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ANAPHYLAXIS

OVERVIEW

An allergen is a substance capable of producing an immediate hypersensitivity or allergic reaction in an individual. Many different substances can cause an allergic reaction. Allergic reactions begin when a susceptible person eats, drinks or touches the allergen, or gets it into their eyes, nose, or mouth. Initial exposure may create no symptoms and go unnoticed. Reactions can occur in minutes or take hours after ingestion or exposure. Symptoms can be mild to life-threatening depending on the location in the body in which the response occurs. An allergic response may be magnified in certain individuals, such as those with:

⦁ heart disease or high blood pressure
⦁ have diabetes
⦁ have thyroid conditions
⦁ have asthma
⦁ have depression or other mental disease
⦁ have Parkinson’s disease
⦁ are pregnant
⦁ are allergic to any of the ingredients in epinephrine auto-injector (EAI)1

Common allergens include foods, venom from insect stings, plants, medications, latex, glue, soaps, and other over the counter products. Foods, including peanuts, shellfish, fish, treenuts (i.e., pecan, walnut, cashes, etc.), eggs, milk, soy, and wheat, are the most common allergens.1,2
Anaphylaxis is a potentially life-threatening medical condition occurring in allergic individuals after exposure to an allergen. Symptoms of anaphylaxis include, but are not limited to breathing difficulties, drop in blood pressure and or shock, all of which may be fatal. Therefore, immediate recognition and intervention is needed.1-4
Identification of individuals with known allergens is vital to early recognition and intervention. Anaphylaxis often mimics an asthma attack. Therefore, it is important to have medical history information for each individual readily available.1,10

Recognition
Signs and symptoms of an allergic reaction usually appear within minutes. However, signs and symptoms of an allergic reaction may occur up to 2 hours after exposure to an allergen. Individuals may also experience a rebound effect in signs and symptoms whereby the signs and symptoms resurface following a period of perceived resolution.

F.A.S.T is a common acronym used to remember the signs and symptoms of an allergic reaction that may require immediate medical intervention:

⦁ Face: redness, itching or swelling of lips tongue or face;
⦁ Airway: trouble breathing, swallowing, or talking;
⦁ Stomach: pain, cramps, vomiting, diarrhea;
⦁ Total Body: hives, itchiness, swelling, paleness, fainting/dizziness, sense of doom.

Other signs and symptoms may include: wheezing, shortness of breath, throat tightness, cough, hoarse voice, chest pain/tightness, trouble swallowing, itchy mouth/throat, nasal stuffiness/congestion, pale/blue color, low pulse, dizziness, lightheadedness/passing out, low blood pressure, shock, loss of consciousness, chest pain, tachycardia.1,5-11

Management
The correct steps to take for emergency treatment of suspected anaphylaxis are to:

  1. Check status of Primary Objectives® (Cardiac, Airway, Breathing);
  2. Assess FAST signs and symptoms;
  3. Remove from environment containing triggers/allergens;
  4. Administer epinephrine as indicated;
  5. Activate Emergency Medical Services (EMS);
  6. Notify the designated EAI official if available;
  7. Place individual on their back with lower extremities elevated above the level of the heart;
  8. Monitor and support vital signs until EMS arrives;
  9. Send Epi-pen with EMS;
  10. Notify parents/guardians and designated administration;
  11. Document time, suspected allergen if known and response steps taken to activate EMS;
  12. Follow local EMS transport protocols;
  13. Report administration to appropriate EAP personnel.1

Epinephrine
Epinephrine, also known as Adrenalin, is a drug used in the treatment of anaphylaxis. Epinephrine constricts blood vessels thereby raising blood pressure. Epinephrine also opens airways to improve breathing, stimulate the heart, and works to reverse hives and swelling secondary to an allergic reaction. The effects of epinephrine are short acting, generally lasting about 10-20min. Therefore, signs and symptoms of anaphylaxis may return as the drug wears off. A second dose of epinephrine may be indicated if advanced medical care is delayed following administration of the first dose of epinephrine.1

Epinephrine Auto-Injectors
An epinephrine auto-injector (EAI), is a disposable, prefilled automatic injection device which is designed to deliver a single pediatric dose of 0.15 or an adult dose 0.30mg of epinephrine to someone showing signs or complaining of symptoms of anaphylaxis. There are 4 types of EAI each with specific directions for use. A comparison chart and video demonstration of each is provided in the EAI Comparison Chart.

Common EAIs

AdrenaclickAdrenaclick
Auvi-Q
Auvi-Q
Epi-Pen / Epi-Pen Jr.Epi-Pen / Epi-Pen Jr.
USP Auto-Injector (Authorized Adrenaclick Generic)
USP Auto-Injector
(Authorized Adrenaclick Generic)

Storage And Stability Of Epinephrine In An EAI

Replace expired or compromised EAIs

There is very little evidence-based literature regarding the stability of epinephrine in an automatic epinephrine injector. However, in accordance with recommendations from the American Academy of Allergy Asthma & Immunology (AAAAI) EAIs shall be stored in the carrier provided by the manufacturer, out of sunlight, and at 25°C (77°F); with excursion permitted to 15° – 30°C (59 ° – 86°F). In practice, patients may be forced to use their EAIs in temperature ranges outside of the advised range. An EAI shall be replaced if the epinephrine in the EAI has frozen (and requires re-thawing), has expired, or if the solution in the EAI does not appear clear and free of particulates.12,13

Indications/Contraindication For Use Of An EAI
EAI are indicated for use when an individual shows signs or complains of symptoms of anaphylaxis. Anaphylaxis should be suspected when any of the three following criteria are met:

  1. Airway or breathing complication (respiration > 30 breaths/min);
  2. Hypotension;
  3. Acute onset of two or more of the following after exposure to a potential allergen;
  4. Any of the aforementioned signs and symptoms;
  5. Persistent gastrointestinal symptoms;
  6. Hypotension.

There are no contraindications to the use of epinephrine in a life-threatening allergic reaction or severe asthma. However, precautions should be taken with elderly patients or patients with heart disease or hypertension.

The most common side effects may include increase in heart rate, stronger or irregular heartbeat, chest pain, sweating, nausea and vomiting, difficulty breathing, paleness, dizziness, weakness or shakiness, headache, apprehension, nervousness or anxiety. These side effects usually go away quickly, especially with rest. Individuals with certain medical conditions, or who take certain medicines, may get more side effects from an EAI, or the side effects may last longer. This includes individuals who take certain types of medicines for asthma, allergies, depression, hyperthyroidism, high blood pressure, and heart disease. Individuals with heart disease may feel chest pain (angina). Individuals with mental disease or Parkinson’s disease may have worsening symptoms of their illness. The risk of death from untreated anaphylaxis outweighs the risk of adverse side effects from using epinephrine. In the event that a pediatric dose EAI is indicated, but not available, an adult dose EAI can administered.12,13

After use of an EAI the remaining liquid that is left after this fixed dose cannot be further administered and should be discarded. Put the EAI, needle first, into the carrying case. Replace the safety cap over the non-needle end of the EAI and close the case. Do NOT throw away in a regular trash can. EAI shall be disposed of in a sharps container in accordance with standard universal precaution procedures.1

The correct sequence of steps to administer an EAI includes:

  1. Have the person sit or lie down;
  2. Check EAI unit to make sure the liquid is clear, and/or the unit has not expired;
  3. Pull off the safety cap. Do not touch the administration end which is clearly identified;
  4. Place the tip or end of the unit against the outer thigh at a 90 degree angle;
  5. Press hard into the victims thigh until auto-injector mechanism clicks or a verbal prompt is heard;
  6. Hold in place for 3 seconds;14
  7. Remove EAI and massage the injection area for 5-10 seconds depending on the brand;
  8. Discard the used auto-injector as indicated by the district plan. Do not throw away in a regular trashcan.1

Reassessment
Following the administration of epinephrine ongoing assessment of and support for airway, breathing and circulation is required. Declining mental status, decreasing blood pressure and increasing difficulty in breathing indicate the allergic reaction or severe asthma is worsening. If the condition is worsening, the medical team will:

⦁ consider a second dose of epinephrine;
⦁ provide emergency care for shock;
⦁ administer positive pressure ventilation with supplemental oxygen if breathing becomes inadequate;
⦁ be prepared to initiate high-quality CPR.

Prevention Guidelines
Known at risk individuals shall be counseled in the following prevention measures:

⦁ Ask your doctor how to avoid your allergens and what to do if you have an allergic reaction, especially a severe reaction;
⦁ Tell their health care providers, including your dentist, about all allergies before accepting any medication, especially injections;
⦁ Always remain in your doctor’s office the full amount of time your doctor says after receiving any injection. Report any unusual reaction immediately;
⦁ Wear a Medic Alert bracelet or pendant that lets others know about your allergies;
⦁ If allergic to insect stings, wear protective clothing when outside;
⦁ Avoid shiny clothing or jewelry, which can attract insects, and cover sugary drinks;
⦁ If allergic to any food, be assertive about seeking detailed information from food manufacturers, restaurant staff, and dinner hosts about ingredients;
⦁ Keep two epinephrine injection kits with them at all times and readily available;
⦁ Be sure family, friends, and colleagues know how to use the kit if you have a reaction;
⦁ If the person at risk is a child, make sure the child’s teachers, friends’ parents, and any other caregivers know how to use the child’s kit in an emergency and that the kit is always with the child and readily available at all times;
⦁ Know the symptoms of a severe reaction, and reach for the epinephrine if you think you are beginning to show signs of a having one. Do not hesitate to use your epinephrine if you suspect an anaphylactic reaction. Waiting to take the shot is a key issue in patients who have poor outcomes;
⦁ Ensure that your epinephrine is up to date and has not expired. Epinephrine typically has a one year shelf life;
⦁ Ask an allergist if you can obtain desensitization therapy for the offending allergen. This therapy is available for insect stings and drugs such as penicillin when appropriate.

Readiness supplies
Basic Life Support Supplies

⦁ AED
⦁ BLS airway adjuncts
⦁ Hear rate monitor
⦁ Blood pressure monitor
⦁ Pulse oximeter

Protocol Specific Supplies

⦁ Benadryl
⦁ EAI
⦁ Second dose EAI
⦁ Communication system
⦁ Ice
⦁ Supplemental oxygen