AnaphylaxisThe Killer Allergy

How to recognize and care for severe allergic reactions

Objectives in Anaphylaxis Education

• What is it?

• Who is at risk?

• When can it happen?

• How do we know it is anaphylaxis?

• Where can it happen?

• What should we do?

• Why is follow-up needed?

A serious allergic reaction that is rapid in onset and may cause death

Each year in the U.S., anaphylaxis to food causes an estimated 14,000 to 90,000 emergency room visits1,2

Individuals with food allergy plus asthma are at greatest risk for this life-threatening reaction

Anaphylaxis

1. Ross MP et al. J Allergy Clin Immunol. 2008; 121:166–171. 2. Clark S et al. J Allergy Clin Immunol. 2011;127: 682-3.

Anaphylaxis: Mechanism

Mast Cell

Mast cell granules

Allergen (Food, Drug or Insect)

IgE antibody

Immediate reactionWheezeUrticaria

HypotensionAbdominal cramping

Late-phase reaction

Lieberman. Clinician’s Manual on Anaphylaxis. 2005.

Warning Signs

Anaphylaxis: Signs and Symptoms

• Mild to Moderate– apprehension, uneasiness, weakness– redness, itching, hives, swelling– abdominal cramps, vomiting, diarrhea– urinary incontinence, uterine cramps– These symptoms can occur as initial signs of severe

anaphylaxis• Severe

– chest tightness, cough, wheezing, difficulty breathing– Lightheadedness, fainting, low blood pressure

• DeathLieberman et al. JACI. 2005

1. Acute onset of Symptoms (minutes to a few hours after

ingestion or sting) with:

a). Skin - redness, hives, swelling, itching.

b). Swelling of lip, tongue and/or other mouth tissues

c). Breathing difficulties,

d). Dizziness/faintness or shock due to reduced blood pressure.

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

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

2. Symptoms involving two or more organ systems that occur

rapidly after exposure to a likely allergen for that patient.

3. Reduced Blood Pressure: Dizziness/Faintness, Shock

following exposure to a known allergen for that patient.

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

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

Most deaths from anaphylaxis, especially from food allergy, are due to obstruction to

airflow in the upper and/or lower respiratory tract that result in respiratory failure.

Bock et al. J Allerg Clin Immunol 2007;119:1016-1018.

Fatal Food Anaphylaxis• Fatal Anaphylaxis

– Clinical features:• Biphasic reaction can contribute –initially better, then

recurs• Cutaneous symptoms may not be present• Respiratory symptoms prominent

• Risk factors: Underlying asthma Delayed epinephrineSymptom denial Previous severe reactionAdolescents, young adults Increased platelet activating

factor

Triggers of Anaphylaxis: Overview

• The most commonly identified triggers are:- Food- Insect stings and bites- Medications

• Idiopathic anaphylaxis (no cause found after

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

Fatal Anaphylaxis Cases

• Food induced anaphylaxis: An estimated 150 fatalities from per year in the US:– Peanut and tree nuts account for 94% of fatalities

reported to a national registry

• Antibiotics: 400-800 fatal episodes of anaphylaxis per year worldwide

• Insect Stings: An estimated 50 fatalities in the US per year. However, the true incidence is unknown. There is evidence from autopsy studies suggesting the true incidence might be higher.

1. Almost everyone knows someone with a food allergy.2. About 1 in 13 children have food allergies.3. 12 million Americans have food allergies1

4. 5.9 million of those with a food allergy are under the age of 182

5. Perceived food allergy is greater than True food allergy

Food Allergy Facts

1. Sicherer SH, Sampson HA. J. Allergy Clin Immunol 2006;117:S470-475.2. Gupta R., et al. Pediatrics 2011;Vol. 128, No. 1.

2

2

People can be allergic to almost any food, but 90% of food allergic reactions are caused by 8 foods:

• Milk• Peanuts• Eggs• Tree Nuts• Wheat• Fish• Soybean• Shellfish

What foods cause allergic reactions?

Anaphylaxis Syndromes• Food-Induced Anaphylaxis

– Food allergy is the #1 cause of ER anaphylaxis– Rapid-onset, up to 30% biphasic– May be localized (single organ) or generalized– Any food, highest risk:

• Peanut, tree nut, seafood (cow’s milk and egg in young children)

• Food-dependent, exercise-induced: 2 forms– Specific foods (wheat, shellfish, celery most common)– Any food (after eating)– Severity increased with alcohol and ASA/NSAIDs

Bock SA, et al. J Allergy Clin Immunol 2001 and 2007.

Triggers of Anaphylaxis: Insect Stings and Bites

COMMON:• Bees• Wasps, Hornets, Yellow Jackets• Fire ants and other ants

RARE:• Scorpions• Deer & horse flies• Mosquitoes

Classification of Insect Sting Reactions

Classification SymptomsNormal Immediate, local,

transientLarge local Delayed, prolonged,

progressiveSystemic Immediate, generalizedOther Toxic, serum sickness

Medication Triggers of Anaphylaxis

• Diagnostic agents – X-ray Contrast

• Medications

– Antibiotics

– Aspirin and other NSAIDs

• Biological response modifiers

– Anti-venoms

– Monoclonal antibodies

• Blood transfusions

• Allergy shots

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

False Assumptions in Anaphylaxis• Anaphylaxis is always preceded by mild symptoms• There is no need to rush because there is always

time to get to a medical facility• Epinephrine is always effective• A mild reaction will not progress and will go away• Antihistamines are effective by themselves in the

treatment of anaphylaxis– Don’t worry about giving antihistamines initially in

treatment: Secondary therapy

ANAPHYLAXISTreatment

BE PREPARED!!!

3 R’s of An Anaphylaxis Emergency Action Plan

• Recognize symptoms early

• Respond quickly

• Review what caused the reaction

For Patients and Providers

• Anaphylaxis Tool Kit, including epinephrine device

• Wallet Card

• Emergency Action Plan

• Educational Material Available At

– www.aaaai.org

– www.foodallergy.org

Identification JewelryFrom www.foodallergy.org

www.medicalert.org

Anaphylaxis Emergency Action Plan

NAME: AGE: ALLERGIC TO: DATE: ASTHMA: NO YES (Increased Risk for Severe Reaction) OTHER HEALTH PROBLEMS: None. CONCURRENT MEDICATIONS: .

WHAT TO DO: 1. Inject Epinephrine into the outer thigh using: EpiPen Epi Pen Jr, Auvi-Q, Auvi-Q Jr, Generic Other Medication: Important: Asthma inhalers and antihistamines cannot be relied on to reverse anaphylaxis! Do not delay administration of Epinephrine while giving other medications. 2. Call 911 before calling contacts. 3. Emergency contact #1: Name: _____________________ Home _____________ Cell _________________ Emergency contact #2: Name: _____________________ Home _____________ Cell _________________ Emergency contact #3: Name: _____________________ Home _____________ Cell _________________ _________________________________ ________________________________ MD Patient/Parent Signature

The Allergy and Asthma Center

SYMPTOMS OF ANAPHYLAXIS INCLUDE:

MOUTH Itching, swelling of lips and/or tongue THROAT Itching, tightness, hoarseness, stridor (inspiratory wheezy sound) SKIN Itching, redness, hives, swelling STOMACHE Vomiting, diarrhea, cramps, pain. LUNGS Shortness of breath, cough, expiratory wheeze, tightness. HEART Weak pulse, dizziness, loss of consciousness

Only a few of these symptoms may be present. Severity often progresses rapidly. Symptoms can rapidly become life threatening.

Act Quickly!! Immediate aggressive treatment is essential.

Action Plans

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

Wallet Card

Accidents Are Never Planned

Emergency medications and a treatment plan

must be immediately available and accessible

at all times!

Treatment• Epinephrine is the drug of choice for all anaphylactic episodes.

• 911 must be called afterwards for treatment of possible biphasic

or second reaction.

• Flexibility in dosing needed to treat effectively.

- Many patients require more than a single injection.

- Lower dose for children under 50 lbs. (50% - 7 yr old)

• Early and aggressive use to maintain breathing, blood pressure.

• Severe side effects are rare with SQ or IM epinephrine

Epinephrine Is Under-Utilized for Acute Treatment

• Only about 30% of individuals requiring epinephrine

during a reaction actually received it.

• Fatal food-induced reactions:

– Failure to use, delayed use, or inappropriate dose of

epinephrine increase the risk of death from

anaphylaxis.

Gold MS and Sainsbury R. J Allergy Clin Immunol 2000; 106:171-6; Sampson HA et al. N Engl J Med 1992; 327:390-4; Pumphrey RS. Clin Exp Allergy 2000; 30:1144-50

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

Which epinephrine auto-injector dose is appropriate – 0.15 mg or 0.3 mg?

Recent guidelines suggest a 50 lb cutoff for the 0.15 dose devices.

>50 lbs, use the 0.3 ml dose devices. This is the weight of

1 )An average 7 year old (2nd grade)

2) Pudgy 5 year old – highest 10% on growth chart.

3) Thin 9 year old.

When in doubt use higher dose.

Simons FER. J Allergy Clin Immunol 2004;113:837-44

Prompt administration of epinephrine is key to surviving anaphylaxis

Prescribed as auto-injectors (such as EpiPen® or Auvi-Q®) or generic epinephrine

Epinephrine (adrenaline)

EpiPen® Use

Epipen is a registered trademark of Dey Pharmaceuticals

Online video at www.epipen.com

Auvi-Q® Overviewwww.auvi-q.com

3) Seek medical attention immediatelyReplace the outer case and take used Auvi-Q™ with you to a healthcare professional for proper disposal and a prescription refill.

Generic Epinephrine

Remove the GRAY cap labeled "1". Never put thumb, finger, or hand over the RED tip

Remove the GRAY cap labeled "2"

Place RED tip on the middle of the outer side of the thigh. Press down hard until the needle penetrates the skin and slowly count to 10

Call 911 after administering to get medical attention.

After injection, the injector needs to be properly discarded.

Once a reaction begins, there is no way to know how severe it will become

Take all food allergy-induced allergic reactions seriously

Every school should have a plan for managing food allergies

Food Allergy in Schools

1. Food allergy management plan 2. Food allergy management team

– Works with parents in supporting students with food allergies on the campus and assist campus staff in implementing administrative procedures and student specific strategies

3. Environmental controls in the school setting 4. Training of school personnel on food allergy

awareness5. Recommend that epinephrine be readily accessible in

a secure, but unlocked area

TX State Guidelines for Students with Food Allergies at Risk of Anaphylaxis

Department of State Health Services local policies to implement by August 1, 2012

The plan to manage a student’s food allergies should take into account:

Unique needs of the child

School environment (size, staff, etc.)

Goal of equal participation in all school-related activities

The Food Allergy Management Plan

Developing the plan is a team effort involving:

School staff

Child’s family (parents/guardians)

Child’s physician

The child who has allergies, as age-appropriate

The Food Allergy Management Team

Create an environment where children,including those with food allergies, will be safe

Employ prevention and avoidance strategies

Be prepared to handle an allergic reaction

Address teasing

School’s Responsibility

Environmental Controls in SchoolCareful Food Preparation;-

Wash hands, cooking utensils, and food preparation surfaces to avoid reactions from trace amounts of proteins left behind.

Liquid soap, bar soap, or commercial wipes for hands, not antibacterial gel sanitizers

Dishwashing detergent and hot water for cooking utensils and cutting boards

Common household cleaners for counters, tables, and other surfaces

Read every label every time• Formulations can change without warning

Don’t rely on “safe lists”

Allergens can be in non-food items• Soaps, shampoos, skin products, medications, pet

foods

Vigilant Label Reading

Clean hands before and after eating or handling food

Plan for safe parties/celebrations

Avoid using foods in classroom art/craft projects or as incentives

Prohibit food trading and sharing

Strategies to Minimize Risk of Reactions

Provide written medical documentationWork with the school to develop a plan Provide properly labeled medications and

replace after use or when expiredKeep emergency contact information up-to-dateTeach the child age-appropriate self-management skills

Family’s Responsibility

Reactions can occur anywhere in school

Early recognition and treatment of anaphylaxis is imperative and life-saving

Education of all staff is important

Key Points for Schools

Objectives in Anaphylaxis Education

• What is it? A severe allergic reaction that can cause death

• Who is at risk? People with food, drug or insect allergies

• When can it happen? Anytime

• How do we know it is anaphylaxis? By the classic symptoms

• Where can it happen? Anywhere

• What should we do? Treat with epinephrine and call 911

• Why is follow-up needed? To treat “second” biphasic reactions

and prevent future reactions

Anaphylaxis Summary• Anaphylaxis is a life-threatening allergic reaction and

should be treated promptly with epinephrine.

• Food, medications, insects and unknown factors can all cause anaphylaxis.

• Careful preparation and precautions are required at home, schools and workplaces for allergic people to avoid exposure to allergens and prevent severe allergic reactions.