Anaphylaxis

Anaphylaxis and its treatment
Gary Darley

Anaphylaxis is a rising threat to the lives of many people. Recent increases in the number of serious reactions seen in emergency rooms, have led to the need for an increased awareness of the causes and treatment of anaphylaxis (Sampson, 1601). The intent of this paper is to explain what is happening during an anaphylactic reaction and what the protocol is to correct it. The science of treating anaphylaxis is relatively well understood, and when established protocols are followed, treatment of anaphylaxis is highly successful.

Anaphylaxis and its treatment
Anaphylaxis is a rising threat to the lives of many people. Recent increases in the number of serious reactions seen in emergency rooms, have led to the need for an increased awareness of the causes and treatment of anaphylaxis (Sampson, 1601). The intent of this paper is to explain what is happening during an anaphylactic reaction and what the protocol is to correct it. The science of treating anaphylaxis is relatively well understood, and when established protocols are followed, treatment of anaphylaxis is highly successful.
To start, anaphylaxis is defined by Brown as, a severe, life-threatening generalized or systemic hypersensitivity reaction (157). Finney states that, anaphylaxis is a severe allergic reaction, where the body’s immune system over-reacts to a harmless substance. The reaction becomes so strong that it threatens imminent death through hypotension, bronco-constriction and hypovolemia, if no action is taken to negate the effect (50).
While anaphylaxis can be mistaken for other conditions such as, an asthma attack, arrhythmia, myocardial infarction, pulmonary embolism, insulin reaction or vaso-vagal response, it is important to note, that most anaphylactic reactions occur within minutes of exposure to an antigen (Finney, 52). Signs and symptoms include pallor, hypotension, anxiety, respiratory distress, pulmonary edema, angio-edema, stridor, tachycardia, urticaria, wheezing and tightness of the chest (53).
Among the chief causes of anaphylaxis are food-induced causes, namely peanuts, tree nuts, fish and shellfish (Sampson, 1601). It is important to note that these are the major foods that cause anaphylaxis, but not the only ones. Other causes include exercise induced, venom reactions or reactions to therapeutic drugs (Brown, 158). In 15-32% of reactions according to Brown, no causative agent was identified. This makes preventing reactions from reoccurring more difficult (157).
There are two major parts of the immune system which are responsible for anaphylactic reactions. First are basophils and second are mast cells. Basophils are a type of white blood cell that carries histamine, heparin and other inflammatory factors. They are found in the blood stream. Mast cells are basophils that have left the blood stream for body tissues, such as loose connective tissue, gastrointestinal mucosa, lungs and the area around blood vessels. In addition to histamine, heparin and inflammatory factors, mast cells also carry spasmogens (Bryant, 24). When working properly these two cell types effectively aid your body in combating invading organisms and keep you healthy. They do this by working with lymphocytes and memory cells. As lymphocytes react to an antigen they produce antibodies and memory cells. The antibody attaches to the antigen inactivating it. Memory cells stay in the vascular system, ready to rapidly produce antibodies, so as to put a quick stop to any identical antigens that may invade. The combination of antigen and antibody attaches to the basophil or mast cell, which then releases chemical signals, primarily histamine. The release of these chemicals attracts another type of white blood cell, an eosinophil for phagocytosis (Bryant, 24-25).
In an individual who is prone to anaphylaxis the basophils and mast cells over produce histamine and other inflammatory factors, or degranulate releasing their entire chemical stores (Bryant, 25). This causes a cascade of events to occur. Vessels dilate and become more permeable to fluids, causing third spacing of fluid and edema. A decrease of up to 35% of blood volume can occur in ten minuets or less, resulting in hypotension and hypovolemia. Airway constriction due to direct histamine action on smooth muscle and edema in the airway decrease a patient’s ability to effectively breathe. Without immediate intervention, most patients will asphyxiate or go into cardiac arrest (Brown, 159).
Several factors exist which predispose an individual to having an anaphylactic reaction, a history of asthma, food allergy (especially to nuts and sea food), history of anaphylaxis, pubescent patients and patients on beta-blockers or angiotensin-converting enzyme inhibitors. As the majority of reactions come from a foreign substance entering the body, the keystone to anaphylactic therapy is prevention (Sampson, 1606). On those occasions when a reaction does occur, treatment must be immediate.
Treatment of anaphylaxis follows the airway, breathing and circulation rule. Epinephrine is the cornerstone of initial treatment for anaphylaxis. Formerly called adrenaline, epinephrine counter-acts the anaphylactic reaction by relaxing the smooth muscles of the airway, constricting blood vessels and suppressing the release of histamine (Finney, 54). 0.15mg for children and 0.3mg of epinephrine for adults can be carried in an easy to use auto-injector called an Epi-pen. The longer it takes to treat the patient with epinephrine, the greater the incidence of complications and fatal reactions. Once initial treatment is performed, an assessment of the patient’s oxygen saturation, overall perfusion and cardiac output must be performed (Sampson, 1604-1605). While epinephrine does a good job initially, additional therapy may be needed in the form of oxygen, to maintain adequate blood saturation, and IV fluids to combat circulatory fluid loss (Brown, 161). Oxygen via mask or nasal canula maybe used, or if necessary artificial ventilation can be used (Brown, 164). Albuterol is sometimes employed to aide in opening the airway. While normal saline may be used, the preferred fluid replacement is an isotonic crystalloid such as Lactated Ringers (Bryant, 161). After treatment has been successful, a four hour observation period is recommended. This is to ensure the reaction does not recur after the epinephrine wears off (Brown, 163). The figure on the following page is a step by step process taken from Brown, showing anaphylactic treatment (164).
Once a patient has been diagnosed with an anaphylactic reaction, education on what to do is essential. A trigger needs to be isolated by an allergist, so that avoidance is possible. The patient needs to be taught the signs and symptoms of an anaphylactic reaction. They then need to understand how to use a portable epinephrine injector, such as the Epi-Pen. Once the Epi-Pen has been used, transport to an emergency room needs to follow, even if the patient seems to recover, as they may still have the antigen in their system. A medical bracelet should be worn, advising any emergency personnel of the patient’s allergy. It must be reiterated, especially to young patients and their care givers, that avoidance of the antigen is vital, but that a normal life is possible.
In conclusion, anaphylaxis is a treatable condition that all medical personnel need to be aware of. It is being seen on a more frequent basis throughout the United States. The reactions are primarily caused by severe food allergies, which can be controlled through avoidance. The cornerstone of treatment is epinephrine, with other therapeutic measures taken as needed. While anaphylaxis complicates a patient’s life, it does not have to stop it. Medical personnel everywhere should be prepared to successfully combat anaphylaxis when it comes knocking at the door.

Intervention #1: Epinephrine Use
While epinephrine is often considered a miracle drug in the treatment of anaphylaxis, there are several disadvantages that surround it. Two of these disadvantages will be discussed. The first is education for patients who use Epi-Pens. In an article by Kumar et al, the authors cited a study that found that in 90% of fatal anaphylactic reactions, patients were not carrying their epinephrine injectors (Epi-Pens). Another cited study showed that some patients had prescriptions for Epi-Pens but never carried them, some carried them but didn’t know how to use them and others carried and used expired equipment, which failed to perform when needed (284). These studies show that patient education is at least as valuable as having the needed supplies to treat an anaphylactic reaction.
Kumar, A., Teuber, S., & Gershwin, M. (2005, December). Why do people die of anaphylaxis: A clinical review. Clinical & Developmental Immunology, 12(4), 281-287. Retrieved February 3, 2008, from Academic Search Premier database.

The second problem found was in the availability of trained staff to recognize an anaphylactic reaction and use epinephrine appropriately. Rankin and Sheikh conducted a survey in the UK that found that epinephrine was available in 97% of schools surveyed. Of those schools with an identified at risk child 80% had staff trained to use epinephrine, while only 48% of schools without an at risk child had staff trained to use epinephrine. 59% of all the schools surveyed did not feel confident in their ability to properly treat and manage an anaphylactic reaction. These numbers become significant when you realize that the highest incidence of anaphylaxis occur due to food sensitivity reactions and those reactions become known when a person is in the primary to high school levels of schooling (1429).
Rankin, K., & Sheikh, A. (2006, August). Serious Shortcomings in the Management of Children with Anaphylaxis in Scottish Schools. PLoS Medicine, 3(7), e326. Retrieved February 3, 2008, from Academic Search Premier database.

Intervention #2: Allergen Avoidance
Another problem with treating anaphylaxis is avoiding the trigger to a reaction. Two difficulties regarding avoidance will be discussed here as well. The first is in non-patient education. One of the major causes of anaphylaxis is an allergy to peanuts (Munoz-Furlong, 33). It seems like such a harmless thing, a peanut. But to some it is deadly.
The Grecos understand because they saw it almost happen to Colby over Labor Day weekend. The toddler, who had safely eaten peanuts before, got three peanut M&Ms as a potty-training reward. "Within 20 minutes, he was sick to his stomach," his grandmother says. "Then he started swelling up and developing hives." Then Colby started struggling to breathe; his face turned pale and his lips turned blue from lack of oxygen. "They did arrive at the hospital in time to save his life," Maureen Greco says. Doctors said Colby had suffered a severe allergic reaction. It could happen again, they said, if he ever touched or ate something containing peanuts. (Even children who have had mild reactions in the past are at risk for severe incidents.) So, Julie Greco has done what any mother would do: She has asked the parents at Colby's preschool to avoid sending in snacks made with peanuts -- and taken him home from one class birthday party because the cake contained them anyway (Painter).
As people who live in this world with others, education is needed so that we can be good neighbors and citizens. Believing a child when they say, “I can’t have that” maybe the difference between attending that child’s funeral or not (Painter).
Munoz-Furlong, A. (2006, February). Going Nuts Over Allergies. Education Digest, 71(6), 33- 34. Retrieved February 3, 2008, from Academic Search Premier database.

Painter, K. (n.d.). In the shadow of the peanut. USA Today, Retrieved February 3, 2008,from Academic Search Premier database.

The second difficulty lies in patient education. In a world where we eat what comes in a box, we have no idea what may have been used in the manufacturing process for that food. Label reading becomes imperative for someone with a known allergic reaction. The food item in question may not even contain the ingredient needing to be avoided, but the plant where it was made can have a risk for cross contamination with other products that do. Labels contain warnings that need to be headed in order to avoid a reaction (Schmit).
Schmit, J. (n.d.). More food labels take an ominous tone on allergens. USA Today, Retrieved February 3, 2008, from Academic Search Premier database.

In summary, anaphylaxis can be treated successfully, but that success rests largely on education. Epinephrine can save a patients life, when used appropriately or it can also cause death when not used or used inappropriately. Avoidance of an allergen is essential to living a wonderful life. When not avoided, allergens can cause a loss of quality of life in the short term as well as the long term in the form of death. Understanding these things becomes a vital necessity to those of use living here on this blue rock we call Earth.


References


Brown, S. (2006, April). Anaphylaxis: Clinical concepts and research priorities. Emergency Medicine Australasia, 18(2), 155-169. Retrieved November 5, 2007, from CINAHL database.

Bryant, H. (2007, May). Anaphylaxis: Recognition, treatment and education. Emergency Nurse, 15(2), 24-28. Retrieved November 5, 2007, from CINAHL database.

Finney, A., & Rushton, C. (2007, May 23). Recognition and management of patients with anaphylaxis. Nursing Standard, 21(37), 50. Retrieved November 5, 2007, from CINAHL database.

Kumar, A., Teuber, S., & Gershwin, M. (2005, December). Why do people die of anaphylaxis: A clinical review. Clinical & Developmental Immunology, 12(4), 281-287. Retrieved February 3, 2008, from Academic Search Premier database.

Munoz-Furlong, A. (2006, February). Going Nuts Over Allergies. Education Digest, 71(6), 33-34. Retrieved February 3, 2008, from Academic Search Premier database.

Painter, K. (n.d.). In the shadow of the peanut. USA Today, Retrieved February 3, 2008, from Academic Search Premier database.

Rankin, K., & Sheikh, A. (2006, August). Serious Shortcomings in the Management of Children with Anaphylaxis in Scottish Schools. PLoS Medicine, 3(7), e326. Retrieved February 3, 2008, from Academic Search Premier database.

Sampson, H. (2003, June). Anaphylaxis and emergency treatment. Pediatrics, 111(6), 1601-1608. Retrieved November 5, 2007, from CINAHL database.

Schmit, J. (n.d.). More food labels take an ominous tone on allergens. USA Today, Retrieved February 3, 2008, from Academic Search Premier database.

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