Transcript Slide 1
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 1200 1000 800 600 400 200 0 840 158 229 113 1 501 312 366 9 153 1995-6 1996-7 1096 390 513 183 10 1997-8 406 558 235 3 1202 1998-9
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 30 25 % of Cases 20 15 10 5 0 Food 35 20 20 20 5 3 Drug/Bio Insect Sting Idiopathic Exercise Allergen Vaccines
Golden.
Anaphylaxis
, 2004
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 Urticaria/angioedema Upper airway edema Dyspnea/wheeze Flushing Hypotension Gastrointestinal Percent 88 56 47 46 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)
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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 auto injectors. 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 auto injectors may be provided to and used by a student authorized to self-administer epinephrine by auto injector 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