Anaphylactic Shock

Miami Dade Fire Dept. EMS Division 19981998-2000

Anaphylactic Shock
= away from  Phylaxis = protection
A

 Ana

term to indicate a lessened resistance to a toxin which results from a previous inoculation of the same material.

Anaphylactic Shock is the most severe type of allergic reaction, and is commonly seen in the pre hospital setting.

THIS IS A TRUE MEDICAL EMERGENCY

Anaphylactic shock accounts for 400-800 400deaths per year Approximately 3 percent of all cases of anaphylactic shock are fatal.
One of the most dangerous aspects of this type of allergic reaction is the speed with which it progresses. The onset of life threatening complications can be from seconds to minutes. Emphasis must be placed on rapid, aggressive pre hospital intervention to prevent death.

PHYSIOLOGY
The body has a protective mechanism called the IMMUNE SYSTEM
This system protects the body from foreign substances that have entered the body by releasing chemicals that bond with the foreign substance to facilitate its removal.

Agents That May Cause Anaphylaxis

       

Antibiotics and other drugs Foods (nuts, eggs, shellfish) Allergen extracts (allergy shots) Hymenoptera stings (bees, wasps) Hormones (insulin) Aspirin Blood products Preservatives (sulfiting agents)

These foreign substances can enter the body in four ways:



Injection Inhalation Absorption Ingestion

  

Antigen
The medical term for a foreign substance. When antigens enter the body they cause the release of protective proteins from the immune system. When the introduction of an antigen causes a violent reaction it can be called an allergen.

ANTIBODY
A general term for the protective proteins that are released from the immune system when a foreign substance (antigen) enters the body.

When the body releases antibodies in response to an invading antigen, this is called an Antigen/Antibody reaction.
This reaction occurs everyday as a standard component of the immune system. Antigen/Antibody reactions vary in intensity depending on the substance that has entered the body and whether the body has had previous exposure to the substance.

When the body is invaded by a foreign substance (antigen), it will release antibodies the remove the antigens.
The body will facilitate the removal of these antigens by increased gastrogastrointestinal activity.

Increased gastrointestinal activity will commonly cause:

Nausea  Diarrhea  Severe abdominal cramping  Vomiting


This GI response is produced from the bodys release of antibodies. These antibodies will cause:
  

Smooth muscle contraction Increased mucous production The shunting of fluid from the intestinal walls to the intestinal lumen All these responses are the bodys attempt at accelerating the removal of the antigen through the GI system.

Anaphylactic Shock occurs when a patient becomes sensitized to a substance from previous exposures.
The immune system reacts more violently because of the familiarity to the substance.

The violent reaction can be described as an excessive release of antibodies, thus any symptoms normally accompanying the release of these antibodies will be exaggerated.

When we speak about anaphylactic shock and antibody release, we are mostly concerned with the Immunoglobulin IgE and the antibody protein known as HISTAMINE

Histamines
When released in elevated amounts due to sensitivity to a substance, histamines are responsible for the symptoms of anaphylactic shock.

Summary of the effects of Histamine



Respiratory System

Difficulty breathing due to smooth muscle spasm and swelling Tachycardia with hypotension and arrythmias.

Cardiovascular

GastroGastrointestinal Neurological Cutaneous

Nausea, vomiting, diarrhea and cramping Anxiety, dizziness, weakness and seizures Angioedema, edema, uticaria (hives), puritis (itching) and tearing

Signs and Symptoms of Anaphylactic Shock

Patient Assessment
Always start with a Primary Assessment
Many times in the management of Anaphylactic Shock, therapeutic interventions will be needed immediately after the primary survey is completed to correct life threatening airway conditions.

Patient Assessment cont.

The airway portion of the primary survey should be assessed for laryngeal edema, tongue swelling, stridor or barking cough. All these abnormalities are warnings of impending complete airway obstruction.

Secondary Assessment


A complete head to toe survey must be completed, paying special attention to the early and frequent assessment of vital signs. The patients neck and face should be continually assessed for swelling, hives (uticaria), and redness (erythemia). Ongoing assessment of lung sounds is of primary importance due to the rapid onset of bronchospasm.

Commonly seen signs and symptoms

       

Pale, diaphoretic skin Tachycardia Hypotension Difficulty breathing Uticaria Swelling of face or neck Stridor, barking or wheezing Syncope

Assessing the reaction



Is it chronic or acute?  The patients history will determine. Is it mild or severe?  If any sign or symptom includes any facial, oral, or neck swelling or edema, it is severe. Is it local or systemic?  It it has spread past the injection site or spread to any organ system, it is systemic. If the reaction is acute, severe, or systemic, expect airway compromise.

The treatment for anaphylactic shock is EPINEPHRINE

Epinephrine has the ability to reverse many of the effects of histamine release. This is accomplished by:
Bronchodilation Vasoconstriction Increased cardiac output

The treatment for anaphylactic shock is EPINEPHRINE

In severe cases, the first dose of Epinephrine should be given subcutaneously (SQ) or by Epi pen (for EMTs) prior to establishing an IV.

Treating anaphylactic shock (ALS)



The first step is maintenance of the airway Give 100% Oxygen Give Epinephrine 1: 1,000 0.5 mg SQ

Treating anaphylactic shock (ALS)

  

IV, Normal Saline EKG If the patient is profoundly hypotensive, give Epinephrine 1:10,000

BP < 80 systolic or no radial pulse

0.3 mg slow IVP Repeat once in 5 minutes if no improvement

Treating anaphylactic shock (ALS)



Administer Diphenhydramine (Benadryl)

25 mg Slow IVP or IM Diphenhydramine is an antihistamine that blocks the histamine receptors. A long term comfort drug that relieves itching.

Treating anaphylactic shock (ALS) for Pedi (< 3 Y/O or < 15 kg)


Epinephrine 1:1,000 dose is 0.01 mg/kg SQ

Do not give more than 0.3 mg SQ in one dose See MOM for additional dosages.

Treating anaphylactic shock (BLS)

Administer one injection from the Epi Pen In upper arm or lateral thigh Delivers a smaller dose (0.3 mg) than the ALS dosage, and should be used only by BLS units

Treating anaphylactic shock for Pedi (BLS)



In children < 3 Y/O (< 15 kg), use the Epi Pen Jr. It delivers 0.15 mg.
In children > 15 kg, use the Epi Pen.

Using the Epi Pen



Medication Name
Generic = Epinephrine Trade Name = Adrenaline

Indications
Treatment of Anaphylactic reaction Approved for EMTs Medication prescribed by MD Medical Director approval

Contraindications
None, in acute allergic reaction

Epinephrine auto-injector auto-

Check the Epinephrine auto-injector for expiration date. If autoit belongs to the patient, insure it is properly prescribed.

Epinephrine auto-injector auto-

Remove the safety cap from the auto-injector auto-

Epinephrine auto-injector auto-

Place the tip on the lateral aspect of the thigh, midway between the hip and knee. Push firmly against the thigh until it activates. Hold in place for 10 seconds.

Epinephrine auto-injector auto-

Properly dispose of the auto injector. Record the time of administration and reassess the patient.

Bibliography
 

Bledsoe, Paramedic Emergency Care 3rd Ed. 1997. PP. 793-803 793Hafen, Prehospital Emergency Care 5th Ed. 1996 PP. 362-371 362M.J. Sanders, Mosbys Paramedic Textbook, 1994 PP. 720-730 720Caroline, Emergency Care in the Streets 4th Ed. 1991, PP. 595-605 595MDFD Medical Operations Manual, 1996