Anaphylaxis

foods that most commonly cause allergic reactions:

milk, eggs, peanuts, tree nuts, fish and shellfish *Allergenicity of a food can be changed by heating or cooking

latex allergy reactions

reactions occur within minutes for sensitised people with latex allergies affects many healthcare workers and certain types of patients (particularly patients who had routine urinary cathetization); increased exposure to latex = increased risk for developing rxns

if the child with known latex allergy is exposed, what should the nurse do?

remove irritating substance and cleanse area with soap and water assess the child, assess need for resuscitation and perform as is needed

max epinephrine dosage in children

0.3 mg in children (0.01mg/kg up to 0.3 mg in children) can repeat every 5 minutes as needed, but sooner if clinically warranted site: IM in the middle of the lateral thigh (large vastus lateralis muscle; w/ 1 inch or larger needle)

types of allergic rhinitis include:

1. Perennial (occur all year around) 2. seasonal (hay fever); intense symptoms concurrent with periods of high allergen exposure (pollens, fungal spores) symptoms that become worse at night may be r/t household allergen and symptoms that improve/disappear at weekends may be r/t occupational exposure

what are the 6 components of the ASAP?

1. skin & mucosa (0-3) 2. respiratory (0-3) 3. cardiovascular (0-3) 4. abdominal & pelvic (0-3) 5. neurological (0-2) 6. risk factors (0-2)

what are the two systemic responses in anaphylaxis that cause s/s of anaphylactic reaction?

1. vasodilation 2. capillary permeability the antigen-antibody reaction --> mast cells to release potent vasoactive substances (histamine, bradykinin) and activates inflammatory cytokines leading to widespread vasodilation and capillary permeability

most anaphylactic reactions occur within what time frame after exposure

5 minutes to 1 hour after exposure; BUT can occur > 10 hours after the exposure

what are the nursing priorities in an anaphylactic reaction?

ABC's: nurse must assess airway patency and adequate of breathing determine if circulation is sufficient note level of consciousness obtain a brief history, enquiring about specific allergen exposure; determine if child has received any medication (epinephrine, diphenhydramine) since onset of reaction and what effect the medication had on symptoms

treatment of the patient in cardiac arrest and respiratory arrest r/t anaphylactic shock:

CPR is performed endotracheal tube intubation may be necessary to establish airway IV access for fluids and medications

medical management of anaphylactic shock:

Remove causative agent (discontinuing antibiotic) administering medications that restore vascular tone - IM epinephrine for its vasoconstrictive action - Diphenhydramine (Benadryl) IV to reverse effects of Histamine to reduce capillary permeability - Nebulized medications (Albuterol) may be given to reverse histamine induced bronchospasm emergency support of basic life functions - fluid management is critical; massive fluid shifts can occur within minutes r/t increased vascular permeability

what is desensitisation

a program of specific immunotherapy 'allergy shots' may be used when symptoms are particularly bothersome desensitisation involves frequent (weekly) injections of offending antigens they are given in increasing doses and stimulate the production of high levels of IgG which acts as blocking antibody by combining with the antigen before it combines with the cell-bound IgE antibodies

Anaphylaxis definition:

a rapid-onset serious reaction that can lead to death usually allergic reaction, but can be non-allergic or idiopathic in origin an acute, systemic mastocytosis (abnormal growth of mast cells) - 2 out of 3 cases are idiopathic (no known cause)

Anaphylaxis score assisting providers (ASAP): 1-4

a score of 1-4 points indicates acute anaphylaxis may still be developing - routine use of Epi not indicated, but MAY be appropriate if symptoms are recent and progressing rapidly or if indicated per patient's anaphylaxis action plan place on monitors, observe closely in environment with trained staff and prepare to treat with Epi if needed

ASAP score > or equal to 5?

acute anaphylaxis very likely, in appropriate clinical context, Epi is indicated

after 3rd dose of IM epinephrine, what should the nurse anticipate?

after third IM dose of Epi, the nurse should anticipate starting epinephrine drip --> PICU consult --> admit to PICU

allergic rhinitis:

allergic rhinitis is characterised by symptoms of sneezing, itching, watery discharge from nose and eyes (rhino conjunctivitis) produces nasal symptoms and is also frequently associated with other chronic airway disorders such as sinusitis and bronchial asthma severe attacks of allergic rhinitis may be accompanied by malaise, fatigue, muscle soreness from sneezing; fever absent; sinus obstruction may cause headache

anaphylactic shock

anaphylactic shock is a distributive shock w/ excessive vasodilation and decreased systemic vascular resistance due to massive histamine release treated first by reversing underlying cause to achieve hemodynamic stability, fluid resuscitation and vasoactive drugs

immunologic definition of anaphylaxis

anaphylaxis, an acute systemic allergic reaction, is most frequently a type 1 hypersensitivity reaction (IgE-mediated) - our body's normal, protective immune system has a harmful effect on the body

most common anaphylaxis triggers in adults

antibiotics (penicillin) contrast media anaesthetic agents insect stings

nurse's role: preventing anaphylactic shock

assess all patients for allergies or previous reactions to antigens (medications, blood products, food, contrast agents, latex) communicate allergies / reactions to others observes all patients for allergic reaction with new medications (antibiotics, beta blockers, angiotensin inhibitors), aspirin, non steroidal anti inflammatory drugs

nursing priorities with anaphylactic reaction

assess for allergy exposure remove antigen if still present ABC's: airway, breathing circulation - Code blue and CPR if needed / call 911 - Epinephrine administration (IM ordered or patient autoinjector)

main components of the nursing assessment in the anaphylactic reaction?

assess patency of airway and adequacy of breathing determine if circulation is sufficient (is patient hypotensive) note level of consciousness obtain a brief history and inquire specifically about allergen exposure has child received any medication since anaphylaxis onset? (Epinephrine or Diphenhydramine) and what effect these medications had on symptoms

atopic diseases that are IgE mediated:

atopic dermatitis, allergic rhinitis, asthma

risk factors for anaphylaxis R/T genetics?

atopy: genetic tendency to develop an exaggerated IgE immune response to normally harmless environmental substances [Allergic rhinitis; Asthma; Atopic dermatitis (Eczema); food allergies]

prevention of anaphylaxis:

avoidance of potential allergens auto-injector system for epinephrine (EpiPen and Auvi-Q) which deliver remeasured doses of epinephrine screening for allergies before medication administration (history of any sensitivity to suspected antigens obtained) ask patients about previous exposure to contrast agents used for diagnostic tests and any allergic reactions, as well as to medications, foods, insect stings, and latex

treatment of allergic rhinitis includes:

avoidance of the offending allergen treatment is symptomatic in most cases including use of oral antihistamines and oral or topical decongestants intranasal corticosteroids are effective when used appropriately intranasal cromolyn (stabilises mast cells and prevents their degranulation) - useful especially when administered before allergen exposure

other risk factors for anaphylaxis

besides atopy biological sex - females have a higher prevalence - contrast media, latex, muscle relaxants - males with insect stings Age: Allergies will decrease with age, but not with anaphylaxis; triggers change and highest incidence is 30-39 years SES: higher socioeconomic classes tend to see an increased prevalence (Hygiene hypothesis: lack of early exposure to microbes/allergens) Geography - rural environments - northern US > southern US - pollution Co-morbidities - asthma, CVD, substance abuse, mastocytosis (increased production of mast cells), MCAS (mast cell activation syndrome) Exposure History - longer time between exposures predicts a lower risk of anaphylaxis occurrence Exercise-induced anaphylaxis

what is a biphasic reaction?

biphasic reaction = a second wave of reaction after first wave has improved - estimated in 15% of pediatric anaphylaxis - most occur within 10 hours, reported > 72 hours after initial rxn

bronchospasm?

bronchospasm or a bronchial spasm is a sudden constriction of the muscles in the walls of the bronchioles caused by release (degranulation) of substances from mast cells or basophils under influence of anaphylatoxins --> difficulty in breathing (mild to severe)

diagnosis of food allergies:

diagnosis is usually based on careful food history and through provocative diet testing - provocative testing includes careful elimination of the suspected allergen from the diet for a period of time to see if symptoms disappear, then reintroducing the food to see if the symptoms reappear - only one food is tested at a time in provocative diet testing

how is diagnosis of a food allergy made?

diagnosis of food allergies is based on a careful food history and through provocative diet testing - provocative diet testing: wherein there is careful elimination of suspected allergen from the diet for a period of time to see if symptoms go away, and reintroducing the food to see if symptoms then re-appear

untreated anaphylaxis leads to:

cardiovascular collapse / cariogenic shock (pump failure) kidney failure brain damage arrhythmias heart attacks death

anaphylaxis presentation - cardiovascular

cardiovascular s/s include tachycardia, chest pain, arrhythmia, and hypotension dizziness, tunnel vision, "leaky" vessels lead to decreased BP, fainting

what are the 'severe' anaphylaxis symptoms

cyanosis an O2 sat < 92% hypotension, collapse confusion, loss of consciousness incontinence

what other medications may be given during an anaphylactic reaction in addition to epinephrine

depending on severity, we may give IV or PO histamine 1 (cetirizine, diphenhydramine) or histamine 2 blockers (cimetidine, ranitidine) steroids (dexamethasone, methylprednisone)

diagnosis of allergic rhinitis includes:

diagnosis depends on a careful history and physical microscopic identification of increased # of eosinophils on a nasal smear skin or serum testing to identify the offending allergens may be done

nursing care: preventing and managing future anaphylactic reactions

educate family on prevention of future episodes - avoid known allergens management - use of injectable epinephrine via IM injection via EpiPen or EpiPen Jr. with dosage based on child's weight - pen should be carried with the child at all times - grey safety release cap should not be removed until just before use - thumb, fingers, hand should not be placed over the black tip - the child and family should call 911 after using EpiPen

treatment of anaphylaxis centers on?

epinephrine administration in a 1:1000 dilution, given subcutaneously in upper extremity or thigh and may be followed by another dose or continuous IV administration

mechanism of action of epinephrine

epinephrine is the only first line medication to treat anaphylaxis, given IM only vasoconstrictor, blocks histamine release, stabilises mast cells, smooth muscle relaxation and increases coronary perfusion

epinephrine and bronchial smooth muscle

epinephrine produces relaxation of bronchial smooth muscle

what are common causes of anaphylaxis

foods - peanuts; tree nuts (walnuts; pecans; cashews; almonds) - shellfish (shrimp; lobster; crab) - fish, milk, eggs, soy, wheat medications - antibiotics (Penicillin and Sulfa antibiotics) - allopurinol - radiocontrast agents - anesthetic agents (lidocaine, procaine) - vaccines - hormones (insulin, vasopressin, adrenocorticotropic hormone) - aspirin - non steroid anti inflammatory drugs other pharmaceutical/biologic agents - animal serums (tetanus antitoxin, snake venom antitoxin, rabies antitoxin) - antigens used in skin testing insect stings - bees, wasps, hornets, yellow jackets, ants latex - medical and non-medical products containing latex

what are the most common triggers of anaphylactic shock?

foods (peanuts), medications and insects

if the patient is clearly in anaphylaxis, what does the nurse do first?

give Epinephrine first, do not wait / delay Epi to score the patient

risk factors for anaphylactic shock include:

history of medication sensitivity transfusion reaction history of reaction to insect bites/stings food allergies latex sensitivity iodine or shellfish allergy (contrast agent) known medication allergy

what happens with accidental Epi-pen injection?

if injected into small areas (fingers, blood vessels) their will be constriction at the site with potential tissue death (worst-case scenario) symptoms of accidental injection typically not severe: temporary numbness, tingling, increased HR and palpitations, pain at the injection site

mild clinical pathway

if patient has received epinephrine or has cutaneous symptoms --> Cetirizine PO (H1 blocker), H2 receptor blocker PO (cimetidine, ranitidine) then assess for patient risk factors including - history of biphasic or severe reaction - history of asthma or wheezing - time from exposure to symptom onset delayed > 1 hour or unknown if symptoms have resolved and RF are absent = no steroids symptoms persist or risk factors present --> Dexamethasone PO

moderate-severe clinical pathway, patient has been given epi, observed 5-10 mins, if score has not improved or > 5 what is done?

if score not improved or > 5 give epi 0.01 mg/kg via IM in lateral thigh place IV (if not already) cetirizine PO (if unable to tolerate PO then diphenhydramine given IV) H2 blocker IV (Cimetidine, Ranitidine) Methylprednisolone IV observe 5-10 minutes with continued monitoring, VS Q 5 mins if not improved or score > 5 --> another epinephrine injection

what is the allergy process (simplified)

immunoglobulin (IgE) is an antibody produced by the B-cells Mast cells (in tissues) and basophils (blood) both have receptors that are specific for IgE antibodies first exposure (Sensitization): Antibody is produced that recognises that specific allergen (antigen) subsequent exposure: Antigen binds to the IgE receptor on the cell surface leading to degranulation and release of histamine when two or more IgE antibodies bind to the antigen there is a disruption in the mast cell or basophil cell membrane leading to overwhelming release of histamine

most common anaphylaxis triggers in children:

in children, the leading cause is food-related (food allergies)

clinical manifestations of anaphylaxis - integumentary

itching; hives; flushing; angioedema; flushing

latex allergy

latex allergy is an IgE mediate response to latex exposure, a natural rubber product used in many items (gloves in healthcare) - latex is a milk fluid from the rubber tree - increased latex exposure increases the risk for developing reactions patho of latex allergy is similar to that of food allergy avoidance of latex is recommended for all who are allergic; immediate allergic reaction can occur or anaphylaxis in response to latex exposure

local (atopic) reactions:

local or atopic reactions occur when the antigen is confined to a particular site by virtue of exposure the term atopic refers to genetically determined hypersensitivity to common environmental allergens mediated by an IgE mast cell reaction (commonly are allergic to more than one environmental allergen)

severe symptoms indicating immediate need for epinephrine include:

lung - short of breath, wheezing, repetitive cough heart - pale, blue, faint, weak pulse, dizzy throat - tight, hoarse, trouble breathing or swallowing mouth - significant swelling of tongue and/or lips skin - many hives over entire body, widespread redness gut - repetitive vomiting or severe diarrhea other - impending doom, anxiety, confusion ONE severe symptom = injection of epinephrine immediately --> call 911 and request ambulance w/ epinephrine

what are some common type I hypersensitivity triggers?

medications - penicillin, iodinated contrast material foods - eggs, peanuts, shellfish insect bites / stings environmental - latex, dust, pollen, mold, animals anaesthetic agents vaccines (rare) blood transfusion (in pts. with IgA deficiency)

moderate systemic anaphylactic reaction symptoms:

moderate symptoms may include flushing; warmth; anxiety and itching in addition to any of the mild symptoms (tingling, warmth, fullness in mouth and throat, nasal congestion, periorbital swelling, itching, sneezing, tearing) More serious reactions include bronchospasm and edema of the airways or larynx with dyspnea, cough, wheezing

patient positioning guidelines in anaphylaxis

most recent guidelines now recommend patients in anaphylaxis be placed in supine position while lying down, sufficient blood may be able to return to the vena cava to maintain reduced circulation, but when a person is sitting or standing, the venous return stops and the vena cava will become empty w/in seconds --> anaphylactic shock

anaphylaxis presentation - respiratory

nasal pruritus, congestion, sneezing, rhinorrhea (runny nose), coughing stridor, wheeze, tightness in throat, dysphagia, dysphonia, hoarseness, shortness of breath, dyspnea, tight chest

mild symptoms that require more than one and in two body systems for epinephrine:

nose - itchy or runny nose, sneezing mouth - itchy mouth skin - a few hives, mild itch gut - mild nausea/discomfort 2 or more mild symptoms in two or more systems = administer epinephrine

can epinephrine be given IV

not given IV first-line; may cause pulmonary edema, lethal arrhythmias; ONLY if patient is profoundly hypotensive or arrest IV gtt okay after 3 IM doses have been given

how long do we observe patient after anaphylaxis?

observe for 4 hours from latest symptoms, epinephrine, or any worsening

based on severity of symptoms, what are epinephrine recommendations

one severe symptom = treat with epinephrine two or more mild symptoms that appear in two or more systems = epinephrine (nose and gut, for example)

oral, GI, and neurological manifestations of anaphylaxis

oral - lip, tongue, palate pruritus - lip or tongue edema GI: bloating, abdominal pain, diarrhea, vomiting neurological - syncope, feeling faint, impending doom, lethargy, disorientation

nursing interventions after epinephrine administration in anaphylactic patient

oxygen via mask or nasal cannula cardiorespiratory monitoring IV fluids --> give bolus if BP is dropping albuterol for respiratory distress and bronchospasm positioning depends on severity (high Fowler if early on and helpful for respiratory effort --> supine/reverse Trendelenburg if BP is dropping or patient is unconscious)

s/e in Epinephrine administration

palpitations tachycardia/dysrhythmias increased BP headache tremors, weakness nervousness/anxiety N/V angina/ischemia stroke +vasoconstrictor

what kind of medication administration is associated with the most severe anaphylaxis reaction

parenteral form

within the mild clinical pathway, how often should patient be evaluated and scored?

patient is evaluated and scored HOURLY and with any symptom change NOT worse or score 1-4 --> go to ED disposition worse or score > or equal to 5 --> Epinephrine likely indicated; condition progressing to moderate-severe

what are the guidelines regarding monitoring after an anaphylactic reaction?

patients who have experienced an anaphylactic reaction and received epinephrine should be transported to the emergency department for observation and monitoring - there is a risk for a 'rebound' or delayed reaction 4-8 hours after initial reaction - observation time is individualized based on severity of reaction longer run times are considered for: - patients who ingested the allergen - required > 1 dose epinephrine - had hypotension or pharyngeal edema - hx of asthma

who is at risk for an anaphylactic reaction r/t contrast agent?

patients with a known allergy to iodine or fish are at increased risk as well as patients with a previous allergic reaction to a contrast agent

mild systemic anaphylactic reaction symptoms:

peripheral tingling; sensation of warmth possibly w/ feeling of fullness in the mouth and throat nasal congestion, periorbital swelling, pruritus, sneezing, tearing of the eyes onset of symptoms within first 2 hours of the exposure

if patient is deemed "high clinical concern" for anaphylaxis --> give epinephrine 0.01 mg/kg IM and repeat 5 mins as needed --> what nursing interventions are warranted next?

place patient on monitors - vital signs every 5 minutes place patient in supine position, as tolerated avoid sudden changes in position, especially to standing supplemental O2 until O2 sat is known and to maintain O2 sat > 90% observe 5-10 minutes, if patients symptoms improve follow "mild" pathway, if symptoms do not improve use "moderate-severe" pathway

what are some challenges evident in recognising anaphylaxis?

presenting symptoms may not meet anaphylaxis criteria but still require epinephrine administration delayed epinephrine is associated with worse symptoms; poorer outcomes; and increased mortality there are no validated tools that exist to aid in the diagnosis (identification of patient w/ mild symptoms heading to Anaphylaxis)

emergency treatment of an anaphylactic reaction

respiratory and CV functions are evaluated, if patient is in cardiac arrest --> CPR instituted supplemental oxygen is provided during CPR for the patient who is cyanotic, dyspneic, or wheezing Epinephrine in a 1:1000 dilution given subcutaneously in upper extremity or thigh and may be followed by a continuous IV infusion antihistamines and corticosteroids may be given in addition to epinephrine - but not in place of. IV fluids (normal saline), volume expanders, and vasopressor agents are given to maintain BP and normal hemodynamic status

severe systemic anaphylactic reaction symptoms:

severe symptoms include an abrupt onset with same s/s as described with mild and moderate rapid symptom progression to bronchospasm, laryngeal edema, severe dyspnea, cyanosis, hypotension dysphagia (difficulty swallowing); abdominal cramping; vomiting; diarrhea and seizures can occur cardiac arrest and coma may follow Anaphylactic shock*

what food allergies correlate with latex allergy possibility?

suspect possible latex allergy if patient reports tropical fruit allergies (bananas, kiwis, avocados)

contraindications to epinephrine use?

symptom-free exposure = do not routinely give episodes without any s/s of anaphylaxis no contraindications to using; there is nearly zero risk in kids with the right dose/route higher risk populations = elderly, history of hypertension, stroke, or ischemic disease

systemic anaphylaxis reactions occur within?

systemic reactions usually occur within about 30 minutes after exposure --> cardiovascular, respiratory, GI and integumentary organ systems

the faster the onset the (more/less) severe the reaction

the faster the onset the more severe the reaction severity depends on degree of allergy and dose of allergen exposure

nursing management: patient experiencing allergic response

the nurse assess for s/s of anaphylaxis - airway - breathing pattern - vital signs observed for signs of increasing edema and respiratory distress rapid response team notified immediately and the provider rapid initiation of emergency measures (intubation; emergency medication; IV access; fluid and oxygen administration) the nurse documents all interventions used and patient's vital signs and response to treatment

after an allergen binds to a specific IgE antibody on a mast cell and/or basophil, causing cellular degranulation, what is the pathophysiology of the anaphylactic reaction?

there is a release of histamine and other bioactive mediators causing the activation of: platelets, eosinophils, and neutrophils Histamine, prostaglandins and inflammatory leukotrienes are potent vasoactive mediators that are implicated in vascular permeability changes, flushing, urticaria, angioedema, hypotension and bronchoconstriction smooth muscle spasm; bronchospasm; mucosal edema and inflammation and increased capillary permeability all result symptoms are sudden in onset and progress in severity over minutes to hours

4 types of hypersensitivity reactions

type I - IgE mediated immediate hypersensitivity (anaphylaxis, atopic) type II - cytolytic and cytotoxic (haemolytic anemia) mediators: IgG and IgM type 3 - immune complex (Arthur reaction, serum sickness); IgG and IgM type 4 - delayed type (T-cell mediated)

What type of reaction is Anaphylaxis

type I hypersensitivity reaction between a specific antigen and antibody (IgE allergic reaction) caused by the cross links of an allergen with an allergen-specific IgE antibody found on the surface membranes of mast cells and basophils --> cellular degranulation

typical allergens r/t allergic rhinitis include?

typical allergens that can lead to allergic rhinitis include pollens from ragweed, grasses, trees, weeds; fungal spores; house dust mites; animal dander and feathers

most common atopic disorders include:

urticaria (hives) allergic rhinitis (hay fever) atopic dermatitis food allergy

the degranulation of mast cells or basophils and release of mediators after sensitisation with allergen leads to what 3 primarily early response symptoms

vasodilation vascular damage ==> leaky vessels smooth muscle spasm

vasoactive drugs in the treatment of anaphylactic shock

vasopressors increase vasoconstriction (epinephrine) inotropes (increase cardiac contractility --> dobutamine, milrinone)

symptomatic progression of anaphylactic reaction:

w/in minutes after exposure: itching; hives; skin erythema followed by bronchospasm and respiratory distress vomiting, abdominal cramps, diarrhea and laryngeal edema and obstruction follow person may go into shock and die if not treated