Notes – Anaphylaxis and Allergic Reaction

Anaphylaxis and Allergic Reaction

Patient Safety Considerations

  1. Time to epinephrine delivery
  2. Concentration of epinephrine in relation to route
  3. Weight-based dosing of medications

Notes/Educational Pearls

Key Considerations

  1. Allergic reactions and anaphylaxis are serious and potentially life-threatening medical emergencies. It is the body’s adverse reaction to a foreign protein (e.g. food, medicine, pollen, insect sting or any ingested, inhaled, or injected substance). A localized allergic reaction (e.g. urticaria or angioedema that does not compromise the airway) may be treated with antihistamine therapy. When anaphylaxis is suspected, EMS personnel should always consider epinephrine as first-line treatment. Cardiovascular collapse may occur abruptly, without the prior development of skin or respiratory symptoms. Constant monitoring of the patient’s airway and breathing is essential.
  2. Contrary to common belief that all cases of anaphylaxis present with cutaneous manifestations, such as urticaria or mucocutaneous swelling, a significant portion of anaphylactic episodes may not involve these signs and symptoms on initial presentation. Moreover, most fatal reactions to food-induced anaphylaxis in children were not associated with cutaneous manifestations.
  3. A thorough assessment and a high index of suspicion are required for all potential allergic reaction patients – consider:
    1. History of Present Illness
      1. Onset and location
      2. Insect sting or bite
      3. Food allergy/exposure
      4. New clothing, soap, detergent
      5. Past history of reactions
      6. Medication history
    2. Signs and Symptoms
      1. Itching or urticaria
      2. Coughing, wheezing, or respiratory distress
      3. Chest tightness or throat constriction
      4. Hypotension or shock
      5. Persistent gastrointestinal symptoms (nausea, vomiting, and diarrhea)
      6. Altered mental status
    3. Other Considerations
      1. Angioedema (drug-induced)
      2. Aspiration/airway obstruction
      3. Vasovagal event
      4. Asthma or COPD
      5. Heart failure
    4. Gastrointestinal symptoms occur most commonly in food-induced anaphylaxis, but can occur with other causes
      1. Oral pruritus is often the first symptom observed in patients experiencing food-induced anaphylaxis
      2. Abdominal cramping is also common, but nausea, vomiting, and diarrhea are frequently observed as well
    5. Patients with asthma are at high risk for a severe allergic reaction
    6. There is no proven benefit to using steroids in the management of allergic reactions and/or anaphylaxis
    7. There is controversy among experts with very low quality evidence to guide management for the use of empiric IM epinephrine after exposure to a known allergen in asymptomatic patients with a history of prior anaphylaxis

Pertinent Assessment Findings

  1. Presence or absence of angioedema
  2. Presence or absence of respiratory compromise
  3. Presence or absence of circulatory compromise
  4. Localized or generalized urticaria
  5. Response to therapy

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01)

  • 9914111 – Medical-Allergic Reaction/Anaphylaxis

Key Documentation Elements

  • Medications given
  • Dose and concentration of epinephrine given
  • Route of epinephrine administration
  • Time of epinephrine administration
  • Signs and symptoms of the patient

Performance Measures

  • Percentage of patients with anaphylaxis that receive epinephrine for anaphylaxis:
    • Via the IM route (vs. other routes)
    • Via the IM route in the anterolateral thigh (vs. other locations)
  • Percentage of patients with anaphylaxis who receive:
    • Epinephrine within 10 minutes of arrival
    • The appropriate weight-based dose of epinephrine
  • Percentage of patients that require airway management in the prehospital setting (and/or the emergency department)
  • EMS Compass® Measure (for additional information, see http://www.emscompass.org)
    • PEDS-03: Documentation of estimated weight in kilograms. Frequency that weight or length-based estimate are documented in kilograms

References

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