Anaphylaxis.audio.2010

Anaphylaxis : 

Anaphylaxis Tom Oertel, NURS 203

Why is it a necessity to promptly treat allergic reactions and anaphylaxis? : 

Why is it a necessity to promptly treat allergic reactions and anaphylaxis? Most anaphylaxis-related deaths occur within 30 minutes after exposure to the allergen.

List at least two causative agents of allergic reaction/anaphylaxis for the following categories: : 

List at least two causative agents of allergic reaction/anaphylaxis for the following categories: medications: food: chemicals: animals stings or bites:

List at least two causative agents of allergic reaction : 

List at least two causative agents of allergic reaction medications: aspirin, PCN, X-ray contrast medium (newer products: less so) food: eggs, peanuts, shellfish, milk chemicals: soap, perfumes, latex animals stings or bites: Hymenoptera (honeybees), hornets, wasps, ants, jellyfish Other: blood and blood products

Briefly describe the steps in the pathophysiology of an allergic reaction : 

Briefly describe the steps in the pathophysiology of an allergic reaction A reaction (e.g. antibody-antigen) occurs on the surface of mast cells or basophils  the cell breaks open (degranulates) with release of vasoactive substances  signs and symptoms of allergic reaction (mild to profound)

What are the age-related changes in the immune system in the elderly? : 

What are the age-related changes in the immune system in the elderly? Expected Aging Changes Clinical Manifestations Secretory IgA declines Poss. Mucosal infections Thymus gland involutes Impaired cell-mediated response Lymphoid tissue decreased Increased malignancy Antibody production impaired Reduced response to infection Decreased response of T cells Recurrence of latent herpes (attack antigen or regulate cellular zoster (shingles) and TB Attack of antigen) And B cells (produce antibodies) Autoantibodies increased  Autoimmune diseases (Lewis (5th ed.), p. 66)

What are the age-related changes in the immune system in the elderly? : 

What are the age-related changes in the immune system in the elderly? The Appropriate Nursing Diagnosis for age-related changes in the immune system in the elderly: Risk for Infection

What are the basic differences between a true allergic/anaphylactic reaction and an anaphylactoid reaction? : 

What are the basic differences between a true allergic/anaphylactic reaction and an anaphylactoid reaction?

What are the basic differences between a true anaphylactic reaction and an anaphylactoid reaction? : 

What are the basic differences between a true anaphylactic reaction and an anaphylactoid reaction? Allergy/anaphylactic reaction: IgE mediated, with prior exposure to the antigen with production of antibodies to the specific antigen anaphylactoid reaction: non-IgE mediated (e.g. complement or fibrinolytic systems), without prior exposure to the allergen

A true anaphylactic reaction and an anaphylactoid reaction: examples : 

A true anaphylactic reaction and an anaphylactoid reaction: examples Allergy/anaphylactic reaction: IgE mediated, with prior exposure to the antigen Example: beestings or peanuts anaphylactoid reaction: non-IgE mediated, without prior exposure to the allergen Example: X-ray contrast dye

In clinical practice, does the distinction make a difference in clinical signs/symptoms or treatment? : 

In clinical practice, does the distinction make a difference in clinical signs/symptoms or treatment?

In clinical practice, does the distinction make a difference in clinical signs/symptoms or treatment? : 

In clinical practice, does the distinction make a difference in clinical signs/symptoms or treatment? NO: the signs and symptoms are the same, the life-threatening complications are the same, and the treatment is the same.

Slide 15: 

Allergic/Anaphylactic Reactions Affect Many Systems

What are the clinical manifestations of an allergic reaction? : 

What are the clinical manifestations of an allergic reaction? Generalized itching [pruritus] Hives/urticaria, wheals Angioedema (nontraumatic swelling), esp. perioral, periorbital (eyes), and points of contact with the antigen (e.g. skin and throat if antigen/food was swallowed) GI upset [nausea/vomiting] Anxious/ restless

Slide 17: 

Periorbital Angioedema of Allergic Reaction

Slide 18: 

Allergic Wheals/Flares, Usually with Intense Itching

Briefly describe the steps in the pathophysiology of anaphylaxis/anaphylactic shock : 

Briefly describe the steps in the pathophysiology of anaphylaxis/anaphylactic shock “It is an immediate reaction that causes massive vasodilation, release of vasoactive mediators, and an increase in capillary permeability. As capillary permeability increases, fluid leaks from the vascular space into the interstitial space.” (Lewis, 6th ed., p. 1802)

The effect of vasoactive substances : 

The effect of vasoactive substances Histamine: vasodilation, increased capillary permeability  tissue swelling and loss of fluid into the interstitial space, bronchoconstriction, coronary vasoconstriction, cutaneous signs (wheals and flares) Leukotrienes: 1000 times more potent than histamine with bronchospasm and vasoconstriction of coronary vessels  depressed myocardial contractility Prostaglandins: bronchospasm and increased airway mucous, increased capillary permeability and vasodilation Bradykinin: increased capillary permeability and vasodilation, contraction of smooth muscles Note: many other vasoactive substances are also released

What is the triad of clinical manifestations of anaphylaxis? : 

What is the triad of clinical manifestations of anaphylaxis? Profound hypotension: r/t vasodilation and increased capillary permeability  loss of fluid into the interstitial space Decreased level of consciousness: r/t profound hypotension and lack of perfusion to major organs Respiratory distress with stridor and cyanosis: r/t bronchoconstriction, increased capillary permeability  tissue swelling of airway, increased airway mucous

What are the chief characteristics of distributive shock? : 

What are the chief characteristics of distributive shock?

What are the chief characteristics of distributive shock? : 

What are the chief characteristics of distributive shock? Vascular tone is lost because of vasodilators (anaphylactic or septic shock) or because of the loss of autonomic/sympathetic nervous innervation (neurogenic/spinal shock). The end result is profound vasodilation of the circulatory system and a decrease in systemic vascular resistance Profound vasodilation increases the size of the vascular bed, producing decreased venous return to the right side of the heart, decreased stroke volume and cardiac output, and decreased blood pressure.

What are the chief characteristics of distributive shock? : 

What are the chief characteristics of distributive shock? The end result is profound vasodilation of the circulatory system and a decrease in systemic vascular resistance  the blood is maldistributed to the periphery and to the interstitial space, away from the central circulation. The all important “central pipes” are not full, so the vital organs are not perfused.

Why is anaphylactic shock a form of distributive shock? : 

Why is anaphylactic shock a form of distributive shock?

Why is anaphylactic shock a form of distributive shock? : 

Why is anaphylactic shock a form of distributive shock? Anaphylactic shock results in maldistribution of the blood volume in the peripheral circulation and interstitial space  making the blood unavailable to maintain cardiac output  creating a “relative hypovolemia” with profound hypotension and decreased cardiac output

Medical Management of Allergic reactions and Anaphylaxis : 

Medical Management of Allergic reactions and Anaphylaxis

What is the cornerstone of treatment for severe systemic allergic reactions or anaphylaxis? why? : 

What is the cornerstone of treatment for severe systemic allergic reactions or anaphylaxis? why?

What is the cornerstone of treatment for severe systemic allergic reactions or anaphylaxis? why? : 

What is the cornerstone of treatment for severe systemic allergic reactions or anaphylaxis? why? Epinephrine/Adrenalin is the cornerstone of treatment for systemic allergic reactions or anaphylaxis. Why?: Only Epi increases SVR (systemic vascular resistance) through vasoconstriction (alpha adrenergic property); Only Epi blocks degranulation of mast cells and basophils (thereby decreasing capillary permeability) Only Epi produces bronchodilation

What is the dosage for epinephrine? : 

What is the dosage for epinephrine? Subcutaneous [mild or early reaction] Usual Adult Dose: 0.3 ml of 1:1000 [1ml = 1mg] (range: 0.2-0.5ml) [may repeat in 10-15 minutes if needed] don’t give too much! “Bee-sting kits” contain An empty syringe and glass Ampule with 1ml/1mg, Benadryl Tablets and NO Instructions! Frequently, pts draw Up the ENTIRE 1ml and inject it: With serious side-effects.

What is the dosage for epinephrine? : 

What is the dosage for epinephrine? Intramuscular [moderate to severe reaction] Usual Adult Dose: 0.3 ml of 1:1000 [1ml = 1mg] (range: 0.2-0.5ml) [may repeat in 10-15 minutes if needed] I.M. route leads to quicker generalized distribution of the medication Example: EpiPen – best effect when in deep intramuscular tissue

What is the dosage for epinephrine? : 

What is the dosage for epinephrine? Subcutaneous [mild reaction] Usual Pediatric Dose: 0.01mg/Kg of 1:1000 [1ml = 1mg] [may repeat in 10-15 minutes if needed]

What is the dosage for epinephrine? : 

What is the dosage for epinephrine? IV or ET (endotracheal) [severe reaction/ anaphylaxis] Usual Adult Dose: 0.1-0.5 mg of 1:10,000 IV or ET which equals 1-5ml of 1:10,000 [10ml = 1mg] [may repeat in 10-15 minutes if needed] IV Epi can cause ventricular arrhythmias [Endotracheal Administration: mix with NS and squirt directly down the ET tube then ventilate to distribute the med through the bronchial tree]

Slide 35: 

Endotracheal Administration: Epinephrine can be very efficiently distributed and absorbed through the highly vascular pulmonary tissue

What is the dosage for epinephrine? : 

What is the dosage for epinephrine? Usual Pediatric Dose: 0.01mg/Kg of 1:10,000 IV or ET [10ml = 1mg] [may repeat in 10-15 minutes if needed]

What is the role of antihistamines (Benadryl) in the treatment? : 

What is the role of antihistamines (Benadryl) in the treatment? Diphenhydramine (Benadryl) prevents further antibody-antigen reactions but also causes sedation and may decrease the blood pressure Does not counteract the increased capillary permeability, bronchoconstriction, or vasodilation Not a first line medication

What other medical treatments are used? : 

What other medical treatments are used? Airway management: High flow oxygen (>10Liters) by MASK Best if intubated EARLY since intubation in a swollen airway is very difficult/ impossible

What other medical treatments are used? : 

What other medical treatments are used? Fluid Resuscitation Give enough IV fluid to maintain blood pressure [“fill the pipes”] Rationale: preserve intravascular volume compromised by vasodilation and extravasation of fluid in interstitial spaces [“third spacing”]

What other medical treatments are used? : 

What other medical treatments are used? Vasopressors: High dose Dopamine [vasoconstriction range] Rationale: counteract the profound vasodilation and hypotension in order to maintain perfusion of vital organs Cimetidine (Tagamet) I.V.: an H1 blocker (histamine that promotes gastric acid) with mild H2 blocking ability (histamine that promotes allergic reactions); given when other measures are not producing full therapeutic effects; not first line medication

Slide 41: 

Medical Antishock Trousers (MAST): apply pressure to extremities and abdomen to create a mechanical vasoconstriction and deliver blood to the central circulation Abdominal compartment Extremity compartment (2) Foot Pump

Nursing Care and Nursing Diagnoses : 

Nursing Care and Nursing Diagnoses

Nursing Care and Nursing Diagnoses : 

Nursing Care and Nursing Diagnoses Nursing diagnosis Nursing/collaborative actions Fluid Volume Deficit collaborate for epinephrine (intravascular) r/t distributive shock (increased capillary permeability and vasodilation)

Nursing Care and Nursing Diagnoses : 

Nursing Care and Nursing Diagnoses Nursing diagnosis Nursing/collaborative actions Respiratory Function, assess: assess ABCs, Risk for Impaired wheezing, work of breathing, r/t bronchoconstriction  LOC (sensitive indicator) 100% O2 Ineffective Airway positive pressure ventilation if Clearance needed r/t bronchoconstriction intubation or airway (place carefully)

Nursing Care and Nursing Diagnoses : 

Nursing Care and Nursing Diagnoses Nursing diagnosis Nursing/collaborative actions Decreased Cardiac fluid resuscitation with Output r/t vasodilation 2 large bore IVs and 3rd spacing vasopressors MAST (med anti- shock trousers)

Nursing Care and Nursing Diagnoses : 

Nursing Care and Nursing Diagnoses Nursing diagnosis Knowledge Deficit: Prevention and Treatment of Anaphylaxis OR Ineffective Therapeutic Regimen Management (allergy and anaphylaxis)

Nursing Care and Nursing Diagnoses : 

Nursing Care and Nursing Diagnoses Nursing/collaborative actions AllergistConsult an allergist regarding evaluation for preventive treatment (immunotherapy/ desensitization/”allergy shots”) AdrenalineCarry injectable epinephrine, “Epi-Pen”. AvoidancePractice insect avoidance and read labels

` : 

` Immunotherapy/desensitization/”allergy shots” Extremely small amounts of the antigen (e.g. bee venom) are given in increasing doses over many weeks/months. The body develops an immunity to the antigen, ie the body does not react to the presence of the antigen with an anaphylactic reaction. Can be life saving for pts with severe allergies. Given in the allergist’s office with a Code Cart available in case the pt suffers an allergic/anaphylactic reaction.

` : 

` Adrenaline: Carry injectable epinephrine, “Epi-Pen” Available in Adult and 2 strengths of Pediatric dosages in preloaded syringes Patient or family member or staff member will administer the prescribed dose into the pt’s thigh (see picture) at the sign of allergy/anaphylaxis. Young children can be taught to self-administer the medication. Must be carried by the pt AT ALL TIMES in all situations

Slide 50: 

Patient removes the top, exposing the needle, applies the syringe to the thigh or other muscular area, firmly applies pressure to cause the syringe to deliver the prescribed dose.

Slide 51: 

Avoidance: Practice insect and/or antigen avoidance Read labels e.g. many foods contain peanuts e.g. many medications contain aspirin

Slide 52: 

Avoidance: Patient Education is critical Become educated about allergies and treatment

Slide 53: 

Avoidance: Patient Education is critical Website and Free Patient Information about allergies and treatment: http://www.allergic-reactions.com/home/freekit_main.html

Wear a Medic Alert bracelet! : 

Wear a Medic Alert bracelet!

Blood Transfusions andTransfusion Reactions : 

Blood Transfusions andTransfusion Reactions

Blood Transfusion Reactions: Prevention : 

Blood Transfusion Reactions: Prevention Prevention: Check the blood with a 2nd licensed staff member; check the pt’s “Blood Band” with the transfusion record [99% of blood reactions are due to human error!]; check the blood transfusion form carefully against the unit of blood or blood products Be sure to have on hand: A patent I.V. with saline Anaphylactic kit Oxygen and Face mask

Blood Transfusion Reactions:Acute Hemolytic Reaction : 

Blood Transfusion Reactions:Acute Hemolytic Reaction Signs of Acute Blood Transfusion Reactions: Chills, fever, back pain, wheals (raised rash), rash/flushing, urticaria/itching (generalized or localized) Shortness of breath, air hunger Tachypnea, tachycardia, hypotension Shock, cardiac arrest

Blood Transfusion Reactions : 

Blood Transfusion Reactions Stop the transfusion! Discontinue the tubing containing the blood; save for the lab Flush the hub with saline and keep the line open with saline Vital signs: maintain airway and BP Follow Hospital Policy about treatment for blood transfusion reaction, e.g. give Benadryl and monitor for signs of anaphylaxis

Blood Transfusion Reactions:Febrile Reaction : 

Blood Transfusion Reactions:Febrile Reaction Febrile reactions (increased temperature) are common and often are caused by leukocyte incompatibility. Common in pts who receive multiple transfusions who then develop antibodies against the small number of WBCs in the blood product. Other pts develop “cold agglutins” to multiple units of cold blood. Note: a low-grade fever may be a normal response to foreign protein: follow hospital policy. Prevention: 1) premedicate with steroid or diphenhydramine (Benadryl); 2) warm the blood.