1. Allergic ReactionsAnaphylaxis Presence Regional EMS System June 2014 C.E.

2. 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

3. 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.

4. Invaders “If you’re not with us, you are againstus!” • 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. Four Cardinal Signs of Inflammation • Redness • Heat • Swelling • Pain

12. However if it goes overboard . . Inflammation causes • Bronchoconstriction • Vasodilation • Increased vascular permeability • Increased gastric motility Can cause a medical emergency

13. Learned/ Acquired Immune Response • 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

14. 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

15. 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

16. 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.

17. Inappropriate Immune Responses • Auto Immune Disorders: Body allergic to itself • Arthritis • Lupus • Exaggerated Immune Response • Hypersensitivity • Allergic Reactions • Anaphylaxis

18. 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

19. Significant allergens • To cause an allergic reaction an allergen must be: • Significantly foreign • Significantly large • Significantly complex • Present in significant amounts

20. 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

21. 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

23. 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

24. 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

25. Anaphylactic shock • Caused by widespread • vascular dilation • increased capillary leaking • bronchoconstriction • Can cause severe • respiratory distress • dizziness • fainting, coma • respiratory and cardiac arrest

26. 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

27. Management: Stable Mild/ModerateAllergic 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. Management: Severe Allergic ReactionUnstable 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

34. 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

35. 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

36. Case Study 1 • Dispatch: 1800 to a residence for a 61 year old male patient with tightness in his chest and trouble breathing

37. 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)

38. 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

39. 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

40. 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

41. 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?

42. 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

43. Case Study 2 • Dispatch: 1100 to a residence for a 38 year old male patient unresponsive

44. 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)

45. 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

46. 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

47. 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

48. Management •  Oxygen at 100% via Bag-Valve-Mask • Consider need for Spinal Motion Restriction • (ALS) Initiate Intravenous Access with 0.9NS at wide open rate • (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

49. 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

50. Review • If doing this CE individually, please e-mail your answers to: Shelley.Peelman@presencehealth.org • Use “June 2014 CE” in subject box. • IDPH site code: 06-7100-E-1214 • You will receive an e-mail confirmation. Print this confirmation for your records and document in your PREMSS CE record book.