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Anaphylaxis

Anaphylaxis is a life-threatening type of allergic reaction.

Anaphylactic Shock

Anaphylaxis is a sudden, severe, potentially fatal, systemic allergic reaction that can involve various
areas of the body. Symptoms occur within minutes to two hours after contact with the allergy-
causing substance, but in rare instances may occur up to four hours later. Minute amounts of
allergens may cause a mild to life-threatening reaction.

Common causes of anaphylaxis include:

 Food - Peanuts, tree nuts (walnuts, cashews, etc.), shellfish, fish, milk, and eggs commonly
cause anaphylactic reactions
 Medication - Anaphylactic reactions to medication will typically occur within an hour after
taking the drug, however reactions may occur several hours later
 Insect stings - The symptoms of anaphylactic reactions to insect stings usually occur within
minutes of the sting.
 Latex - Approximately 10 to 17 percent of those employed in the health care occupations
have this allergy.

Signs and Symptoms

 An itchy nettlerash (urticaria, hives)

 Faintness and unconsciousness due to very low blood pressure. Unlike an ordinary fainting
attack, this does not improve so dramatically on lying down.
 Swelling (angioedema)
 Swelling in the throat, causing difficulty in swallowing or breathing
 Asthma symptoms
 Vomiting
 Cramping tummy pains
 Diarrhoea
 Anxiety
 A tingling feeling in the lips or mouth if the cause was a food such as nuts
 Death due to obstruction to breathing or extreme low blood pressure (anaphylactic shock)
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The symptoms are related to the action of immunoglobulin E (IgE) which acts to release histamine
and other mediator substances from mast cells. Histamine induces, beside other effects, vasodilation
and bronchospasm (constriction of the airways).

Management

GO DR SHAVPU ACBC

Patient position - lying flat with legs raised if comfortable, Consider use of salbutamol for any
wheezing, High concentration of O2 Adrenaline 1:1000, Get paramedic backup running, Be prepared
to carry out BLS

Secondary Survey

ASHICE (Consider)

Transport to Hospital

Professional Handover

Causes

Anaphylaxis is a severe, whole-body allergic reaction. After being exposed to a substance like bee
sting venom, the person's immune system becomes sensitized to that allergen. On a later exposure,
an allergic reaction may occur. This reaction is sudden, severe, and involves the whole body.

Tissues in different parts of the body release histamine and other substances. This causes the
airways to tighten and leads to other symptoms.

Some drugs (polymyxin, morphine, x-ray dye, and others) may cause an anaphylactic-like reaction
(anaphylactoid reaction) when people are first exposed to them. This is usually due to a toxic
reaction, rather than the immune system response that occurs with "true" anaphylaxis.

The symptoms, risk for complications without treatment, and treatment are the same, however, for
both types of reactions.

Anaphylaxis can occur in response to any allergen. Common causes include:

 Drug allergies

 Food allergies

 Insect bites/stings

Pollens and other inhaled allergens rarely cause anaphylaxis. Some people have an anaphylactic
reaction with no known cause.

Anaphylaxis rarely occurs. However, it is life-threatening and can occur at any time. Risks include
history of any type of allergic reaction.
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Symptoms

Symptoms develop rapidly, often within seconds or minutes. They may include the following:

 Abdominal pain or cramping

 Abnormal (high-pitched) breathing sounds

 Anxiety

 Confusion

 Cough

 Diarrhea

 Difficulty breathing

 Fainting, light-headedness, dizziness

 Hives, itchiness

 Nasal congestion

 Nausea, vomiting

 Sensation of feeling the heart beat (palpitations)

 Skin redness

 Slurred speech

 Wheezing

Exams and Tests

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Signs include:

 Abormal heart rhythm (arrhythmia)

 Fluid in the lungs (pulmonary edema)

 Hives

 Low blood pressure

 Mental confusion

 Rapid pulse

 Skin that is blue from lack of oxygen or pale from shock

 Swelling (angioedema) in the throat that may be severe enough to block the airway

 Swelling of the eyes or face

 Weakness

 Wheezing

The health care provider will wait to test for the specific allergen that caused anaphylaxis (if the
cause is not obvious) until after treatment.

Treatment

Anaphylaxis is an emergency condition requiring immediate professional medical attention. Call 911
immediately.

Check the ABCs (airway, breathing, and circulation from Basic Life Support) in all suspected
anaphylactic reactions.

CPR should be started, if needed. People with known severe allergic reactions may carry an Epi-Pen
or other allergy kit, and should be helped if necessary.

Paramedics or physicians may place a tube through the nose or mouth into the airways
(endotracheal intubation) or perform emergency surgery to place a tube directly into the trachea
(tracheostomy or cricothyrotomy).

Epinephrine should be given by injection in the thigh muscle right away. This opens the airways and
raises the blood pressure by tightening blood vessels.

Treatment for shock includes fluids through a vein (intravenous) and medications that support the
actions of the heart and circulatory system.

The person may receive antihistamines, such as diphenhydramine, and corticosteroids, such as
prednisone, to further reduce symptoms (after lifesaving measures and epinephrine are
administered).
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Outlook (Prognosis)

Anaphylaxis is a severe disorder that can be life-threatening without prompt treatment. However,
symptoms usually get better with the right therapy, so it is important to act right away.

Possible Complications

 Airway blockage

 Cardiac arrest (no effective heartbeat)

 Respiratory arrest (no breathing)

 Shock

When to Contact a Medical Professional

Call 911 if you develop severe symptoms of anaphylaxis. If you are with another person, he or she
may take you to the nearest emergency room.

Prevention

Avoid known allergens. Any person experiencing an allergic reaction should be monitored, although
monitoring may be done at home in mild cases.

Occasionally, people who have a history of drug allergies may safely be given the medication they
are allergic to after being pretreated with corticosteroids (prednisone) and antihistamines
(diphenhydramine).

People who have a history of allergy to insect bites/stings should carry (and use) an emergency kit
containing injectable epinephrine and chewable antihistamine. They should also wear a MedicAlert
or similar bracelet or necklace stating their allergy.

Alternative Names

Anaphylactic reaction; Anaphylactic shock; Shock - anaphylactic

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Anaphylaxis is an acute systemic (whole body) type of allergic reaction which occurs when a person
has become sensitized to a certain substance or allergen and is again exposed to the allergen. Some
drugs, such as those used for pain relief or for X-rays, may cause an anaphylactoid reaction on first
exposure. Histamines and other substances released into the bloodstream cause blood vessels to
dilate and tissues to swell. Anaphylaxis may be life-threatening if obstruction of the airway occurs, if
blood pressure drops, or if heart arrhythmias occur.

Physical Signs

 General

o Physical examination of patients with anaphylaxis depends on affected organ

systems and severity of attack. Vital signs may be normal or significantly disordered
with tachypnea, tachycardia, and/or hypotension.

o Place emphasis on determining the patient's respiratory and cardiovascular status.

o Frank cardiovascular collapse or respiratory arrest may occur in severe cases.

Anxiety is common unless hypotension or hypoxia causes obtundation. Shock may
occur without prominent skin manifestations or history of exposure; therefore,
anaphylaxis is part of the differential diagnosis for patients who present with shock
and no obvious cause.

o General appearance and vital signs vary according to severity of attack and affected
organ system(s). Patients commonly are restless due to severe pruritus from
urticaria. Anxiety, tremor, and a sensation of cold may result from compensatory
endogenous catecholamine release. Severe air hunger may occur when the
respiratory tract is involved. If hypoperfusion or hypoxia occurs, the patient may
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exhibit a depressed level of consciousness or may be agitated and/or combative.

Tachycardia usually is present, but bradycardia may occur in very severe reactions.

 Skin

o The classic skin manifestation is urticaria (ie, hives). Lesions are red and raised, and
they sometimes have central blanching. Intense pruritus occurs with the lesions.
Lesion borders usually are irregular and sizes vary markedly. Only a few small or
large lesions may become confluent, forming giant urticaria. At times, the entire
dermis is involved with diffuse erythema and edema. Hives can occur anywhere on
the skin.

o In a local reaction, lesions occur near the site of a cutaneous exposure (eg, insect
bite). The involved area is erythematous, edematous, and pruritic. If only local skin
reaction (as opposed to generalized urticaria) is present, systemic manifestations
(eg, respiratory distress) are less likely. Local reactions, even if severe, are not
predictive of systemic anaphylaxis on reexposure.

o Lesions typical of angioedema also may manifest in anaphylaxis. The lesions involve
mucosal surfaces and deeper skin layers. Angioedema usually is nonpruritic and
associated lesions are nonpitting. Lesions most often appear on the lips, palms,
soles, and genitalia.

 Pulmonary

o Upper airway compromise may occur when the tongue or oropharynx is involved.
When the upper airway is involved, stridor may be noted. The patient may have a
hoarse or quiet voice and may lose speaking ability as the edema progresses.
Complete airway obstruction is the most common cause of death in anaphylaxis.

o Wheezing is common when patients have lower airway compromise due to

bronchospasm or mucosal edema.

o In angioedema, due to ACE inhibitors, marked edema of the tongue and lips may
obstruct the airway.

 Cardiovascular

o Cardiovascular examination is normal in mild cases. In more severe cases,

compensatory tachycardia occurs due to loss of vascular tone.

o Intravascular volume depletion may take place as a consequence of capillary

leakage. These mechanisms also lead to development of hypotension.

o Relative bradycardia has been reported.

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Antigens are large molecules (usually proteins) on the surface of cells, viruses, fungi, bacteria, and
some non-living substances such as toxins, chemicals, drugs, and foreign particles. The immune
system recognizes antigens and produces antibodies that destroy substances containing antigens.

Pathophysiology

The clinical symptoms derive from pro-inflammatory and vasoactive mediators and cytokines
released by massive deregulation or release of basophils and mast cells. Classically, this cascade is
initiated by an IgE-mediated hypersensitivity reaction.

Allergens are introduced into the body by various routes: ingestion, inhalation, parenteral or skin
contact. Upon first exposure, a susceptible person forms IgE antibodies specific to the antigen
presented. IgE antibodies attach to high-affinity Fc receptors on basophils and mast cells.

On subsequent exposure, binding of antigen to the IgE antibodies leads to bridging and triggers the
degranulation of mast cells. Histamine, prostaglandin D2, leukotrienes, platelet-activating factor,
tryptase, nitric oxide, and eosinophil and neutrophil chemotactic factors have diverse effects on
target organs and lead to the clinical manifestations of anaphylaxis. These manifestations include
increased vascular permeability, vasodilation and myocardial dysfunction leading to hypotension
and cardiovascular collapse, as up to 50% of intravascular volume can shift to the extravascular
compartment in minutes. Altered smooth muscle tone in the respiratory tract results in
bronchospasm and asthma, and may also lead to uterine cramps. Activation of the autonomic
nervous system causes tachycardia, anxiety and mucous hypersecretion. Increased platelet
aggregation and subsequent recruitment of more immune cells complete the picture of the systemic
inflammatory response.

NSAIDs may also trigger cell activation by altering arachidonic acid metabolism. Activation of
complement, the complement protein anaphylatoxins such as C3a and C5a, direct action on mast
cells and basophils may lead to mediator release, producing symptoms indistinguishable from the
classic IgE-mediated reaction.
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