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SpecimenStudy #2: Anaphylaxis - Prehospital Research Support Site Home About Resources Links Forum Contact Us Menu Home About Resources Links Forum Contact UsSpecimenStudy #2: AnaphylaxisSpecimenStudy #2: Anaphylaxisby Alan Batt. Last modified: 02/03/14 Print PDFPatient & Apparent Chief Complaint A 65 year old sexuality tabbed her family doctor weeping of pain in her shoulder. Doctor tabbed to house, and administered 40mg diclofenac (Difene) IM at 1720. Doctor left house. 30 minutes post administration, patient felt her throat whence to swell, ripened a rash, and felt qualmy and weak. Emergency undeniability is made by patient at 1800. Ambulance responded from wiring approximately 30 minutes from incident. History Patient ripened anaphylactic reaction to IM diclofenac administered by family doctor 30 minutes prior. The patient was tabular in an armchair, semi-conscious upon inrush of ambulance hairdo at 1825. Initial Clinical Findings Airway – partially obstructed (laryngospasm) C Spine – not suspected, no MOIZoetic– regular, fast, shallow, well-marked wheeze Circulation – Pulse present, regular; skin colour flushed, cap refill normal (<2 sec) Disability – Partial LOC surpassing ambulance inrush Clinical Impression Severe anaphylactic reaction Secondary Survey AMPLE History A No known allergies, had received Difene previously with no reaction M Not currently taking medications P No medical history of significance L Last oral intake 3 hours previous E NOK stated patient became dizzy, confused, c/o throat swelling, difficulty breathing, rash and itch. Obvious urticaria, cyanosis of lips and nostrils and angioedema present Observations – Pre-hospital Pulse rate 102bpm Pulse rhythm Regular ECG rate 104 ECG rhythm Sinus Tachycardia Resp rate 18 per minute, shallow, well-marked wheeze Resp quality Equal air entry bilaterally SaO2% 99% on 100% O2 via NRB Cap Refill <2secs BP 176/68 Pupils PEARRL, size 3 GCS 15/15 (E4, V5, M6) BGL 7.6mmol/l Pre-hospital superintendency & management Patient placed on 100% O2 via non-rebreather. Epinephrine 1:1,000 0.5mg IM administered. Patient commenced on Salbutamol 5mg/2.5ml nebuliser. Second dose of Epinephrine 1:1,000 0.5mg IM administered with good effect. Angioedema, urticaria, peripheral cyanosis and laryngospasm fully resolved post 2nd Epinephrine administration. Patient began to towards less confused, reported dizziness resolving. Patient began to mutter of a pain in her chest post Epinephrine administration. Aspirin 300mg PO chewed and GTN 1.2mg SL administered with good effect. Transferred to ambulance. En-route patient reported easing of chest pain, and zoetic effort. No well-marked wheeze. Angioedema and peripheral cyanosis remained resolved. In-hospital superintendency & management Patient arrived to ED Resus at 1926. Triaged as Category 1 (Life-Threatening Condition) with Anaphylaxis. Brought directly to Resus room. Hartmann’s solution 1000ml commenced. Bloods taken. Admitted to high-dependency unit on medical ward for observation overnight. Patient diagnosed with anaphylactic reaction to diclofenac. Family doctor well-considered of same. Discharged home the pursuit day with no long-term effects. Identification of all interventions initiated and rationale Epinephrine 1,1000 IM – to reverse laryngospasm, urticaria and angioedema associated with anaphylactic reaction Salbutamol nebuliser – to resolve well-marked wheeze associated with bronchospasm due to anaphylactic reaction Aspirin PO – as indicated for cardiac chest pain, possibly due to Epinephrine 1:1,000 wardship GTN SL – as indicated for cardiac chest pain, possibly due to Epinephrine 1:1,000 wardship Pulse oximetry – to monitor oxygen saturation levels in the thoroughbred Supplemental oxygen – to re-oxygenate patient 3 Lead ECG – to identify any life-threatening arrhythmias 12 Lead ECG – to identify any life-threatening arrhythmias or ECG changes indicative of myocardial forfeiture (secondary to hypoxia etc. CXR – to identify aspiration, pleural effusion etc. that may increase morbidityThoroughbredtests – to identify any electrolyte imbalances etc. Hartmann’s Solution IV – as per anaphylaxis protocol Learning Outcomes Improving pre-hospital intervention The recommended management of anaphylaxis follows the acronym EASIO (as per Lieberman et al., 2010 & Haskell, 2006) Epinephrine 1:1,000 IM Antihistamines IM/PO (e.g. chlorphenamine) Steroids IM/PO/IV (e.g. hydrocortisone) Inhaled β2-agonists (i.e. salbutamol) if wheeze present / IV fluids if hypotensive (NaCl) Oxygen @ 15lpm The next obvious step in the management of anaphylactic reactions prehospital is to introduce antihistamines and steroids to the range of medications authorised for use. This would indulge for patients post-anaphylaxis to be admitted to the ED with full anaphylaxis interventions initiated. This would ensure that the short-term effects of IM Epinephrine would not result in the patient redeveloping an anaphylactic reaction en-route to the ED post treatment. (Haskell, 2006) Chlorphenamine IM/IV Chlorphenamine is an antihistamine wontedly used in the treatment of anaphylaxis as a secondary therapy to Epinephrine 1:1,000 IM and as a first nomination therapy for allergic reactions that are not life threatening, but with symptoms that are causing the patient distress, such as urticaria. The use of an antihistamine is recommended for prehospital use, due to the release of histamine and other vasoactive chemical mediators released during anaphylaxis (Seidel & Henderson, 1996) The use of antihistamines in a prehospital context can be useful for refractory anaphylaxis, and moreover as a redundancy therapy to the IM wardship of Epinephrine 1:1,000. Other antihistamines such as diphenhydramine may moreover be considered. Hydrocortisone IM/IV Hydrocortisone is a glucocorticoid medication (steroid) that reduces inflammation and suppresses immune response. It is used to prevent deterioration post-anaphylaxis treatment. It can moreover be used in the treatment of severe and life-threatening asthma and Addisonian Crisis. The use of steroids in the treatment of anaphylaxis in a prehospital context is recommended by JRCALC Guidelines (2006) if the undeniability to hospital time is greater than 30 minutes. Steroids can take 4-6 hours to take effect, but the quick wardship of IV steroids can prevent a biphasic response from developing at a later stage. Both Chlorphenamine and Hydrocortisone are tried medications for use by State Registered Paramedics in the UK under the JRCALC Guidelines (JRCALC, 2006) Epinephrine 1:1,000 IM Presentation: Vial 1mg/1ml Administration: IM Dosage: 0.5mg IM every 3-5 minutes if required Effects: Alpha & beta adrenergic stimulant. Reversal of laryngospasm & bronchospasm in anaphylaxis. Antagonises the effects of histamine Side-effects: Palpitations, tachyarrythmias, hypertension, angina-like symptoms Additional Info: Double trammels concentrations on pack Chlorphenamine IV/IM Presentation: Vial 10mg/1ml Administration: IV Dosage: 10mg slow IV push Effects: Antihistamine and anticholinergic Side-effects: Dry mouth, headache, voiceless vision, GI upset Additional Info: Elderly increasingly likely to suffer side effects (JRCALC, 2006) Although not authorised for IM use in the JRCALC Guidelines, Chlorphenamine can be safely given IM, with a recommended dose of 10-20mg for adults (NHS, 2007) Hydrocortisone IV/IM Presentation: Vial 100mg/1ml (as sodium succinate) or powder for reconstitution with 2ml of water for injection. Administration: IV/IM Dosage: 200mg Effects: Reduces inflammation, suppresses immune response Side-effects: Burning or itching sensation if administered too quickly Additional Info: If thrombolysis indicated, do not supervise IM (JRCALC, 2006) Diclofenac IM and anaphylaxis The IM wardship of diclofenac has rare, but severe, and often fatal side effects in some patients. These side effects would not be seen in the PO or PR wardship of diclofenac, yet these routes provide similar traction rates. It is recommended that where possible, medical practitioners supervise diclofenac through the PO or PR route first, with IM as a last resort. These rare side effects can be experienced by patients who have previously taken diclofenac PO or PR with no wrongheaded side effects or reaction. (Schäbitz et al., 2001) Chest pain and its management post epinephrine wardship This patient ripened crushing, inside chest pain, radiating to left arm and mandible post wardship of Epinephrine 1:1,000 IM . She became diaphoretic and dyspnoeic as a result. A 12-lead ECG showed no obvious changes. However, as per Chase et al. (2006) a normal or non-diagnostic ECG during chest pain does not rule out vigilant coronary syndrome. However, unwont changes in anaphylaxis may be noted as per Gikas (2005) “Acute ST-elevation MI is a rare but potential multiplicity of anaphylactic reactions, plane in young adults with normal coronary arteries.” The physiological process of anaphylaxis involves the release of many chemical mediators in the thoroughbred stream. There is vestige to suggest that histamine release and indeed the unstipulated process of anaphylaxis have the potential to rationalization myocardial forfeiture through coronary vasculature spasm (Gupta et al., 2001). The wardship of epinephrine in vigilant anaphylaxis can precipitate an vigilant coronary event through coronary spasm induced infarct and through vasospastic angina (Saff et al., 1993; Caballero et al., 1999) Therefore it would be prudent for pre-hospital superintendency providers to treat patients presenting with chest pain during anaphylaxis, (pre- or post-epinephrine administration) as per ACS treatment guidelines. If no contraindications to either are present the wardship of Aspirin PO and GTN SL should be firsthand therapy for chest pain in the anaphylactic patient. References (non-Pubmed) Haskell G (2006) Paramedic Pearls of Wisdom. Massachusetts: Jones & Bartlett NHS (2007) Kingston PrimarySuperintendencyTrust: Anaphylaxis Handbook. London: NHS Seidel J, Henderson D (1996) PrehospitalSuperintendencyof Pediatric Emergencies. Massachusetts: Jones & Bartlett   References   1. Chase M1, Brown AM, Robey JL, Pollack CV Jr, Shofer FS, Hollander JE. Prognostic value of symptoms during a normal or nonspecific electrocardiogram in emergency department patients with potential vigilant coronary syndrome. Acad Emerg Med. 2006 Oct;13(10):1034-9. PMID: 16973638. Emergency department (ED) patients with symptoms concerning for vigilant coronary syndrome (ACS) and a normal electrocardiogram (ECG) are at risk for wrongheaded cardiovascular events. The authors hypothesized that patients with a normal or nonspecific ECG during symptoms have a lower risk for ACS than do […]   2. Rev Esp Cardiol. 1999 Apr;52(4):273-6. PMID: 10217970. A 41-year-old-man without previous ischemic heart disease, ripened a severe anaphylactic reaction.Withoutwardship of epinephrine (0.5 mg) the patient complained of chest pain. The electrocardiogram showed an elevation of ST segment in junior leads. Myocardial necrosis was ruled out. Corona […]   3. Lieberman P1, Nicklas RA, Oppenheimer J, Kemp SF, Lang DM, Bernstein DI, Bernstein JA, Burks AW, Feldweg AM, Fink JN, Greenberger PA, Golden DB, James JM, Kemp SF, Ledford DK, Lieberman P, Sheffer AL, Bernstein DI, Blessing-Moore J, Cox L, Khan DA, Lang D, Nicklas RA, Oppenheimer J, Portnoy JM, Randolph C, Schuller DE, Spector SL, Tilles S, Wallace D. The diagnosis and management of anaphylaxis practice parameter: 2010 update. J Allergy Clin Immunol. 2010 Sep;126(3):477-80. PMID: 20692689. These parameters were ripened by the Joint Task Force on Practice Parameters, representing the American Academy of Allergy, Asthma & Immunology (AAAAI); the American College of Allergy, Asthma & Immunology (ACAAI); and the Joint Council of Allergy, Asthma and Immunology. The AAAAI and the […]   4. Gikas A1, Lazaros G, Kontou-Fili K.VigilantST-segment elevation myocardial infarction without amoxycillin-induced anaphylactic shock in a young sultana with normal coronary arteries: a specimen report. BMC Cardiovasc Disord. 2005 Feb 25;5(1):6. PMID: 15733315.Vigilantmyocardial infarction (MI) pursuit anaphylaxis is rare, expressly in subjects with normal coronary arteries. The word-for-word pathogenetic mechanism of MI in anaphylaxis remains unclear. […]   5. Gupta MK1, Gupta P, Rezai F. Histamine–can it rationalization an vigilant coronary event? Clin Cardiol. 2001 Mar;24(3):258-9. PMID: 11288975. Myocardial infarction (MI) occurring during the undertow of an allergic urticarial reaction in the sparsity of systemic hypotension has been rarely reported. This paper reports the specimen of a 28-year-old woman with no significant risk factors for coronary street disease who presented with generalized ur […]   6. Saff R1, Nahhas A, Fink JN. Myocardial infarction induced by coronary vasospasm without self-administration of epinephrine. Ann Allergy. 1993 May;70(5):396-8. PMID: 8498731. A specimen of a 30-year-old man who ripened a myocardial infarction without self-administering an Epi-Pen for an episode of idiopathic anaphylaxis is reported. The patient had numerous risk factors for coronary street disease, and it was suspected that epinephrine-induced coronary spasm caused the infar […]   7. Schäbitz WR1, Berger C, Knauth M, Meinck HM, Steiner T. Hypoxic smart-ass forfeiture without intramuscular self-injection of diclofenac for vigilant when pain. Eur J Anaesthesiol. 2001 Nov;18(11):763-5. PMID: 11580784. We present a specimen of hypoxic smart-ass forfeiture that occurred without intramuscular injection of diclofenac due to a severe anaphylactic reaction. A 38-year-old nurse treated herself for vigilant lower when pain with 100 mg diclofenac intramuscularly. Five minutes later, she tabular and ripened slumber and re […] The pursuit two tabs transpiration content below.BioLatest Posts Alan BattParamedic, educator, researcher Alan is a hair-trigger superintendency paramedic, paramedic educator and prehospital researcher, currently working virtually the world as an educator and researcher. He has previously worked and studied wideness Europe, North America and the Middle East. He holds a Graduate Certificate in IntensiveSuperintendencyParamedic Studies, and an MSc inHair-triggerCare. His main interests are in superintendency of the elderly, end-of-life care, patient safety, professionalism (including role and identity), and paramedic education. Latest posts by Alan Batt (see all) Free access: Resuscitation Today Vol 3 Issue 2 - 27/06/16 Free CPD at the Emergency Services Show - 23/05/16Superintendencyat the Scene – Research for Ambulance Services - 17/05/16 Canadian Paramedicine Feb/Mar 2016 – Open Access Issue - 11/04/16 Eat, sleep and be healthy – a paramedic’s guide to healthier shift work - 10/04/16 Tags: anaphylaxis, cardiac, specimen study, clinical management, prehospital One thought on “Case Study #2: Anaphylaxis” Uppalapati Sree Lakshmi says: 13/04/18 at 09:20 Very well explained Alan. Reply Leave a Reply Cancel reply Search & Translate Translate Site: Search Site: Get weekly email updates! Cast Your Vote Does your training institution utilise simulation for prehospital education? No, but planning to No Yes, occassionally Yes, regularly View Results  Loading ... 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