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2001 DEY B9-508-00 7/01. Anaphylaxis: Screen, Educate, and Protect to Improve Patient Outcomes 2001 DEY B9-508-00 7/01.

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Presentation on theme: "2001 DEY B9-508-00 7/01. Anaphylaxis: Screen, Educate, and Protect to Improve Patient Outcomes 2001 DEY B9-508-00 7/01."— Presentation transcript:

1 2001 DEY B /01

2 Anaphylaxis: Screen, Educate, and Protect to Improve Patient Outcomes 2001 DEY B /01

3 Definition of Anaphylaxis Systemic allergic reaction – –Affects body as a whole – –Multiple organ systems may be involved Onset generally acute Manifestations vary from mild to fatal

4 Myth: Anaphylaxis Is Rare REALITY : Anaphylaxis is underreported Incidence seems to be increasing Up to 41 million Americans at risk (Neugut AI et al, 2001) 63,000 new cases per year (Yocum MW et al, 1999) 5% of adults may have a history of anaphylaxis (various surveys)

5 Pathogenesis of Anaphylaxis IgE-mediated (Type I hypersensitivity) Sensitization stage Subsequent anaphylactic response

6 Sensitization Stage Antigen (allergen) exposure Plasma cells produce IgE antibodies against the allergen IgE antibodies attach to mast cells and basophils Mast cell with fixed IgE antibodies IgE Granules containing histamine Antigen Plasma cell

7 Anaphylactic Reaction More of same allergen invades body Antigen Mast cell granules release contents after antigen binds with IgE antibodies Histamine and other mediators. Allergen combines with IgE attached to mast cells and basophils, which triggers degranulation and release of histamine and other chemical mediators

8 Common Causes of IgE-mediated Anaphylaxis Foods Insect venoms Latex Medications Immunotherapy – –Insect venom – –Inhalant allergens

9 Anaphylactoid Reactions Non–IgE-mediated – –Complement-mediated Anaphylatoxins, eg, blood products – –Direct stimulation eg, radiocontrast media – –Mechanism unknown Exercise NSAIDs

10 Myth: The Cause of Anaphylaxis is Always Obvious REALITY : Idiopathic anaphylaxis is common Triggers may be hidden – –Foods – –Latex Patient may not recall details of exposure, clinical course

11 Clinical Manifestations of Anaphylaxis Skin: Flushing, pruritus, urticaria, angioedema Upper respiratory: Congestion, rhinorrhea Lower respiratory: Bronchospasm, throat or chest tightness, hoarseness, wheezing, shortness of breath, cough

12 Clinical Manifestations of Anaphylaxis Gastrointestinal tract: – –Oral pruritus – –Cramps, nausea, vomiting, diarrhea Cardiovascular system: – –Tachycardia, bradycardia, hypotension/shock, arrhythmias, ischemia, chest pain

13 Clinical Manifestations of Anaphylaxis Signs/symptomsIncidence (%) Urticaria and angioedema Upper airway edema* Dyspnea and wheezing Flush* Dizziness, syncope, and hypotension Gastrointestinal symptoms Rhinitis* Headache* Substernal pain* Itch without rash* Seizure* *Symptom or sign not reported in all four series

14 Myth: Anaphylaxis Always Presents with Cutaneous Manifestations REALITY : Approximately 10%-20% of anaphylaxis cases will not present with hives or other cutaneous manifestations 80% of food-induced, fatal anaphylaxis cases were not associated with cutaneous signs or symptoms

15 Clinical Course of Anaphylaxis Uniphasic Biphasic – –Recurrence up to 8 hours later Protracted – –Hours to days

16 Myth: Prior Episodes Predict Future Reactions REALITY : No predictable pattern Severity depends on: – –Sensitivity of the individual – –Dose of the allergen

17 Anaphylaxis Fatalities Estimated 500–1000 deaths annually 1% risk Risk factors: – –Failure to administer epinephrine immediately – –Beta blocker, ?ACEI therapy – –Asthma – –Cardiac disease – –Rapid IV allergen

18 Food-induced Anaphylaxis: Incidence 35%–55% of anaphylaxis is caused by food allergy 6%–8% of children have food allergy 1%–2% of adults have food allergy Incidence is increasing Accidental food exposures are common and unpredictable

19 Food-induced Anaphylaxis: Common Triggers Children and adults (usually not outgrown): – –Peanuts – –Tree nuts – –Shellfish – –Fish Additional triggers in children (commonly outgrown): – –Milk – –Egg – –Soy – –Wheat

20 Food-induced Anaphylaxis: Common Symptoms Oropharynx: Oral pruritus, swelling of lips and tongue, throat tightening GI: Crampy abdominal pain, nausea, vomiting, diarrhea Cutaneous: Urticaria, angioedema Respiratory: Shortness of breath, stridor, cough, wheezing

21 Food-induced Anaphylaxis: Fatal Reactions Fatal reactions are on the rise – –~150 deaths per year – –Usually caused by a known allergy Patients at risk: – –Peanut and tree nut allergy – –Asthma – –Prior anaphylaxis – –Failure to treat promptly w/epinephrine Many cases exhibit biphasic reaction

22 Fatal Food-induced Anaphylaxis (Bock SA, et al. JACI 2001;107:191–193) 32 cases of fatal anaphylaxis Adolescents or young adults Peanuts, tree nuts caused >90% of Rxn 20 of 21 with complete history had asthma Most did not have epinephrine available

23 Food-induced Anaphylaxis: Prevention Learn to read product labels –Identify alternative names for ingredients –Find hidden ingredients Avoid high-risk foods (eg, baked goods) Avoid sharing food, utensils, or food containers –Minute amounts can be life-threatening Provide educational materials –FAAN- (www.foodallergy.org) I. AVOID ALLERGENS

24 Food-induced Anaphylaxis: Prevention Complete avoidance is impossible Must always be prepared to treat a reaction – –Have an emergency action plan – –Keep EpiPen or EpiPen Jr on hand at all times – –Train caregivers and teachers on EpiPen use – –Wear MedicAlert bracelet II. RISK MANAGEMENT

25 Venom-induced Anaphylaxis: Incidence 0.5%–5% (13 million) Americans are sensitive to one or more insect venoms Incidence is underestimated Incidence increasing due to fire ants and Africanized bees Incidence rising due to more outdoor activities At least 40–100 deaths per year

26 Venom-induced Anaphylaxis: Common Culprits Hymenoptera –Bees –Wasps –Yellow jackets –Hornets –Fire ants Geographical –Honeybees, yellow jackets most common in East, Midwest, and West regions of US –Wasps, fire ants most common in Southwest and Gulf Coast

27 Venom-induced Reactions: Common Symptoms Normal: Local pain, erythema, mild swelling Large local: Extended swelling, erythema Anaphylaxis: Usual onset within 15–20 minutes –Cutaneous: urticaria, flushing, angioedema –Respiratory: dyspnea, stridor –Cardiovascular: hypotension, dizziness, loss of consciousness 30%–60% of patients will experience a systemic reaction with subsequent stings

28 Venom-induced Anaphylaxis: Prevention Avoidance Measures What to doWhat not to do Have professionals Use scented products remove hives or nests Wear bright colors Wear white, smooth- finish clothes, ankle- Go barefoot high shoes Drink from open cans Keep outdoor areas freewhen contents are not of garbagevisible

29 Venom-induced Anaphylaxis: Prevention Risk Management Keep EpiPen or EpiPen Jr on hand at all times Educate and train on EpiPen use Develop emergency action plan Wear a MedicAlert bracelet Consult an allergist to determine need for venom immunotherapy

30 Venom-induced Anaphylaxis: Immunotherapy Medical criteria –Hx of any systemic reaction in adults –Hx of life-threatening reaction in children –Positive venom skin test 97% effective Can be discontinued in most after 3–5 years; 10% risk of systemic reaction to subsequent stings

31 Venom-induced Anaphylaxis: Immunotherapy Risk of anaphylaxis – –10%-15% of patients experience systemic reactions during early weeks of treatment – –Sx generally occur within 20 minutes – –Patients at risk: asthma, prior reactions, beta blocker or ACEI therapy

32 Immunotherapy-induced Anaphylaxis Risk management – –Trained physician, equipped facility – –Epinephrine immediately available – –Monitor closely for 20–30 minutes – –Consider supply of EpiPen for those at high risk

33 Latex-induced Anaphylaxis: Incidence 1%–6% of US population (up to 16 million) affected 8%–17% incidence among health care workers Repeated exposure leads to a higher risk Incidence has increased since mid 1980s –Latex gloves, especially powdered gloves

34 Latex-induced Anaphylaxis: Triggers Proteins in natural rubber latex Component of ~40,000 commonly used items –Rubber bands –Elastic (undergarments) –Hospital and dental equipment Latex-dipped products are biggest culprits –Balloons, gloves, bandages, hot water bottles

35 Reactions to Latex Irritant contact dermatitis – –Dry, itchy, irritated hands Allergic contact dermatitis – –Delayed hypersensitivity Latex allergy – –Immediate hypersensitivity – –Sx: hives, itching, sneezing, rhinitis, dyspnea, cough, wheezing – –Greatest risk with mucosal contact

36 Latex-induced Anaphylaxis: Prevention Use latex-free products Alert employer/health care providers, schools about need for latex-free products and equipment Wear MedicAlert bracelet Awareness of cross-sensitivity with foods: I. AVOIDANCE – –Banana – –Avocado – –Chestnuts – –Kiwi – –Stone fruit – –Others

37 Latex-induced Anaphylaxis: Prevention Prescribe EpiPen ® or EpiPen ® Jr –Accidental exposure –Patients at risk Educate re: EpiPen ® use Develop emergency action plan II. RISK MANAGEMENT

38 Other Causes of Anaphylactic and Anaphylactoid Reactions Drugs –Antibiotics –Chemotherapeutic agents –Aspirin, NSAIDs –Biologicals (vaccines, monoclonal antibodies) Radiocontrast media Exercise Idiopathic

39 Diagnosing Anaphylaxis Based on clinical presentation, exposure Hx Cutaneous, respiratory Sx most common Some cases may be difficult to diagnose –Vasovagal syncope –Scombroid poisoning –Systemic mastocytosis

40 Diagnosing Anaphylaxis Careful history to identify possible causes Can be confirmed by serum tryptase –Specific for mast cell degranulation –Remains elevated for up to 6 hours Other labs to rule out other diagnoses Refer to allergist for specific testing

41 Diagnosing Anaphylaxis Skin tests/RAST –Foods –Insect venoms –Drugs Challenge tests –Foods –NSAIDs –Exercise Allergists can identify specific causes by:

42 Treatment of Anaphylaxis Immediate treatment with epinephrine imperative –No contraindications in anaphylaxis –Failure or delay associated with fatalities –IM may produce more rapid, higher peak levels vs SC –Must be available at all times Antihistamine (oral or parenteral; if oral, use liquid or chewable tablet) Call 911; proceed to Emergency Room

43 EpiPen /EpiPen Jr: Directions for Use

44 EpiPen /EpiPen Jr: Directions for Use

45 EpiPen /EpiPen Jr: Directions for Use

46 Myth: Epinephrine is Dangerous REALITY : Risks of anaphylaxis far outweigh risks of epinephrine administration Minimal cardiovascular effects in children (Simons et al, 1998) Caution when administering epinephrine in elderly patients or those with known cardiac disease

47 Treatment of Anaphylaxis Additional measures may include –Corticosteroids –Supplemental O 2 ; airway maintenance –IV fluids, vasopressor therapy –Repeat epinephrine if Sx persist or increase after minutes –Repeat antihistamine ± H 2 blocker if Sx persist –Observe for a minimum 4 hours –Arrange follow-up care, provide EpiPen ® Rx and education

48 Myth: Anaphylaxis is Reported REALITY : Most individuals do not inform their personal physician of an anaphylactic reaction either at the time of the reaction or during routine exams

49 Risk Management for Anaphylaxis SCREEN –Atopy 10% of children with asthma have food allergy 30%–40% of children with atopic dermatitis have food allergy –Previous reactions 75% will have more than one 57% will have three or more

50 Screening Patients at Risk Did you ever have a severe allergic reaction: – –To any food? – –To any medicine? – –To an insect sting? – –To latex? – –That caused breathing trouble? Severe hives and swelling? Severe vomiting or diarrhea? Dizziness? – –That required you to go to the hospital?

51 SCREEN, Educate, and Protect Patients at Risk

52 Risk Management for Anaphylaxis EDUCATE –Teach avoidance measures –Accidents are never planned –Stress importance of: Always having a current EpiPen on hand Immediate treatment –Emphasize the need for follow-up care

53 EpiPen ® 2-Pak * EpiPen ® 2-Pak was launched in April 2001

54 Risk Management for Anaphylaxis EDUCATE: Draft an Emergency Plan –Provide specific instructions on when to administer EpiPen or EpiPen Jr –Call for help (911); transport patient to emergency care facility –Stay calm; keep patient warm –Specify directions for antihistamine use –Report EpiPen administration

55 Screen, Educate, and Protect AAAAI Board of Directors. Position statement: Anaphylaxis in schools and other childcare settings. J Allergy Clin Immunol 1999;102: Reprinted with permission. Emergency Health Care Plan ALLERGY TO:_____________________________________________________________ Childs Name: ___________________________ D.O.B: ____________ Teacher: ___________________ Asthmatic Yes (High risk for severe reaction) No Signs of an allergic reaction include: Systems: Symptoms: MOUTH itching & swelling of the lips, tongue, or mouth THROAT* itching and/or a sense of tightness in the throat, hoarseness, and hacking cough SKIN hives, itchy rash, and/or swelling about the face or extremities GUT nausea, abdominal cramps, vomiting, and/or diarrhea LUNG* shortness of breath, repetitive coughing, and/or wheezing HEART* thready pulse, passing-out The severity of symptoms can quickly change! *All above symptoms can potentially progress to a life- threatening situation! ACTION: 1. If ingestion is suspected give ________________________________________________ medication/dose/route and _____________________________________________________ immediately! 2. CALL RESCUE SQUAD: _________________________________________________ 3. CALL: Mother __________________ Father ___________________ or emergency contacts 4. CALL: Dr. ____________________________ at ____________________________ DO NOT HESITATE TO ADMINISTER MEDICATION OR CALL RESCUE SQUAD EVEN IF PARENTS OR DOCTOR CANNOT BE REACHED! ________________________ _______ _______________________ M.D. _______ Parent Signature Date Doctors Signature Date For children with multiple food allergies, use one form for each food. Emergency Health Care Plan ALLERGY TO:_____________________________________________________________ Childs Name: ___________________________ D.O.B: ____________ Teacher: ___________________ Asthmatic Yes (High risk for severe reaction) No Signs of an allergic reaction include: Systems: Symptoms: MOUTH itching & swelling of the lips, tongue, or mouth THROAT* itching and/or a sense of tightness in the throat, hoarseness, and hacking cough SKIN hives, itchy rash, and/or swelling about the face or extremities GUT nausea, abdominal cramps, vomiting, and/or diarrhea LUNG* shortness of breath, repetitive coughing, and/or wheezing HEART* thready pulse, passing-out The severity of symptoms can quickly change! *All above symptoms can potentially progress to a life- threatening situation! ACTION: 1. If ingestion is suspected give ________________________________________________ medication/dose/route and _____________________________________________________ immediately! 2. CALL RESCUE SQUAD: _________________________________________________ 3. CALL: Mother __________________ Father ___________________ or emergency contacts 4. CALL: Dr. ____________________________ at ____________________________ DO NOT HESITATE TO ADMINISTER MEDICATION OR CALL RESCUE SQUAD EVEN IF PARENTS OR DOCTOR CANNOT BE REACHED! ________________________ _______ _______________________ M.D. _______ Parent Signature Date Doctors Signature Date For children with multiple food allergies, use one form for each food. EMERGENCY CONTACTSTRAINED STAFF MEMBERS 1. __________________________________ Relation: ________________ Phone: ________ 1. _________________________ Room_ _____ 2. __________________________________ Relation: ________________ Phone: ________ 2. ________________________ _Room_ _____ 3.__________________________________ Relation: ________________ Phone: ________ 3. _________________________ Room ______ Place Childs Picture Here

56 Myth: Anaphylaxis is Easy to Avoid If You Know What You are Allergic To REALITY : Most cases of anaphylaxis are due to accidental exposures

57 Risk Management for Anaphylaxis PROTECT: –Prescribe self-injectable EpiPen –Teach patient proper use of EpiPen –Educate family, friends, teachers, caregivers

58 Anaphylaxis Screen, educate, and protect + Immediate treatment = Saved lives


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