EMT Chapter 20: Immunologic Emergencies

Do not give epinephrine to:

-pts *without* signs of respiratory compromise or hypotension -Those who do not meet the criteria for a diagnosis of *anaphylaxis*

Allergic reactions may present as a

-respiratory condition -or as cardiovascular distress in the form of "shock".

Respiratory system- signs/sxs of allergic reaction

-sneezing, runny nose -SOB -tightness in chest or throat -hoarseness -rapid, labored, noisy respirations -wheezing, stridor

Cardiovascular system- signs/sxs of allergic reaction

-tachycardia -red flushed skin=early -cyanotic, cool skin= late sign -hypotension

____, a harsh, high-pitched sound heard on inspiration, can eventually lead to total obstruction.

Stridor

Leukotriene

Substance made by the body that is released in anaphylaxis

Which of the following statements regarding epinephrine administration via the intramuscular (IM) route is correct?

The 1:1000 concentration should be used.

Which of the following would MOST likely provide clues regarding the source of a patient's allergic reaction?

The environment where the patient was found

Which of the following signs/symptoms are indicative of respiratory involvement of an allergic reaction?

Tightness in the chest or throat

side effects: with epi injection

a. Increased pulse rate b. Anxiety c. Cardiac arrhythmias d. Pallor e. Dizziness f. Chest pain g. Headache h. Nausea i. Vomiting

Signs of symptoms of insect stings or bites include all of the following EXCEPT:

ecchymosis

When a foreign substance invades the body, the body will __________.

protect itself, go on alert, and attempt to inactivate the foreign substance

When an allergic reaction proceeds to life-threatening anaphylaxis, it will usually do so __________.

quickly, within 30 minutes.

Epinephrine, whether made by the body or by a drug manufacturer, works rapidly to:

raise the pulse rate and blood pressure, inhibit an allergic reaction, and relieve bronchospasm

Your assessment of the patient experiencing an allergic reaction should include evaluations of all the following EXCEPT the:

reproductive system

You have administered one dose of epinephrine to a 40-year-old female to treat an allergic reaction that she developed after being stung by a scorpion. Your reassessment reveals that she is still having difficulty breathing, has a decreasing mental status, and has a blood pressure of 80/50 mm Hg. You should:

request permission from medical control to give another dose of epinephrine.

If a stinger is present,

"scrape the skin" with the edge of a sharp, stiff object such as a "credit card". -Do not use tweezers or forceps.

Approximately ____ of adults and ___of children are allergic to the venom of bees, wasps, and hornets.

-3% adults -1% children

Medication allergens

-Antibiotics (eg, penicillin) -Nonsteroidal anti-inflammatory drugs (NSAIDs)

In severe (anaphylactic) cases of insect stings, patients may experience:

-Bronchospasm and wheezing -Chest tightness and coughing -Dyspnea -Anxiety -GI complaints -Hypotension

Plant- allergens

-Dusts, pollens, and other plant materials -Ragweed, ryegrass, maple, and oak

Airway and breathing with anaphylaxis - Quickly assess for:

-Increased work of breathing -Use of accessory muscles -Head bobbing -*Tripod* positioning -Nostril flaring -Abnormal breath sounds

if pt goes into anaphylactic shock

-Oxygen -recumbent or *supine* as tolerated -prevent heat loss -The definitive treatment for anaphylactic shock is "epinephrine"

Signs and symptoms: insect stings

-Sudden pain -Swelling -Localized heat -Urticaria -Redness in light-skinned individuals -Itching and a wheal

Three common signs of anaphylaxis:

-Urticaria =hives -angioedema -wheezing

insect sting tx

-Wash the area with soap or antiseptic. -Remove any jewelry from the area. -*Position the injection site below the heart*. -Apply ice or cold packs.

Signs and symptoms of an anaphylactic reaction include

-difficulty breathing, -urticaria (hives) over large parts of the body, and -signs of shock (eg, tachycardia, hypotension).

Skin - allergic reaction

-flushing, itching, or burning skin= common over face and upper chest -urticaria= large areas of the body -swelling- especially, feet, hands, neck, face, tongue -cyanosis or pallor around lips -warm tingling

"tx" for pt in respiratory distress following anaphylaxis

-high Fowler's position -Do not hesitate to initiate high-flow oxygen. -In severe situations, assist using bag-valve mask, attached to oxygen.

Anaphylaxis is an extreme, life-threatening allergic reaction.

-involves multiple organ systems -Can rapidly result in "shock and death"

Which of the following sounds indicates swelling of the upper airway?

Stridor

You have been called to a park where a local church is holding a potluck dinner. As you exit your ambulance, a woman approaches you holding her 7-year-old son who is wheezing and having difficulty breathing. She informs you that he inadvertently ate a brownie with nuts, and he is allergic to nuts. The child's mother has an EpiPen that contains the appropriate dose of epinephrine for a child. What dose would that be?

0.15 mg

infant-child system EpiPen delivers __ of epinephrine;

0.15 mg

Adult EpiPen delivers __ of epinephrine

0.3 mg

The dosage of epinephrine in an adult EpiPen is:

0.30 mg

The effects of epinephrine are typically observed within _________ following administration.

1 minute

When administering epinephrine by auto-injector, the EMT should hold the injector in place for:

10 seconds

When assisting with an auto-injector, how long should you hold the pen against the thigh?

10 seconds

if the patient is stable, reassess every

15 minutes.

Because the stinger of the honeybee is barbed and remains in the wound, it can continue to inject venom for up to:

20 minutes

Food allergen May take more than ____ to appear

30 minutes

If the patient is unstable, reassess vital signs every

5 minutes

Allergic reactions to insect stings cause at least ___ in the United States.

50 deaths/year

Which of the following patients would MOST likely have a delayed onset of an allergic reaction?

A 45-year-old male who ingested penicillin

If a systemic reaction continues, the body will have difficulty supplying blood and oxygen to the vital organs. _____ is one of the first signs.

AMS

A 37-year-old male is having a severe allergic reaction to penicillin. He does not have an epinephrine auto-injector and your protocols do not allow you to carry epinephrine on the ambulance. How should you proceed with the treatment of this patient?

Administer oxygen, transport at once, and request a paramedic intercept.

Epinephrine is prescribed by a physician and comes pre-dosed in an epinephrine injector (EpiPen).

All kits should contain a prepared, auto-injectable syringe of epinephrine. -Epinephrine can have an effect within 1 minute

Care for a victim of an immunologic emergency who is severely hypotensive should include which of the following?

Apply high-flow oxygen therapy, place the patient in a shock position, and help maintain the patient's body temperature.

Angioedema

Areas of localized swelling

Why do patients wheeze?

Bronchioles are constricting

Which of the following medications blocks the release of histamines?

Diphenhydramine (Benadryl)

Which of the following is NOT one of the five common allergen categories?

Environments

Rapidly reverses the effects of anaphylaxis

Epinephrine

___ cannot withdraw their stinger. (continuous venom injected for 20 minutes)

Honeybees -Fly away and die

BP with anaphylaxis

Hypo-tension -due to vasodilation and increased capillary permeability -also Gastrointestinal dysfunction (eg, nausea, vomiting, and abdominal cramps)

Some ants, especially the fire ant, strike repeatedly.

Inject a particularly irritating toxin at bite sites

Chemical- allergens

Makeup, soap, and hair dye *Latex is of particular concern to health care providers* -Nitrile gloves are an alternative.

____ are the second most common source of anaphylactic reactions

Medications

Epinephrine

Mimics the sympathetic (fight-or-flight) response -vasoconstriction, increase HR, bronchodilation -Reverses vasodilation and hypotension, relieves Bronchospasm

Patients may experience allergic reactions to which of the following substances?

Plant material, Food and medications, Insect or animal bites and stings

an allergic reaction Causes the body's immune system to

Release chemicals to combat stimulus -Includes histamines and leukotrienes

Which of the following negative effects of anaphylaxis will be the MOST rapidly fatal if not treated immediately?

Upper airway swelling

What are small, raised areas that itch?

Urticaria

Which of the following physiologic actions does epinephrine produce when given for an allergic reaction?

Vasoconstriction and bronchodilation

___ and ___ can sting multiple times.

Wasps and hornets

High-pitched, whistling breath on expiration

Wheezing

____, a whistling sound, is caused by narrowed bronchioles; it indicates narrowing or swelling of the "lower airway".

Wheezing

Insect bites and stings= allergens

When an insect bites and injects the bite with its venom, this is called *envenomation*. -The reaction may be localized (swelling and itchiness) or systemic (involving the entire body).

At the site of the injury, signs and symptoms of an animal or insect bite or sting may include pain, localized heat, and a wheal, which appears as __________.

a raised, well-defined area of the skin

A raised, swollen, well-defined area on the skin that is the result of an insect bite or sting is called:

a wheal

Shellfish, nuts

account for 30% of deaths from anaphylaxis, most commonly in adolescents and young adults.

A 19-year-old female was stung multiple times on the legs by fire ants. She states that she is allergic to fire ants, but does not carry her own epinephrine. The patient is conscious and alert and complains of pain to the area of the bites. Her blood pressure is 122/70 mm Hg, her pulse is 100 beats/min and strong, and her respirations are 18 breaths/min and unlabored. You should:

administer oxygen and transport her to the hospital.

In dealing with allergy-related emergencies, you must be aware of the possibility of acute______ and cardiovascular collapse

airway obstruction

The foreign substance responsible for causing an allergic reaction is called a(n):

allergen

An ______ is an exaggerated immune response to any substance.

allergic reaction -Not caused directly by an outside stimulus (bee)

An exaggerated immune response to any substance

allergic reaction.

Insect sting Pts may occasionally experience respiratory failure. If untreated, ___ reaction can proceed rapidly to death.

anaphylactic

Patients experiencing a severe allergic reaction will often appear very

anxious.

Common side effects of epinephrine include all of the following, EXCEPT:

drowsiness

A young male is experiencing signs and symptoms of anaphylactic shock after being stung by a scorpion. His level of consciousness is diminished, his breathing is severely labored, you can hear inspiratory stridor, and his face is cyanotic. The patient has a prescribed epinephrine auto-injector. What should you do first? a. Assist him in administering his epinephrine. b. Apply high-flow oxygen via nonrebreathing mask. c. Provide ventilatory assistance with a bag-valve mask. d. Elevate his legs and cover him with a warm blanket.

c. Provide ventilatory assistance with a bag-valve mask.

man with difficulty breathing states that he ate a package of peanuts approximately 30 minutes ago and denies any allergies or past medical history. Your assessment reveals widespread urticaria, tachycardia, and a BP of 90/60 mm Hg. You can hear him wheezing, even without a stethoscope. You should be MOST suspicious of a(n): a. acute asthma attack. b. mild allergic reaction. c. anaphylactic reaction. d. moderate allergic reaction.

c. anaphylactic reaction.

The negative effects associated with anaphylactic shock are the result of: a. severe internal fluid loss. b. inadequate pumping of the heart. c. vasodilation and bronchoconstriction. d. the nervous system's release of adrenaline.

c. vasodilation and bronchoconstriction.

Speed is essential because in severe cases of anaphylaxis, ____ can occur rapidly.

death

tx: Anaphylaxis requires

epinephrine and ventilatory support.

Anaphylaxis is MOST accurately defined as a(n):

extreme allergic reaction that may affect multiple body systems.

Wheezing occurs because excessive ____ and mucus are secreted into the bronchial passages

fluid

The most common trigger of anaphylaxis is:

food -shellfish and peanuts

The immune system protects the body from

foreign substances and organisms.

The two chief chemicals released by the body that result in the signs and symptoms of an allergic reaction are

histamines and leukotrienes.

Urticaria is the medical term for:

hives

Questions to ask when obtaining a history from a patient appearing to have an allergic reaction include:

how the patient was exposed

anaphylaxis- BP

hypo-tension

Anaphylaxis: Assess for rapid pulse rate; cool, cyanotic, or red, moist skin; delayed capillary refill=

hypoperfusion

Applying ___ sometimes helps with insect stings

ice -Localized manifestations are not serious.

If the medication is "injected", the allergic reaction may be

immediate (within 30 minutes) and severe.

Anaphylaxis caused by stinging insects is typically an allergic reaction to ____________ rather than the bite or sting itself.

injected poison, irritating toxin, or deadly venom

After administering 0.3 mg of epinephrine via auto-injector to a 22-year-old female with an allergic reaction, you note improvement in her breathing and resolution of her hives. However, she is still anxious and tachycardic. You should:

monitor her closely but recall that anxiety and tachycardia are side effects of epinephrine.

Reactions to "oral" medications may take ___ to appear, but can also be very severe.

more than 30 minutes

Anaphylaxis is not always life threatening, but it typically involves:

multiple organ systems

After removing the auto-injector from the patient's thigh, you should do all of the following EXCEPT:

place ice on the injection site.

Immediately after giving an epinephrine injection, you should:

properly dispose of the syringe

The stinger from a honeybee should be:

scraped away from the skin

The stinging organ of most insects is a small hollow spine projecting from the abdomen. Venom can be injected directly into

skin.

Certain foods, such as shellfish and nuts, may result in a relatively ___ onset of symptoms, but the symptoms can become just as severe.

slow

Eating certain foods, such as shellfish or nuts, may result in a relatively ___ reaction that can still be quite severe

slow

You should not use tweezers to remove an embedded stinger because:

squeezing may cause the stinger to inject more venom in the wound

The MOST reliable indicator of "upper airway swelling" during a severe allergic reaction is:

stridor

Place the patient in ___ position, and give oxygen as needed- immunologic emergencies

supine -injection site below the heart

tx: Mild allergic reactions require

supportive care and monitoring.

Epinephrine stimulates the ________ response, increasing blood pressure and relieving bronchospasm.

sympathetic

Prolonged respiratory difficulty can cause______, shock, and even death.

tachycardia

Steps for assisting a patient with administration of an EpiPen include:

taking body substance isolation precautions

Anaphylaxis can cause rapid swelling of the ___ airway.

upper

Small areas of generalized itching or burning that appear as multiple, small, raised areas on the skin

urticaria

Generalized itching or burning that appears as multiple, small, raised areas on the skin

urticaria.

The goal of invaders such as bacteria and viruses is to __________.

use a human body as a home

Insect stings and bites can cause a _____, which is a *raised, swollen, well-defined area on the skin*.

wheal

One of the most common signs of anaphylaxis is ____, a high-pitched, whistling breath sound that is typically heard on expiration, usually resulting from bronchospasm/bronchoconstriction and increased mucus production.

wheezing

_____ is due to narrowing of the air passages, resulting from contraction of muscles around the bronchioles in reaction to the allergen, and "mobilization of mucus" in an attempt to "push out" the allergen.

wheezing -As the patient's condition worsens, breathing may diminish to the point of being almost silent.

Epinephrine is indicated for patients with an allergic reaction when:

wheezing and hypotension are present