Anaphylaxis:

Recognition and Response Essentials in the School

Bernard S. Zeffren, MD

Objectives in Anaphylaxis Education

• What is it?

• Who is at risk?

• Where and when can it happen?

• How do we know it is anaphylaxis?

• What should we do?

• Why is follow-up needed?

Proposed Definition-2006

• Anaphylaxis is a serious allergic reaction that is rapid in onset

and may cause death.

Sampson HA et al. J Allergy Clin Immunol 2006;117:391-7

Anaphylaxis is highly likely when any one of the following three criteria are fulfilled:

1. Acute onset (usually in minutes to within an hour) of symptoms involving the skin (pallor, hives, flushing, or swelling) PLUS any of: abdominal symptoms (colicky discomfort/nausea/vomiting/ diarrhea), respiratory compromise (chest tightness/shortness of breath/wheezing/rapid or shallow breathing), or signs of reduced blood pressure (lightheadedness/passing out).

2. Symptoms involving two or more of the typical organ systems (skin, GI, respiratory, cardiovascular) that occur rapidly after exposure to a likely allergen for that patient.

3. Reduced BP following exposure to a known allergen for that patient. (My personal opinion is this provision should read “Acute onset of any of the typical symptoms following…”)

Sampson HA et al. J Allergy Clin Immunol 2006;117:391-7

• Many deaths in anaphylaxis, especially from food allergy, are due to obstruction of airflow in the upper and/or lower respiratory tract that results in respiratory failure.

• If you wait to administer injectable epinephrine until the patient goes into shock, you have waited too long!

• Treat with epinephrine long before signs and symptoms of respiratory and/or cardiovascular collapse occur!

• Epinephrine can stop/reverse ALL the symptoms of anaphylaxis within 2-5 minutes if given early enough.

• Shoot first, ask questions later, then give oral antihistamines.

• Epi Epi Epi Epi Epi Epi Epi !!! (NOT Benadryl !)

Be aware:

Epidemiology of Anaphylaxis

How many people are at risk forfatal anaphylaxis?

• We do not know for sure how many are at risk.

• Best guess from available data is under 1%.

Incidence of Anaphylaxis in U.S.

• A medical record review in a Minnesota community found

an incidence of 21 per 100,000 person years, with an

occurrence rate of 30 per 100,000 person years, and a

fatality rate of less than 1%.

• A record review of children and adolescents in a national

HMO found an incidence of anaphylaxis of 10.5 per

100,000 person years.

Yocum MW et al. J Allergy Clin Immunol 1999;104:452-6

Reported Incidence of Anaphylaxis: Increase in England: 1995-1999

(the effect of good P.R.)

158

312

513 558

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153

840

10961202

390 406

229366

9 101113

183 235

501

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200

400

600

800

1000

1200

1400

1995-6 1996-7 1997-8 1998-9

# P

ati

en

ts

Food Unspecified Serum Medicinal Substance Overall

Wilson R. BMJ 2000; 321:1021-2 ( comment on Sheikh A, Alves B. BMJ 2000;320:1441)

Physiology of Anaphylaxis

Physiology of Anaphylaxishttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC2683407

• A lock-and-key specific antibody/antigen interaction.• Antibodies are typically IgE bound to IgE receptor molecules on the

surfaces of mast cells in affected tissues and basophils in circulation.• Activation of these cells causes release of preformed mediators from

secretory granules that include histamine, tryptase, carboxypeptidase A, and proteoglycans. These then cascade into multiple physiologic effects.

• These overlapping and synergistic physiologic effects on skin, GI tract, heart, blood vessels, and lungs contribute to the overall pathophysiology of anaphylaxis.

• Symptoms variably present as any combination of generalized urticaria and angioedema, bronchospasm, and other respiratory symptoms, hypotension, syncope, and other cardiovascular symptoms, and nausea, cramping, and other gastrointestinal symptoms.

• Biphasic or protracted anaphylaxis may occur.

Triggers of Anaphylaxis

Triggers of Anaphylaxis: Overview

• The most commonly identified triggers are:

- Foods

- Insect stings

- Medications

• Many patients with symptoms consistent with anaphylaxis

who are referred to allergists have no specific cause found

after extensive evaluation.

Lieberman P. Ann Allergy Asthma Immunol 2006;97:39-43

Overview of Anaphylactic Triggers

35

20 20 20

53

0

5

10

15

20

25

30

35

% of Cases

Food Drug/Bio InsectSting

Idiopathic Exercise AllergenVaccines

Golden. Anaphylaxis, 2004

Triggers of Anaphylaxis: FoodTriggers of Anaphylaxis: Food

• Peanuts• Tree nuts • Seafood • Eggs • Milk• Soy• Wheat• Other

• Peanuts• Tree nuts • Seafood • Eggs • Milk• Soy• Wheat• Other

Triggers of Anaphylaxis: Insect Stings and (rarely) Bites

Triggers of Anaphylaxis: Insect Stings and (rarely) Bites

• Fire ants (most common here in Central FL)

• Yellow Jackets, Hornets, Wasps • Honey Bees

• Scorpions• Deer & horse flies• Mosquitoes (?)

Iatrogenic Triggers of Anaphylaxis Iatrogenic Triggers of Anaphylaxis

• Diagnostic agents (technically anaphylactoid…)

– Intravenous contrast media

– Has nothing to do with iodine per se, and no relation to shellfish

• Medications

– Antibiotics

– Aspirin and other NSAIDs

• Biological response modifiers

– Anti-venoms

– Monoclonal antibodies

• Blood transfusions

• Allergen immunotherapyJoint Task Force on Practice Parameters: AAAAI, ACAAI, and JCAAI. J Allergy Clin Immunol 2005;115:S483-523

Triggers of Anaphylaxis: Latex

• Some groups are at increased risk

– Healthcare workers

– Children with spina bifida

– Patients with multiple surgeries

• Increased incidence during the 1990’s was due largely to

implementation of universal precautions.

• Incidence has decreased since latex-free and non-powdered

gloves have become more widely available

Kelly KJ et al, J Allergy Clin Immunol 1994;93:813-6

Triggers of Anaphylaxis: Physical

• Exercise- and Food/Exercise- induced

– Food or medication are sometimes co-triggers with exertion

• Fish, wheat , celery, peanut and multiple others

• Cold-induced

• Heat-induced

Burgess B. EMedHome.com

Signs and Symptoms

Most Frequent Signs and

Symptoms of Anaphylaxis

ManifestationPercent

Urticaria/angioedema 88

Upper airway edema56

Dyspnea/wheeze 47

Flushing 46

Hypotension 10-33

Gastrointestinal 30

General: a feeling of impending doom, a sudden sense

that “things aren’t right”, or panic

Oral: pruritus of lips, tongue, and palate; edema of lips

and tongue; metallic taste in mouth

Cutaneous: flushing or pallor, pruritus, urticaria,

angioedema, morbilliform rash, and pilor erecti;

Symptoms/Signs of Anaphylaxis:The patient’s perspective

Gastrointestinal: nausea, abdominal pain (colicky),

vomiting, diarrhea

Cardiovascular: feeling of faintness, syncope,

chest pain, dysrhythmia, hypotension

Symptoms/Signs of Anaphylaxis:The patient’s perspective (cont’d)

Respiratory

• Nose: pruritus, congestion, rhinorrhea, and

sneezing

• Laryngeal: pruritus and “tightness” in the throat,

dysphagia, dysphonia and hoarseness/stridor, dry

“staccato” cough

• Lungs: shortness of breath, dyspnea, chest

tightness, cough, and wheezing

Symptoms/Signs of Anaphylaxis:The patient’s perspective (cont’d)

Diagnosis

Anaphylaxis: In Search of the Culprit, Allergy Test Results are PART of the

Answer

• An allergy test that is (+) for a particular allergen-specific

IgE is just an indication of sensitization, not an absolute

indicator of a cause of anaphylaxis, nor even evidence for

the presence of allergic disease.

• One MUST correlate test results with timing of exposure of

the suspected trigger AND presence/absence of the

symptoms of anaphylaxis

Treatment

Accidents Are Never Planned

Emergency medications (injectable epinephrine)

and

A treatment plan

Both must be immediately available and

accessible at all times!

When in Doubt, Inject Epinephrine!

Anaphylaxis Emergency Action Plan

An Anaphylaxis Emergency Action Plan should include:

– What symptoms to look for

– What medications to use

– What dose of medication

– Where medications are kept

– What others should do

– Anaphylaxis emergency practice drills

For Patients and Providers

• Anaphylaxis Tool Kit

• Wallet Card

• Emergency Action Plan

• Educational Material

– www.aaaai.org

– www.foodallergy.org

Simons FER. J Allergy Clin Immunol 2006;117:367-77

Simons FER. J Allergy Clin Immunol 2006;117:367-77

Treatment(Epi Epi Epi Epi - not Benadryl - Shoot first ask questions later)

• Epinephrine is the drug of choice for all anaphylactic

episodes.

• Flexibility in dosing needed to treat effectively.

- Many patients require more than a single injection.

- Different doses for children and adults.

• Early and aggressive use to maintain airway, blood

pressure, and cardiac output.

Outdated Epinephrine Loses Efficacy

• As time passes, percent of labeled dose and epinephrine

bioavailability are reduced.

• Improper storage and exposure to sunlight and heat

increase degradation.

• Degradation often occurs without a color change in the

epinephrine solution.

Simons FER et al. J Allergy Clin Immunol 2000;105:1025-30

Inadequate Knowledge of

Epinephrine Usage

• Healthcare professionals and patients have inadequate

knowledge about outpatient use.

- 76% of physicians are unaware that two EpiPen dose

formulations exist!

- Only 55% of patients at risk have in-date auto-injectors

on hand!

- Only 30%-40% know how to use auto-injectors correctly!

Grouhi M et al. J Allergy Clin Immunol 1999; 104:190-3; Sicherer SH et al. Pediatrics 2000; 105:359-62; Huang SW. J Allergy Clin Immunol 1998;102:525-6

Auto-injectable Epinephrine Device

Demonstration

• EpiPen

• Auvi-Q

• Twinject (generic epinephrine injector)

Injectable Epinephrine in Schools - The New Florida Legislation

• http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&URL=1000-1099/1002/Sections/1002.20.html

• Students may carry injectable epinephrine to use in emergencies at school and at all school-related activities.

• Schools may acquire their own supply of injectable epinephrine.

• Schools/districts (pub. and priv.) shall adopt policies developed by a licensed physician regarding administration of injectable epinephrine.

• School districts/employees are not liable for any injuries from proper use of injectable epinephrine used within the auspices of these policies

(i) Epinephrine use and supply: 1. A student who has experienced or is at risk for life-threatening allergic reactions may carry an epinephrine auto-injector and self-administer epinephrine by auto-injector while in school, participating in school-sponsored activities, or in transit to or from school or school-sponsored activities if the school has been provided with parental and physician authorization. The State Board of Education, in cooperation with the Department of Health, shall adopt rules for such use of epinephrine auto-injectors that shall include provisions to protect the safety of all students from the misuse or abuse of auto-injectors. A school district, county health department, public-private partner, and their employees and volunteers shall be indemnified by the parent of a student authorized to carry an epinephrine auto-injector for any and all liability with respect to the student’s use of an epinephrine auto-injector pursuant to this paragraph. 2. A public school may purchase from a wholesale distributor as defined in s. 499.003 and maintain in a locked, secure location on its premises a supply of epinephrine auto-injectors for use if a student is having an anaphylactic reaction. The participating school district shall adopt a protocol developed by a licensed physician for the administration by school personnel who are trained to recognize an anaphylactic reaction and to administer an epinephrine auto-injection. The supply of epinephrine auto-injectors may be provided to and used by a student authorized to self-administer epinephrine by auto-injector under subparagraph 1. or trained school personnel. 3. The school district and its employees and agents, including the physician who provides the standing protocol for school epinephrine auto-injectors, are not liable for any injury arising from the use of an epinephrine auto-injector administered by trained school personnel who follow the adopted protocol and whose professional opinion is that the student is having an anaphylactic reaction:

a. Unless the trained school personnel’s action is willful and wanton;b. Notwithstanding that the parents or guardians of the student to whom the epinephrine is

administered have not been provided notice or have not signed a statement acknowledging that the school district is not liable; and

c. Regardless of whether authorization has been given by the student’s parents or guardians or by the student’s physician, physician’s assistant, or advanced registered nurse practitioner.

Anaphylaxis

• Who is at risk? Anyone, especially those allergic to foods

such as peanut, tree nut, seafood, finned fish, milk, or egg; or

to insect stings or bites, natural rubber latex, or medications.

• When can it happen? Anytime, usually within minutes after

the patient comes in contact with their trigger.

• How do we know? Several symptoms occur at the same

time, such as itching, hives, flushing, difficulty breathing,

vomiting, diarrhea, dizziness, confusion, or shock.

Simons FER. J Allergy Clin Immunol 2006;117:367-77

Anaphylaxis

• Where can it happen? Anywhere, such as home, restaurant,

school, child care or sports facility, summer camp, car, bus,

airplane.

• What should we do? Inject epinephrine, call 911 or local

emergency medical service number, and notify the individual's

family (in that order)! Act quickly. Anaphylaxis can be mild, or it

can be fatal.

• Why is follow-up needed? Anaphylaxis can occur repeatedly.

The trigger needs to be confirmed, and long-term preventive

strategies need to be implemented.

Simons FER. J Allergy Clin Immunol 2006;117:367-77

Questions/Discussion