol 2006;117:367-77
Anaphylaxis
• Where can it happen? Anywhere, such as home, restaurant,
school, child care or sports facility, summer camp, car, bus,
airplane.
• What should we do? Inject epinephrine, call 911 or local
emergency medical service number, and notify the individual's
family (in that order)! Act quickly. Anaphylaxis can be mild, or it
can be fatal.
• Why is follow-up needed? Anaphylaxis can occur repeatedly.
The trigger needs to be confirmed, and long-term preventive
strategies need to be implemented.
Simons FER. J Allergy Clin Immunol 2006;117:367-77
Questions/Discussion