Anaphylaxis

Anaphylaxis

1. Anaphylaxis Case Examination – Diagnosis, and management of anaphylaxis in the pre-hospital setting Adam Khan MCoP Paramedic Clinical Tutor

2. Aim: The student should be able to demonstrate a clear understanding of the safe approach, diagnosis and timely management of a patient presenting with anaphylaxis in the pre-hospital setting.

3. Objectives: Understand the causes, prevalence & clinical manifestation of anaphylaxis. Demonstrate a safe approach to a patient presenting with anaphylaxis. Understand the diagnosis and management of a patient presenting with acute life-threatening anaphylaxis. Understand the definitive management and referral options to a patient suffering with anaphylaxis

4. Case Presentation: you are dispatched to a 30-year-old female ‘Louise’ who is complaining of acute onset of dyspnea. Acute onset of dyspnea, choking. Occurrence following what is described as a ‘Bee sting’ Previous medical history: Childhood Asthma

5. Case Presentation: continued Location: Louise is located in a busy public park with her boyfriend. Warm, sunny and dry afternoon.

6. Case Presentation: continued Patient Assessment Triangle (PAT): Marginally obstructed airway. resp. rate 32 resp /min . Shallow & laboured. Flushed in appearance, clear agitation, swelling around the eyes and mouth. Palpable Radial pulses, bi-laterally rate of 133 b/min. Responding verbally in broken sentences – clear hoarse voice

7. Anaphylaxis: What is it? Anaphylaxis is a severe, life-threatening, generalised or systemic hypersensitivity reaction Multisystem involvement, including the airway, vascular system, gastro intestinal (GI) tract and skin and central nervous system. Acute onset .

8. Anaphylaxis: What is it? Patients who have anaphylactic reaction have life-threatening airway and/or breathing and/or circulation problems usually associated with skin and mucosal changes Resuscitation council UK (2012)

9. Causes: of anaphylaxis Stings 47 Nuts 32 Food 13 Food Possible Cause 17 Antibiotics 27 Anaesthetic Drugs 39 Other Drugs 24 Contrast Media 11 Other 3 Figures taken from Resuscitaiton Council (UK) 2008 . Table 1. Suspected triggers for fatal anaphylactic reactions in the UK between 1992-2001

10. Lifetime Prevalence: According to the Resuscitation Council (2008) approx. in 1 in 1,333 of the English population have experienced anaphylaxis at some point in their lives. The current incidence rate suggests that between 30 and 950 cases per 100,000 persons per year present in the ED with anaphylaxis

11. Anaphylaxis: Mortality Post Mortem Findings: Airway (laryngeal) and tissue (visceral) edema Gastrointestinal Hemorrhage Myocardial injury

12. Anaphylaxis: Risk Factors Fatal cases – 4% Risk factors Asthmatics Mast Cell Disease – (rare) Personal/Familial history of anaphylaxis Age Sex

13. Anaphylaxis – Clinical Presentation The Skin (Integumentary System) Pruritus (Itching), Urticaria (Hives), Angioedema, Flushing Example of urticaria (hives) presenting in a child

14. Anaphylaxis – Clinical Presentation Angioedema affecting the eyes and mouth. If left untreated this can develop into a life-threatening airway obstruction

15. Anaphylaxis – Clinical Presentation Respiratory System: Dyspnea, Tachypnoea, Universal Wheeze/crackles, Stridor and/or hoarseness, throat swelling Cardiovascular system: Hypotension, Hypoxia, Tachycardia, arrhythmias Gastro-Intestinal system: Nausea, Diarrhea, Stomach cramp, Bloating and/or abdominal distension, vomiting Central Nervous System (CNS) Confusion, Dizziness, Headache, agitation and/or anxiety

16. Case Presentation: Vital Signs: Angioedema, Dyspnoea & tachypnoea 32 r/min SpO2: 89 % (air) Tachycardia: 133 b/min Blood pressure: 88 / 52 mm/hg Temperature: 37.1 degrees Celsius 12 lead ECG: Sinus Tachycardia Blood sugar: 6.6

17. Anaphylaxis: Initial management Should consist of: Removal of offending agent (if possible) Rapid primary assessment ABCDE Focused Secondary assessment which includes Head to toe physical assessment NIBP 12 Lead ECG monitoring

18. Anaphylaxis: Initial management Algorithm to the right indicates the steps required to appropriately manage a patient suffering with acute onset of sever anaphylaxis Algorithm taken from Resus Council UK 2012

19. Anaphylaxis: Treatment Joint Royal Colleges Ambulance Liaison Committee (JRCALC) ABC Assessment – Anaphylaxis OXYGEN – 15L if SpO2 <95% ADRENALINE (ADX) 1:1,000 Intra-muscular (IM) 500 mcgs HYDROCORTISONE (HYC) Intra-venous/muscular 200mgs SALBUTAMOL (SLB) Nebulised 5.0mg

20. Anaphylaxis: Treatment (cont.) CHLORPHENAMINE (CPH) Intra-venous 10mg SODIUM CHLORIDE (SCP) Intra-venous. 250 mL (titrated) NOTE: E stablishing IV access should not delay transport to ED Adrenaline can be re-administered after 5 minutes if no effect Hydrocortisone is considered if transport time to ED is >30 mins

21. Transport Considerations Rapid Transport to Accident & Emergency ATMIST pre-alert en-route Consider HEMS if in a rural location or >45mins from hospital

22. Anaphylaxis: Temporal Pattern Uni-phasic: Singular allergic reaction, can be self limiting Bi-phasic: Initial allergic reaction Recurrence of same manifestations up to 8hrs later Protracted Up to 32 hours May not be prevented by glucocorticoids

23. Further treatment: ED will consider admittance if patient: Presents with biphasic or protracted reactions. If this is the patients first reaction. Age of patient – Risk management Children Elderly Referral onto an immunologist or allergy specialist will be required

24. Differential Diagnosis Life Threatening: Severe Asthma Sepsis (SIRS) Pulmonary Embolism (PE) Choking Non life-threatening Syncope (vasovagal episode) Panic Attack Idiopathic Urticaria Isolated Angioedema

25. Summary: Anaphylaxis is a life-threatening condition. Prompt identification, assessment and management is vital for positive outcomes. Rapid transport is key to definitive treatment. Do not delay on scene time Be aware of future treatment options