Recognize Anaphylaxis

A person who has a severe allergic reaction called anaphylaxis can die quickly if their airway swells shut or they go into shock. This usually occurs when the allergen enters the body by eating it (food or medication) or by injection (venom from an insect sting or an injected medication). It is possible, but less likely, to have anaphylaxis from skin contact or from inhalation. Also, in rare cases, people with certain risk factors can have anaphylaxis from vigorous exercise or idiopathic (unknown) causes. Timely and proper use of an epinephrine auto-injector (EpiPen, Adrenaclick, or generic) can save the person's life.[1]

Steps

  1. Understand that Anaphylaxis is the allergic response by more than one of the following bodily systems:[2]
    • Cardiovascular / CV - This is the 'shock' known as Anaphylactic Shock and is potentially fatal when untreated. This is also reaction with the fewest outward symptoms.
    • Respiratory - This usually manifests as difficulty breathing and is also potentially fatal when untreated. People with asthma may try to use only asthma rescue medications not realizing it is anaphylaxis which has lead to fatalities due to shock. It is important to look for multi-system symptoms and once confirmed treat with epinephrine.
    • Skin - these alone are not considered life threatening, but is an indicator to look for other reactions.
    • Gastrointestinal - these alone are not considered life threatening, but is an indicator to look for other reactions.
    • Neurological - These are the most difficult reaction to isolate to anaphylaxis since the symptoms can have many other causes. It is important to realize that true anaphylaxis may cause the victim to be confused or irrational, thus may not know how to seek the best treatment.
  2. Look for symptoms in the following groups. Shock or breathing symptoms alone, or more than one of the other three groups is considered Anaphylaxis and should be treated with epinephrine:
    • Shock - weak but rapid pulse, falling blood pressure, pale skin, dizziness, fainting.
    • Breathing - wheezing or throat swelling indicated by the feeling of a lump or tightness in the throat, or difficulty talking.
    • Skin - itching, hives, flushing, rash, or swelling.
    • Stomach - Cramps, nausea, vomiting, and/or diarrhea.
    • Brain/Cognitive/Emotion - an impending sense of doom and/or anxiety, confusion, or dizziness.
  3. Determine if the person affected can make their own decisions regarding treatment. The anaphylaxis itself may cloud their judgment or prevent them from administering the medication even if they know they want to. Early treatment with epinephrine can reduce the chances of a secondary reaction later. [3]
    • Ask them if they need help and if so look for medic alert information or have them tell you what to do. Enlist someone else to call emergency services if possible.
  4. Ask them if they have an epinephrine auto-injector and if so do they need to use it immediately. If they cannot give you a clear definitive answer they may be going into shock. Ask them if they need help administering the injection. They may not be able to do so without assistance.
    • If they are clear that they do not want the injection, then now is the time to call emergency services if you are alone.
    • Advise them they should not be standing or walking. Laying down is recommended.[4]
    • If they have a history of anaphylaxis and expect to need an injection but do not have their own injector, send people to find one by asking all bystanders, going into a place of business and ask for the first aid kit or go to the closest pharmacy.
  5. Monitor their state of mind and ability speak.
    • If they cannot talk, their airway is closing and they need the epinephrine injection immediately.
    • If they need an injection but do not have one available, they should be lying down and remaining as calm as possible.
    • If they lose consciousness, they need the injection immediately. 
  6. Administer the epinephrine auto-injector. An auto-injector is a single-use device and, once it is triggered, it cannot be reused.
    • Remove the injector from its case and follow the instructions on the side of the injector.
    • The injection should only to be made in the middle of the thigh from the outside of either leg. It can be made through one layer of clothing or to bare skin.
    • Hold the injector in the middle according to the instructions; do not put your hand over either end.
      • For a child or someone agitated restrain the leg to be injected.
      • Do not swing and jab, bounce or poke the tip into the thigh because, if it bounces out, or the victim jerks away, the injection will be unsuccessful.
      • For EpiPen: Remove the blue safety cap and place the orange tip firmly to the thigh.
      • For AdrenaClick/generic: Remove cap #1, then cap #2, then place the red tip firmly to the thigh.
    • Press it into the thigh until you feel the trigger occur or an audible 'click' is heard and hold it for 10 seconds.
    • Remove the injector and massage the injection site for 10 seconds to speed delivery of the medication.
    • The injector will have triggered if the orange sheath extends on the EpiPen or the needle is visible on the Adrenaclick. If the device did not trigger you may not have pushed hard enough, or the device is defective.
  7. Get the patient to the hospital or seek professional medical attention as soon as possible. The epinephrine only temporarily relieves the symptoms. A secondary reaction is possible so it is critical to get to a hospital, ambulance, or qualified medical personnel as soon as possible.
    • If professional medical care is not available it is important to have a second auto-injector available in case of a secondary reaction.



Tips

  • The risk of one epinephrine injection, even if not needed, is very small; nearly zero.
  • If treated with epinephrine and the patient has anaphylaxis without shock they will have elevated heart rate and blood pressure which may lead to jitters. This is only temporary; keep them calm until the shakes go away.
  • If the person has a known heart condition and also a doctor prescribed EpiPen then the guidelines above still apply. If they are unconscious due to anaphylaxis the prescription of an EpiPen by the doctor should take precedence over the possible risk associated with a heart condition.
  • There are two types of equivalent auto-injectors available. EpiPen (self-sheathing needle) and AdrenaClick (exposed needle). The AdrenaClick is also available from some medical providers as a 'generic' medication.

Warnings

  • Epinephrine only treats the symptoms, it does not eliminate the allergen in the body. Once the initial dose wears off a repeat reaction (biphasic) may occur. If you are unable to reach a hospital or ambulance quickly then be prepared to administer a second injection if the anaphylaxis returns or if one injection does not bring relief. A second injection should only be administered after consulting with emergency response team over the telephone.
  • If the injection is mistakenly made into the hand of the caregiver, they may also experience an adrenaline rush. They will need medical attention.
  • Anaphylaxis is a treat first, then call emergency.[5] The only way to treat anaphylaxis is with epinephrine which must be circulated throughout the body via the cardiovascular system. Anaphylactic shock itself prevents the treatment of the anaphylaxis by diminishing the supply and circulation of blood in the cardiovascular system. It is a vicious cycle and there is a definite point of no return when treating anaphylactic shock, that's why all anaphylaxis is classified as a "treat first, then call for help" medical emergency.
  • Always inject only into the thigh. The auto-injector dose is intended for intra-muscular (IM) injection and is too strong to be used for intravenous injection. Using an auto-injector intravenously can lead to death. The thigh is a large muscle in the body and provides a diffuse but rapid introduction of epinephrine into the cardiovascular system.

Related Articles

References

  1. ↑ http://news.ubc.ca/2016/05/16/parents-struggle-with-epipen-during-anaphylaxis/
  2. ↑ http://www.allergyhome.org/handbook/table-of-contents/recognize-and-treat-allergic-reactions/signs-and-symptoms/
  3. ↑ http://www.jacionline.org/article/S0091-6749(16)00430-9/abstract
  4. ↑ http://www.ncbi.nlm.nih.gov/pubmed/27144664
  5. ↑ http://www.nhs.uk/Conditions/Anaphylaxis/Pages/Treatment.aspx
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