This is an interesting article written by Andree Kuypers regarding the condition known as Anaphylaxis or Anaphylatic Shock. It offers us some sound advice on how to manage a patient we suspect of having an Anaphylactic reaction and has principles that can be applied to the outdoor environment.

Recent studies have shown that people are often reluctant to use an Epipen to treat a life-threatening reaction and may not even recognise anaphylaxis. Andree Kuypers explores these issues and finds out what you should be doing.

Emergency action

A few years ago, I thought an allergic reaction consisted of a succession of sneezes, persistent nose blowing (good for the Kleenex brand!) and, at worst, an annoying itchy rash, all these symptoms causing mood alteration in the most severe cases.

It wasn’t until my daughter was diagnosed with peanut allergy that I had to embark on a steep learning curve about allergies, and the words “anaphylaxis” and “life threatening” were being frighteningly bandied about.

But just what is a “life-threatening allergic reaction” and what do we do when we are faced with handling a situation where a person is going through this traumatic and incredibly frightening experience? What can be expected in the emergency room or when an ambulance is called?

Anaphylaxis

Anaphylaxis is a life-threatening allergic reaction and is defined by the Australasian Society of Allergy and Clinical Immunology (ASCIA) as a rapidly evolving generalised reaction involving several systems of the body. It should have one or more symptoms or signs of respiratory and/or cardiovascular involvement. These symptoms could be: difficulty/noisy breathing, swelling of the tongue, swelling/tightness of the throat, difficulty talking and/or hoarse voice, wheeze or persistent cough, loss of consciousness, collapse, pale and floppy (in young children) or hypotension (drop in blood pressure).

Other manifestations of anaphylaxis could include hives (urticaria), generalised redness of the skin, swelling of the lips and eyes (angioedema), runny nose, itchy red eyes (Rhinoconjunctivitis), vomiting, diarrhoea and abdominal cramps.

This certainly blew my simplistic and somewhat misguided definition of an allergic reaction out the back door and made me realise just how many allergy sufferers have to face living with the reality of anaphylaxis every day of their lives.

One such person that lives with this reality is 34-year-old Sue Morriss from Christchurch, who was diagnosed with allergies to eggs and nuts as a toddler and has experienced five severe reactions requiring emergency attention in her lifetime.

Emergency

Sue’s latest experience occurred in November 2004 after she ate a “ready made” chicken meal that she suspects was contaminated with egg. Sue had eaten this type of meal before so just grabbed it confident it would be fine. It wasn’t. (Ed’s note: remember to check the label every time and if in doubt, don’t’ eat it. Ingredients do change.)

“I was going to an open home with my parents and I began to feel slightly nauseous and knew I should not have driven as I was feeling ‘spacey’. Mum and Dad took me home again where I began to fade in and out of consciousness,” she says.

Sue’s parents panicked and she was faced with calling for an ambulance despite coping with her frightening symptoms and an acute shortness of breath.

Although Sue carries an Epipen and all her children are trained to use it, in this situation because of her parent’s obvious distress, Sue chose to phone the emergency services.

“As soon as I said ‘anaphylaxis’ they said, ‘It’s okay, try and relax your breathing,’ and they knew exactly where I was coming from,” she says.

Sue stresses, however, the importance of stipulating when you phone the emergency services that you need a paramedic that can administer adrenaline. This was confirmed by the St John’s ambulance service, which advised that not all ambulances carry adrenaline.

Tania Alach, Clinical Standards Unit Administrator for St John Northern Region, says the qualification structure of ambulance officers dictates what level of treatment they can offer.

“All advanced paramedics and some upskilled paramedics carry adrenaline for a number of conditions, including severe allergic reactions/anaphylaxis,” she says.

“If a crew that is unable to give adrenaline is attending someone in this presentation they will have to call for appropriate back-up to attend and administer.”

If the reaction is severe then the information needs to be passed on to the emergency call taker, who indicates an advanced paramedic needs to be included in the ambulance response/dispatch. It may not be the nearest ambulance that will be sent, but the initial crew can commence other forms of treatment until the ambulance with the paramedic on board arrives.

Andrenaline a life-saver

Auckland Allergy Specialist Dr Vincent Crump says adrenaline is the only life-saving drug in anaphylaxis and should therefore be the first drug given.

“In the emergency room adrenaline should be administered first, yet I still hear stories of antihistamines being given first,” he says.

Recent research on the treatment of anaphylaxis, conducted by P. Ponda and colleagues from Mt Sinai School of Medicine in New York, concluded that more paediatrician education is needed regarding correct dosage and route of administering adrenaline.

An anonymous survey was given to 61 paediatricians regarding treatment of food-induced anaphylaxis, the results of which were presented at a recent American Academy of Allergy, Asthma and Immunology conference.

The survey presented the case of a 12-year-old boy with peanut allergy and asthma who developed hives and cough within 30 minutes of ingesting a lolly. The boy received initial treatment at home before being taken to the emergency department. Paediatricians were asked to answer questions regarding duration of observation, discharge medications and risk factors for food-induced anaphylaxis.

More than one-third of the paediatricians surveyed indicated an inadequate observation period prior to discharge. Upon discharge, 85 per cent did choose to prescribe adrenaline, but only 16 of the 61 paediatricians surveyed correctly identified the risk factors for fatal food induced anaphylaxis (asthma, previous severe reactions and peanut allergy).

While adrenaline was recognised as the gold standard of treatment, many of the paediatricians selected the incorrect dose and route of administration.

Dr Crump believes the findings would be no different in New Zealand and he says it would be interesting to do the same survey here. He reinforced the importance of the observation time in the emergency department before discharge.

“In an ideal world the patient should be admitted for between 12 to 24 hours after a severe reaction” he says.

“The logistics of that is, of course, 24 hours is not possible so we need to ensure when the patient is discharged early, they are told of the possibility of recurrence of the anaphylactic reaction.”

Dr Crump says it also may not be widely known that adrenaline should be given intramuscularly because absorption is faster.

In the American survey, only 48 per cent of the paediatricians would have administered the medications intramuscularly.

While the results of this survey carried out in America are more than slightly alarming, can we feel confident in the procedures used and the treatment received for anaphylaxis in our emergency rooms?

Early administration

Maureen Baker from Tauranga described her experience with her nine-year-old daughter, Lara, who has suffered from milk and egg allergies since birth.

Last October, Lara Baker accidentally consumed some chicken nuggets that had milk product in them and began to feel unwell. Although they were unsure what it was, Lara said that it “felt like my allergy problem”.

As Lara’s throat was getting sore and “tighter”, the EpiPen Junior that Lara always carries on her was administered and her mother drove her to Tauranga Hospital’s accident and emergency department.

Despite the fact that Lara’s symptoms started to disappear when she has had the injection, the accident and emergency staff admitted her immediately and put her on a drip.

Because her daughter has been admitted to hospital on several occasions with severe allergic reactions, Maureen Baker is quite used to the procedure and says her experience in October was good and she felt confident that the staff in the hospital knew what they were doing and there was a procedure in place.

This is contrary to Maureen Baker’s first or second experience when Lara was admitted to hospital with an allergic reaction when she was a toddler.

“I was having to state what had happened and the staff went away to discuss things,” she says.

“There was not a clear procedure then but I had a completely different experience in October. Lara was quite comfortable with what was happening and the staff were good at explaining things to her.”

Lara was given an antihistamine orally as back up to the adrenaline and was under observation for four hours. As they were about to go home, her face began to swell slightly and she started to show signs of further reaction so Lara was kept in hospital overnight.

Despite the frightening experiences they have had, Maureen Baker describes their last experience in a positive manner and she felt confidence in the procedure that was in place to handle this emergency situation.

Recognition and appropriate treatment

Dr Crump says in the emergency care setting, being prepared, being able to recognise anaphylaxis and giving the appropriate and aggressive treatment is the key to the successful management of anaphylaxis. Stocking and maintaining anaphylaxis supplies and making them readily available is also vital. These should include as a bare minimum, adrenaline, intravenous fluids, injectable antihistamines, hydrocortisone, oxygen and mask, nebuliser with bronchodilators (salbutamol) and a stethoscope and sphygmomanometer for recording.

Steroids, he says, even when given via injection, take several hours to work and are, therefore, not life-saving in anaphylaxis. They can be given when the anaphylaxis is under control, to help prevent late phase (bi-phasic) reactions occurring after the primary anaphylaxis event. Patients are usually discharged with antihistamine and prednisone and, although the use of steroids for preventing or reducing the severity of the biphasic reaction has not been resolved, steroid administration is recommended.

Life-threatening allergic reactions are frightening, not only for the allergy sufferer, but also for the caregivers and any other person who happens to be there at the time.

It is important to be well informed, have an anaphylaxis management plan and to wear a medic alert bracelet.

Dr Crump advises that Epipens should always be prescribed within the context of an Anaphylaxis Management Plan which should include (ASCIA guideline.) a referral to an allergy specialist, identification of the anaphylactic trigger(s), education on avoidance of triggers, provision of an anaphylactic action plan and appropriate follow-up.

The anaphylaxis action plan should document the name of the patient, allergic triggers, carer contact details, symptoms and signs indicating when to use the EpiPen and instructions on how to use the EpiPen. These action plans can be downloaded from ASCIA’s website, www.allergy.org.au.