Anaphylaxis. Syahlxpnaia. Symptoms 8/7/2015. Toni B. Vento, MS, RN, NCSN Supervisor of Health Services Medford Public Schools

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1 Anaphylaxis Toni B. Vento, MS, RN, NCSN Supervisor of Health Services Medford Public Schools Syahlxpnaia Multisystem allergic reaction Wide range of pathophysiologic responses Elicited by re-exposure to a sensitizing allergen Antibodies (IgE) release chemical mediators such as histamine, leukotrienes Symptoms Upper Airway: stridor, laryngeal and epiglottal edema Lower Airway: bronchospasm, cough, wheeze Cardiovascular: chest pain, hypotension, syncope, dysrhythmia Dermatologic: urticaria, pruritis, erythema Gastrointestinal: nausea, vomiting, abdominal cramping, diarrhea 1

2 Major Life Threatening Symptoms Upper Airway Obstruction Biphasic Reaction Bronchospasm Circulatory Collapse Hypotension with Syncope Differential Diagnosis Asthma Infection with septic shock Vasovagal Response Oral Allergy Syndrome Clinical Red Flags Drooling, complaints of throat tightness, anxiousness, feelings of impending doom, any respiratory or cardiovascular symptoms Children with asthma: Increased risk of anaphylaxis Pollen-allergic Children: Increased incidence of food-induced anaphylaxis during the deciduous tree pollen season Developmentally at risk: Young elementary students, Teens, Students with special needs 2

3 Treatment Mild reaction without respiratory or cardiovascular compromise Ice to areas of swelling Obtain baseline Pulse, Blood Pressure, PaO2, Breath Sounds Administer Benadryl liquid mg po as per MD order or school standing order Monitor Vital Signs X 30 minutes Treatment Moderate/Severe reactions with respiratory and cardiovascular symptoms Epinephrine 1: ml/kg per dose subcutaneously Children lbs: ml (Rule of thumb 0.15cc) Adults: > 66 lbs: 0.3 ml May repeat Epi every minutes if symptomatic and HR < 180. Activate 911 Benadryl liquid mg po as per MD/Standing Order Albuterol 1 unit dose per nebulizer as per MD/Standing Order Place in Trendelenburg position while waiting for ambulance Do Not Stand Student Up If nauseous, place in Recovery position Monitor Vital Signs, PaO2, Breath Sounds frequently If cardiac and or respiratory arrest, start CPR Oral Allergy Syndrome Complaints of itchy mouth, runny nose, urticaria Cross-reactivity when immune system recognizes proteins found in pollen with proteins found in fruit/vegetables Occurs in 33% of pollen-allergy patients Most cases mild, but may progress to anaphylaxis (estimated at 2%) 3

4 Foods that cross-react with pollen Ragweed Allergy: banana, melon, tomato, zucchini, sunflower seeds, dandelions, chamomile Birch Pollen Allergy: kiwi, apples, pears, peaches, plums, coriander, fennel, parsley, celery, cherries, carrots, hazelnuts and almonds Grass Pollen Allergy: peaches, celery, tomatoes, melons and oranges Natural Latex Allergy: banana, avocados, kiwi, chestnut, papaya Case Study #1 Joshua is a thin 7 year old boy who presented with hives on cheeks, neck and abdomen at 2:50pm. Assessment Student reports he ate lunch of bologna sandwich, celery and carrot No known history of food allergy PaO2 98%, BP 102/58, Breath Sounds were clear, no cough or wheeze 4

5 This is what happened Ice applied to urticaria School Nurse continued to monitor Vital Signs Mother came and administered Benadryl 25 mg po Mother reports student was symptomatic the previous day after eating peanut butter sandwich (hives) Assessment continued After receiving Benadryl, Joshua began coughing, urticaria presented on lips Wheezing audible upon auscultation Interventions Explained need for epinephrine and reassured child and parent 0.15 cc Epinephrine 1:1000 given SC as per standing order 911 Activated PaO2 97%, BP 102/58 AP 101 EMT noted wheezing LUL Joshua was transported by ambulance to local ER with parent 5

6 Case Study #2 Ernie is a 12 year old overweight boy with special needs At dismissal time, he is stung by a bee while waiting for his bus. Assessment No known history of Venom Allergy Bee remained inside shirt Inspection of chest reveals 3 stings with localized redness and swelling No urticaria, respiratory distress Intervention Inspected site for presence of stinger Ice applied to sting sites PaO2 100%, AP 114 BP 118/70 Breath Sounds clear, no cough or wheeze Called mother to pick up student 6

7 This is what happened: 13 minutes after student arrived in nurse s office Ernie complains of throat tightness RN notices drooling at one side of mouth Ernie s speech is garbled The Clinical Red Flags are: 1. Special needs student 2. Onset of drooling 3. Speech Pattern SN Assessment and Interventions PaO2 97%, Breath Sounds with moist rales Ernie appeared distressed 911 Activated Epinephrine 1: mg SC given as per standing order EMT Assessment and Interventions BP 128/82, AP 108 O2 sat 100% Nasal cannula O2 started Ernie was transported via ambulance to local ER with parent 7

8 Followup Mother reports student was in ER for 1 ½ hours No medications prescribed!!! Mother made appointment with PCP for next day PCP prescribed EpiPen & Benadryl for school. Called School Nurse Allergy testing + for Venom Allergy Case Study #3 Tom is a 13 year old, tall thin 7 th grade student whose medical history includes asthma, seasonal allergies and eczema. In November, he eats a kiwi and complains of a tingly lower lip. Identify the red flags in this scenario 1.Asthma/eczema 2.Thin and tall 3.Adolescent 4.Kiwi Fruit 8

9 Red Flags Adolescent Medical history of asthma and eczema Seasonal allergy link to kiwi Birch Pollen: kiwi, apple, pear, peach, plum, celery, cherries, carrot, hazelnut, almond Assessment Tonsils red & enlarged, nasal membranes boggy Breath Sounds clear, no cough or wheeze No evidence of hives or swelling PaO % Interventions and Follow-up Benadryl 50 mg po given by mother Student referred to PCP Diagnosis: Oral Allergy Syndrome PCP did not prescribe EpiPen or Benadryl for prn administration. 9

10 Case Study # 3 Continued In December, Tom arrives in nurse s office with reports that he ate a pear. He complains of lower lip feels big SN assessment and interventions Tom s lower lip was swollen. His PaO2 100%, breath sounds were clear without cough or wheeze. He did not have hives. His SN rinsed out his mouth and washed his lips, applied ice to his lower lip and monitored VS until Tom s mother arrived. His mother gave Benadryl and he was referred to PCP. Followup PCP prescribed EpiPen and Benadryl for prn administration School Nurse provided EpiPen training for parent Emergency Health Care Plan developed and reviewed with teachers, cafeteria staff 10

11 Case Management Incidents of Oral Allergy Syndrome noted to occur in morning School Nurse spoke with teacher Discovered that both incidents occurred during the Fresh Fruit and Vegetable Program designed to introduce new foods to middle school students Arrangements were made with teacher for student to receive a non-allergenic fruit or vegetable Case Study #3 Continued 2 months later, Tom ate an apple. He reports he spit it out immediately because he felt his lower lip itching and came to nurse s office at 8:50am. SN assessment and interventions Breath Sounds clear, no cough or wheeze PaO % Lower lip swollen Benadryl 25 mg po given as per MD order at 8:55a Ice applied to lower lip 11

12 Monitoring School Nurse notes that both lips continue to swell after administration of Benadryl Breath sounds remain clear, no cough or wheeze No complaints of throat symptoms No changes in PaO2 Application of ice continued Further Monitoring At 9:00am, Tom s lips have stopped swelling He states itchiness is better At 9:10a, lip swelling is diminishing and itchiness has resolved At 9:20a, PaO2 is 100% and Breath Sounds are clear without cough or wheeze. Lip swelling and itchiness resolved Case Management and Followup Tom s allergy testing was positive for Shellfish, Kiwi, Pear and Apple Started on Loratadine QD EpiPen and Benadryl were prescribed for school 12

13 Indications to Monitor Mild reaction in 1 body system without respiratory or cardiovascular compromise. Skin: a few hives around mouth/face, mild itch Gut: mild nausea/discomfort Interventions Mild reaction without respiratory or cardiovascular compromise Ice to affected areas Give Antihistamine as ordered by MD Monitor student for at least 30 minutes including Vital Signs, PaO2, Breath Sounds, symptomatology Indications for Emergency Referral Severe Symptoms: One or more of the following Lung: SOB, wheeze, repetitive cough Heart: Pale, blue, faint, weak pulse, dizzy Throat: Tight, hoarse, trouble breathing/swallowing Mouth: Obstructive swelling (tongue/lips) Skin: Many hives over body 13

14 Interventions for Severe Symptoms Inject Epinephrine immediately Activate 911 Monitor Vital Signs, PaO2, Breath Sounds, Symptomatology Repeat Epinephrine if symptoms recur or continue after minutes Resources Asthma and Allergy Foundation Food Allergy Research and Education (FARE) Pistiner, M. et al. Living confidently with Food Allergy: A guide for parents and families. Downloadable PDF from lergyandanaphylaxis 14

15 References Vetander M, et al. Anaphylaxis and reactions to foods in children: a population-based study of emergency department visits. Clin Exp Allergy Apr; 42 (4): National Institute of Allergy and Infectious Disease (NIAID)- Sponsored Expert Panel. Guidelines for the Diagnosis and Management of Food Allergy in the United States: Report of the NIAID-Sponsored Expert Panel. the Journal of Allergy and Clinical Immunology (2010): S1-S58. Sampson, H.A. et al. Second symposium on the definition and management of anaphylaxis: Summary report-second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network symposium. The Journal of Allergy and Clinical Immunology (2006): References Sampson, H.A. Mendelson, L. and Rosen, J.P. Fatal and ner-fatal anaphylactic reactions to food in children and adolescents. New England Journal of Medicine 327 (1992): Bock, A.S., Munoz-Furlong, A. and Sampson, H.A. Fatalities due to anaphylactic reactions to foods. The Journal of Allergy and Clinical Immunology (2001): Young, M.C., Munoz-Furlong, A. and Sicherer, S.H. Management of food allergies in schools: a perspective for allergists. The Journal of Allergy and Clinical Immunology (2009): McIntyre, C.L., Sheetz, A.H., Carroll, C.R., and Young, M.C. Administration of epinephrine for life-threatening allergic reactions in school settings. Pediatrics (2005):