1. 20
Allergic Reaction

2. Multimedia Directory
Slide 31 Allergic Reaction—Anaphylaxis Video Slide 32 Information About Allergic Rhinitis Video
These videos appear later in the presentation; you may want to preview them prior to class to ensure they load and play properly. Click on the links above in slideshow view to go directly to the slides.

3. Topics Allergic Reactions Self-Administered Epinephrine
Planning Your Time: Plan 70 minutes for this chapter.
Allergic Reactions (40 minutes)
Self-Administered Epinephrine (30 minutes)
Note: The total teaching time recommended is only a guideline.
Core Concepts:
How to identify a patient experiencing an allergic reaction
Differences between a mild allergic reaction and anaphylaxis
How to treat a patient experiencing an allergic reaction
Who should be assisted with an epinephrine auto-injector

4. Allergic Reactions Teaching Time: 40 minutes
Teaching Tips: Relate the pathophysiology of anaphylaxis to previous lessons on shock and respiratory problems. Discuss how the signs and symptoms may be similar. Multimedia graphics may be helpful in demonstrating patient assessment of an allergic reaction. Use examples of real-life allergic reaction and anaphylaxis to add realism to pathophysiology. Spend time discussing how to differentiate anaphylaxis. Epinephrine is not a benign drug, and EMTs should take care to give it only in the correct circumstances. Teach providers to be constantly alert for anaphylaxis. Rapid changes occur.

5. Allergic Reactions
Immune system naturally responds to foreign substances in body.
Allergic reaction
Exaggerated response to foreign substance
Allergen
Substance causing exaggerated effect
Covers Objective: 20.3
Point to Emphasize: An allergic reaction is an exaggerated immune response to a foreign invader in the body.
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6. Allergic Reactions Inside First exposure
Immune system forms antibodies.
Antibodies identify and attempt to attack particular foreign substance.
Antibodies combine only with allergen they were formed in response to.
Covers Objective: 20.3
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7. Allergic Reactions Inside Second (and subsequent) exposures
Antibodies exist.
Antibody combines with allergen, leading to release of histamine and other chemicals into bloodstream.
Chemicals cause harmful effects.
Covers Objective: 20.3
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8. Allergic Reactions Outside Effects of histamine and other chemicals
Inflammation (swelling)
Bronchoconstriction
Vasodilation
Covers Objective: 20.4
Knowledge Application: Have students work in small groups. Assign each group a negative effect of an allergic reaction (for example: bronchoconstriction). Have each group describe how assessment would identify that effect (for example: bronchoconstriction = wheezes).
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9. Allergic Reactions Anaphylaxis
Severe, life-threatening allergic reaction
Can cause:
Rapid dilation of blood vessels (hypotension)
Airway swelling (airway obstruction)
Bronchoconstriction (respiratory failure)
Covers Objective: 20.4
Point to Emphasize: Anaphylaxis is a severe and systemic form of an allergic reaction and should be considered a life-threatening emergency.
Discussion Topic: Define allergy. How is an allergic reaction different from an anaphylactic reaction?
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10. Allergic Reactions Common allergens Insects Foods Plants Medications
Others
Dust, makeup, soap, etc.
Covers Objective: 20.5
Point to Emphasize: Food, insect bites and stings, plants, and certain medications can cause allergic reactions.
Discussion Topic: Discuss the potential causes of an allergic reaction. Describe at least three common allergies.
Knowledge Application: Assign common causes of allergy. Ask students to research and report on prevalence, severity, and morbidity and mortality.
Critical Thinking: How might an ingested allergen cause a different reaction from that of an injected allergen? Why might these reactions present differently?

11. Substances that may cause allergic reactions.
Common Allergens
Covers Objective: 20.5
Point to Emphasize: Food, insect bites and stings, plants, and certain medications can cause allergic reactions.
Discussion Topic: Discuss the potential causes of an allergic reaction. Describe at least three common allergies.
Knowledge Application: Assign common causes of allergy. Ask students to research and report on prevalence, severity, and morbidity and mortality.
Critical Thinking: How might an ingested allergen cause a different reaction from that of an injected allergen? Why might these reactions present differently?
Substances that may cause allergic reactions.

12. Allergic Reactions Latex allergy Common concern in EMS
Many patients have latex sensitivity
Providers can develop latex allergy from prolonged exposure
Covers Objective: 20.5
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13. Allergic Reactions
No way to predict exact course of an allergic reaction.
Severe reaction often takes place immediately, but can be delayed 30 minutes or more.
Mild allergic reaction can rapidly progress to anaphylaxis.
Covers Objective: 20.6
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14. Allergic Reactions Signs and symptoms Skin Itching Hives
Flushing (red skin)
Swelling of the face
Warm, tingling feeling in face, mouth, chest, feet, or hands
Covers Objective: 20.6
Talking Points: Swelling (edema) is most common in the face (especially the eyes and lips), neck, hands, feet, or tongue.

15. Signs and Symptoms: Skin
Covers Objective: 20.6
Talking Points: Swelling (edema) is most common in the face (especially the eyes and lips), neck, hands, feet, or tongue.
Signs of an allergic reaction may include facial swelling. © Edward T. Dickinson, MD

16. Signs and Symptoms: Hives
Covers Objective: 20.6
Talking Points: Hives, also known as urticaria, can be localized, especially around the area of a bite or sting, or generalized, presenting over wide areas of the body.
Signs of an allergic reaction may include hives. © Edward T. Dickinson, MD

17. Allergic Reactions Signs and symptoms Respiratory
Tightness in throat or chest
Cough
Rapid, labored, and/or noisy breathing
Hoarseness, muffled voice, loss of voice
Stridor
Wheezing
Covers Objective: 20.6
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18. Allergic Reactions Signs and symptoms Cardiac Increased heart rate
Decreased blood pressure
Covers Objective: 20.6
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19. Allergic Reactions Signs and symptoms Generalized findings
Itchy, watery eyes
Headache
Runny nose
Sense of impending doom
Covers Objective: 20.6
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20. Allergic Reactions Signs and symptoms of shock Altered mental status
Flushed, dry skin or pale, cool, clammy skin
Nausea or vomiting
Changes in vital signs
Increased pulse, respirations
Decreased blood pressure
Covers Objective: 20.6
Point to Emphasize: Anaphylaxis can be identified by the signs of an allergic reaction plus airway, breathing, or circulatory challenges.
Discussion Topic: Describe the common signs and symptoms of an allergic reaction and of anaphylaxis. What signs are specific to anaphylaxis?

21. Distinguishing Anaphylaxis from Mild Allergic Reaction
Any of previous signs and symptoms can be associated with an allergic reaction.
Anaphylaxis
Patient has either respiratory distress or signs and symptoms of shock.
Covers Objective: 20.6
Point to Emphasize: Patient assessment will determine if the patient is having an anaphylactic reaction or just an allergic reaction. Beware, however, for allergy can rapidly progress to anaphylaxis.

22. Patient Assessment Primary assessment
Identify and treat life-threatening problems.
Airway
Breathing
Circulation
Covers Objective: 20.6
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23. Patient Assessment Secondary assessment History of allergies Exposure
What was the patient exposed to?
How (what method/route) was the patient exposed?
Signs and symptoms
Progression
Interventions
Covers Objective: 20.6
Class Activity: Describe scenarios involving various patients having allergic reactions and anaphylactic reactions. Have a class discussion about whether the signs and symptoms described in each case would be classified as an allergic reaction or an anaphylactic reaction.
Knowledge Application: Use a programmed patient and/or multimedia graphics. Demonstrate various types of allergic reactions and ask groups of students to use patient assessment to identify anaphylaxis.
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24. Patient Assessment Assess baseline vital signs.
Obtain remainder of past medical history.
Covers Objective: 20.6

25. Patient Care Manage patient's airway and breathing.
Apply high-concentration oxygen if patient is in distress or appears to be having an anaphylactic reaction.
Mild allergic reactions do not require oxygen.
If not breathing, adequately provide artificial ventilations.
Covers Objective: 20.6
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26. Patient Care
Consider assisting patient with epinephrine auto-injector.
If patient is not wheezing or showing signs of respiratory distress or shock:
Continue with assessment.
Consult medical direction regarding use of auto-injector.
Covers Objective: 20.6
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27. Patient Care When use of auto-injector may be appropriate
If patient has come in contact with substance that caused allergic reaction in the past
If patient also has respiratory distress or exhibits signs and symptoms of shock
Covers Objective: 20.7
Discussion Topic: Discuss the indications for epinephrine.
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28. Patient Care After using auto-injector
Record administration of auto-injector
Transport patient
Reassess after 2 minutes
Covers Objective: 20.6
Knowledge Application: Describe various patients with allergic reactions. Ask students whether they would administer epinephrine. Critique the decision and discuss.

29. After Administering Auto-Injector
Covers Objective: 20.6
Knowledge Application: Describe various patients with allergic reactions. Ask students whether they would administer epinephrine. Critique the decision and discuss.
11. Perform a reassessment, paying special attention to the patient's ABCs and vital signs en route to the hospital.

30. Think About It
Should you administer an auto-injector for a simple allergic reaction?
What assessment findings would indicate the need for epinephrine?
Covers Objectives: 20.6 and 20.7
Talking Points: You should probably not administer epinephrine for a simple allergic reaction. Epinephrine is a potent drug with potential complications and should not be given without serious consideration. In this case medical control may be able to offer better insight. The findings that would indicate administration in a patient with an allergic reaction include respiratory distress and shock.

31. Allergic Reaction—Anaphylaxis Video
Covers Objective: 20.3
Video Clip
Allergic Reaction—Anaphylaxis
What causes anaphylaxis?
What happens to the patient's blood pressure during an anaphylactic reaction?
Explain why a severe allergic reaction can result in respiratory failure.
Click on the screenshot to view a video on the topic of anaphylactic shock.
Back to Directory

32. Information About Allergic Rhinitis Video
Covers Objective: 20.3
Video Clip
Information About Allergic Rhinitis
What is allergic rhinitis?
What happens when someone with a sensitized immune system inhales an allergen?
Discuss the role of histamine in an allergic reaction.
What are some treatments for allergic rhinitis?
Click on the screenshot to view a video on the subject of allergic rhinitis.
Back to Directory

33. Self-Administered Epinephrine
Teaching Time: 30 minutes
Teaching Tips: Relate epinephrine to previous discussions on the sympathetic nervous system. Discuss how they relate. Have epinephrine auto-injectors and/or auto-injector training devices on hand for demonstration purposes. Always follow sharps safety procedures when handling actual injectors. Take time to discuss anaphylaxis and the true indications of epinephrine. Compare these indications with potential side effects of the medication. Discuss the absolute need for reassessment.

34. Self-Administered Epinephrine
Commonly prescribed to patients with a history of allergy
Auto-injectors are common for people to carry or have at home.
Hormone produced by body
Constricts blood vessels
Dilates bronchioles
Covers Objective: 20.8
Point to Emphasize: Epinephrine is a natural hormone produced by the body. It is given in cases of anaphylaxis to constrict blood vessels and dilate the bronchioles.
Discussion Topic: Describe the indications for the use of epinephrine.
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35. Self-Administered Epinephrine
If authorized by medical direction, you can administer or help patient administer dose of epinephrine from auto-injector that has been prescribed for patient by a physician.
Covers Objective: 20.8
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36. Self-Administered Epinephrine
Side effects
Increased heart rate
Increased cardiac workload
Covers Objective: 20.8
Point to Emphasize: Epinephrine is indicated in anaphylactic reactions but not in localized allergic reactions.
Discussion Topic: Describe the side effects of the use of epinephrine.
Class Activity: Present a variety of allergic reaction and anaphylaxis scenarios to the class. Ask students whether they would administer epinephrine. Discuss the decision-making process.
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37. Self-Administered Epinephrine
Administering auto-injector
Spring-loaded needle and syringe with a single dose of epinephrine
Upon administration, medication automatically releases and injects.
Covers Objective: 20.9
Point to Emphasize: An auto-injector is a spring-loaded needle and syringe with a single dose of epinephrine that will automatically release and inject the medication. People with severe allergies commonly carry these devices to deploy in the event of an anaphylactic reaction.
Knowledge Application: Review various types of epinephrine auto-injectors. Review the steps in administering each type.

38. Epinephrine auto-injectors: EpiPen® and EpiPen Jr.®
Covers Objective: 20.9
Point to Emphasize: An auto-injector is a spring-loaded needle and syringe with a single dose of epinephrine that will automatically release and inject the medication. People with severe allergies commonly carry these devices to deploy in the event of an anaphylactic reaction.
Knowledge Application: Review various types of epinephrine auto-injectors. Review the steps in administering each type.
Epinephrine auto-injectors: EpiPen® and EpiPen Jr.®

39. Self-Administered Epinephrine
Administering auto-injector
Obtain patient's prescribed auto-injector and ensure:
Prescription is written for patient.
Medication is not discolored.
Medication has not expired.
Obtain order from medical direction.
Remove safety cap.
Covers Objective: 20.9
Point to Emphasize: Always consider the "five rights" of medication administration before administering an epinephrine auto-injector.
Knowledge Application: Use programmed patients and practice assisting with an epinephrine auto-injector. Pay particular attention to explaining the steps to the patient.
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40. Self-Administered Epinephrine
Administering auto-injector
Press tip of auto-injector firmly against patient's thigh (outside of thigh midway between the knee and waist).
Hold injector in place until medication is injected.
Covers Objective: 20.9
Discussion Topics: Describe the steps involved in correctly administering an epinephrine auto-injector. Describe the circumstances that might indicate the need for additional epinephrine administration.
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41. Self-Administered Epinephrine
Administering auto-injector
Record administration and time.
Carefully dispose of single-dose injector in biohazard container
Save two-dose injector
Covers Objective: 20.9
Discussion Topics: Describe the steps involved in correctly administering an epinephrine auto-injector. Describe the circumstances that might indicate the need for additional epinephrine administration.

42. Additional Doses of Epinephrine
Reassessment may show patient condition deteriorating.
Additional doses of epinephrine may be necessary.
Requires on-line medical control
Requires bringing patient's additional auto-injectors in ambulance
Covers Objective: 20.10
Point to Emphasize: In a severe anaphylactic patient, additional doses of epinephrine may be necessary.
Knowledge Application: Use programmed patients to present reassessment scenarios. Have students work through the decision-making process of secondary epinephrine administration.
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43. Additional Doses of Epinephrine
If no auto-injector available:
Request ALS intercept.
Treat for shock.
Covers Objective: 20.7
Class Activity: Take a voluntary class poll. Find out what types of allergies are present in the class. How severe have prior reactions been? Ask willing students to discuss.

44. Pediatric Note Two sizes of auto-injectors Adult dose
0.3 mg
Children's dose (for child less than 66 pounds)
0.15 mg
Covers Objective: 20.9
Skill Demonstration: Using a manikin and an auto-injector training device, demonstrate the proper procedure for administering medication via an auto-injector device.

45. Chapter Review

46. Chapter Review
Allergic reactions are common. Anaphylaxis, a true life-threatening allergic reaction, is rare.
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47. Chapter Review
The most common symptom in these cases is itching. Patients with anaphylaxis will also display life-threatening difficulty breathing and/or signs and symptoms of shock. Patients with anaphylaxis will be extremely anxious. Their bodies are in trouble and are letting them know it.
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48. Chapter Review
The signs and symptoms of anaphylaxis result from physiological changes: vasodilation, bronchoconstriction, leaky capillaries, and thick mucus.
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49. Chapter Review
By quickly recognizing the condition, consulting medical direction, and administering the appropriate treatment, you can literally make the difference between life and death for these patients.

50. Remember
In an allergic reaction, the body's immune system overreacts to an allergen and causes potentially harmful side effects.
Anaphylaxis is a severe, systemic form of allergic reaction; it is a life-threatening emergency.
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51. Remember
EMTs must use assessment to differentiate a localized allergic reaction from a systemic anaphylactic reaction.
Epinephrine is useful in anaphylaxis because it constricts dilated blood vessels and opens bronchial passages.
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52. Remember
Epinephrine has potentially dangerous side effects and should be used only in the event of anaphylaxis.

53. Questions to Consider
What are the indications for administration of an epinephrine auto-injector?
List some of the more common causes of allergic reactions.
Talking Points: Indications include signs of an allergic reaction plus respiratory distress and/or shock. Allergic reactions are caused by an exaggerated immune response. Common allergens include medications, insects, and foods.
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54. Questions to Consider
List signs or symptoms of an anaphylactic reaction associated with each of the following:
Skin
Respiratory system
Cardiovascular system
Talking Points: Skin signs include flushing, tingling sensation, and hives. Respiratory signs include difficulty breathing, wheezing, and difficulty speaking. Cardiovascular signs include increased heart rate, hypotension, and pale skin.

55. Critical Thinking
A 24-year-old male ate a meal that he believes contained shellfish. He is allergic to shrimp. He is sweating and nervous. He appears to be breathing adequately. You do not note any wheezing or stridor.
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56. Critical Thinking
His face is slightly red. His pulse is 88 strong and regular, respirations 24, blood pressure 108/74, and skin warm and moist. Should you administer epinephrine?
Talking Points: Probably not yet and definitely not until you contact medical control. Although this patient is at high risk due to his known allergy, he does not yet have the signs of anaphylaxis. He is breathing normally and no signs of shock are present. You should reassess frequently and consult medical control.