anaphylaxis

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ANAPHYLAXIS
Francina Hyatt Clinical Nurse Trainer/Advisor
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Anaphylaxis Training for Practice Nurses

• Aim of Session for nurses to have the knowledge
  and skills to manage a client presenting with
  anaphylactic reaction as set out in the Croydon
  PCT Guidelines

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Learning Outcomes

• The Participant will have an understanding of the
  altered pathophysiology of a patient who is
  experiencing an anaphylactic reaction.
• Recognise the causes, signs and symptoms of an
  anaphylactic reaction.
• Be competent to administer emergency treatment
  and to support to the patient.
• Document actions and treatments as per Nursing
  and Midwifery Council guidelines
• Will have an understanding of how to debrief
  after managing an anaphylactic reaction in a
  client.

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Anaphylaxis Facts

• 55 million doses of vaccine supplied throughout
  UK, only 87 reported episodes of anaphylacitc and
  no deaths.
• Anaphylaxis campaign state 1-70 children are
  allergic to peanuts.
• Most common food peanuts, tree nuts (almonds,
  brazils, hazelnuts, cashews and walnuts), sesame
  seeds, fish, shellfish, eggs and diary products.
• 200-250 episodes of severe food-induced
  anaphylaxis each year a proportion die.
• Most life threatening anaphlylaxis to food is
  IgE-mediated
• 4-5 deaths annually from bee/wasp sting.
• Anaphylactic reaction likely to occur within 10
  min, majority of adverse reactions occur within
  two minutes

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Diagrammatic representation of Anaphylaxis
Anitgen presented to B cell
Sensitisation
B Lymphocyte
Antibody Production
Memory Cell
Antibody attaches to Mast Cells and Basophils

• Sensitisation to a Foreign Protein
• The foreign protein (antigen) gains access to the
  body by means of inoculation,
• ingestion, inhalation or absorption. Once in, it
  is recognised by the immune system as
• being an antigen. The antigen causes the
  B-lymphocytes to proliferate and differentiate
  into either memory cells or to produce
  antibodies. The antibodies produced attach
  themselves to the mast cells and basophils. The
  antigen is then destroyed leaving antibodies
  permanently attach to the mast cells and
  basophils.

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Degranulation Leading to Anaphylaxis
Anitgen/Antibody Complexl
Degranulation of Mast Cells and Basophils
Anitgen /Antibody Complex
Eosinophils attracted to Antigen/ntibody Complex
Anaphylaxis Mediators released

• When the body encounters the foreign protein
  again, antibody production is increased. The
  antibodies on the mast cells and basophils bind
  with the antigen to form the antibody/antigen
  complex. Eosinophils area attracted in order to
  rid the body of these cells. Degranulation
  occurs releasing anaphylaxis mediators such as
  histamine, inflammatory activators and slow
  reacting substance of anaphylaxis. It is the
  release of these powerful chemicals that gives
  rise to the clinical picture of an allergic (or
  anaphylactic) rection3.
• 3 Henderson, N. 1998

Croydon PCT -2002
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Common Allergens (Antigens)

• Medical agents
• Antibiotics-Penicillins, Tetracyclines
• Chemotheraputic agents Methotrexate, Vincrystine
• Vaccines
• Intraveneous colloids/Plasma expanders/Bloods
• Local Aesthetics
• Non-steroidal Anti Inflammatory agents

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Common Allergens (Antigens) cont.

• Animals
• Bites, stings, venom, hair/skin
• Food
• Legumes ie. Peanuts, beans, peas, soybeans
• Shellfish ie.crab, lobster, prawns
• Milk, eggs, wheat, fish
• Nuts common brazil, pecan, walnuts
• Seeds ie. Sesame, poppy
• Spices ie. Cinnamon, nutmeg
• Fruit
• Chocolate
• Potato, Corn

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Common Allergens (Antigens) cont.

• Others
• Rubber including latex
• Paperr (usually associated with the chemicals
  used to bleach paper)
• Perfume
• Aerosols ( usually associated with the
  propellant)

NOTE Any protein is a potential allergen, which
may cause an anaphylactic reaction
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Symptoms that may present in Anaphylaxis

• CENTRAL NERVOUS SYSTEM
• Confusion
• Feeling of impending doom
• Apprehension
• Metallic Taste
• Altered levels of consciousness

• GASTROINTESTINAL
• Nausea
• Diarrhoea
• Abdominal Pain
• Vomiting

• RESPIRATORY
• Wheezing
• Dyspnoea
• Rhinitis
• Laryngeal obstruction causing stridor
• Hypoxia

• CUTANEOUS
• Swelling (angio-oedema
• Urticaria
• Redness (erythema)
• Itching (pruritus)

• CARIOVASCULAR
• Hypotension
• Tachycardia
• Arrhythmias

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Differentiating Between Anaphylaxis and a
Vascovagul Episode (faint)
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Anaphylactic Reactions Treatment Algorithm for
Adults by First Medical Responders
Consider when compatible history of severe
allergic-type reaction with respiratory
difficulty and/or hypotension especially if skin
changes present
Oxygen treatment when available
Stridor, wheeze, respiratory distress or
clinical signs of shock 1
Adrenaline (epinephrine) 2,3 11000
solution 0.5 mL (500 micrograms) IM
Repeat in 5 minutes if no clinical improvement
Antihistamine (chlorphenamine) 10-20 mg IM/or
slow IV
IN ADDITION
For all severe or recurrent reactions and
patients with asthma give Hydrocortisone 100-500
mg IM/or slowly IV
If clinical manifestations of shock do not
respond to drug treatment give 1-2 litres IV
fluid. 4 Rapid infusion or one repeat dose may
be necessary
January 2002 updated May 2005
Notes 1-4 cont.
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Notes continued

• An inhaled beta2-agonist such as salbutamol may
  be used as an adjunctive measure if bronchospasm
  is severe and does not respond rapidly to other
  treatment.
• If profound shock judged immediately life
  threatening give CPR/ALS if necessary. Consider
  slow IV adrenaline (epinephrine) 110,000
  solution. This is hazardous and is recommended
  only for an experienced practitioner who can also
  obtain IV access without delay. Note the
  different strength of adrenaline (epinephrine)
  that may be required for IV use.
• If adults are treated with an adrenaline
  auto-injector, the 300 micrograms will usually be
  sufficient. A second dose may be required. Half
  doses of adrenaline (epinephrine) may be safer
  for patients on amitriptyline, imipramine, or
  beta blocker.
• A crystalloid may be safer than a colloid.

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Anaphylactic Reactions In Children Treatment By
The First Clinical Respondent.
Consider Anaphylaxis, if compatible history of
severe allergic type reaction with respiratory
difficulty and/or hypotension, stridor, wheeze,
respiratory distress or clinical signs of shock
especially if skin changes are present.
Remember Basic Life Support- Airway
Breathing Circulation
PAEDIATRIC

small or prepubertal child
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Contd.
Repeat dose every five minutes if no clinical
improvement noted
In Addition (if available) administer oxygen 15
litres per min via a re-breathing mask
Transfer to AE! Never Discharge A Child Who Has
Been Given Epinephrine
Basic Life Support Anaphylaxis Policy

May 2005
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Anaphylactic Reactions Treatment Algorithm for
Children by First Medical Responders
Consider when compatible history of severe
allergic-type reaction with respiratory
difficulty and/or hypotension especially if skin
changes present
Oxygen treatment when available
Stridor, wheeze, respiratory distress or clinical
signs of shock1
Adrenaline (epinephrine) 11000 solution 2 gt12
years 500 micrograms IM (0.5 mL) 250
micrograms if child is small or prepubertal
3 6-12 years 250 micrograms IM (0.25 mL) 3 gt 6
months - 6 years 120 micrograms IM (0.12 mL) 3 lt
6 months 50 micrograms IM (0.05 mL) 4
Repeat in 5 minutes if no clinical improvement
Antihistamine (chlorphenamine) gt12 years 10-20
mg IM 6-12 years 5-10 mg IM 1-6 years 2.5-5 mg
IM
IN ADDITION
For all severe or recurrent reactions and
patients with asthma give hydrocortisone gt12
years 100-500 mg IM or slow IV 6-12 years 100
mg IM or slow IV 1-6 years 50 mg IM or slow IV
If clinical manifestations of shock do not
respond to drug treatment give 20 mL/kg body
weight IV fluid.5 Rapid infusion or one repeat
dose may be necessary
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Notes cont.

• An inhaled beta2-agonist such as salbutamol may
  be used as an adjunctive measure if bronchospasm
  is severe and does not respond rapidly to other
  treatment.
• If profound shock judged immediately life
  threatening give CPR/ALS if necessary. Consider
  slow intravenous (IV) adrenaline (epinephrine)
  110,000 solution. This is hazardous and is
  recommended only for an experienced practitioner
  who can also obtain IV access without delay. Note
  the different strength of adrenaline
  (epinephrine) that may be required for IV use.
• For children who have been prescribed an
  adrenaline auto-injector, 150 micrograms can be
  given instead of 120 micrograms, and 300
  micrograms can be given instead of 250 micrograms
  or 500 micrograms.
• Absolute accuracy of the small dose is not
  essential.
• A crystalloid may be safer than a colloid.
• January 2002
• updated May 2005

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Documentation

• 10.1 The following information should be recorded
  in the patients records or on checklist
  (Appendix three) -
• Date and time of event.
• Trigger factor(s) if known.
• Condition of the patient on initial presentation.
• Any history obtained prior to treatment
  including documenting the source of the
  information.
• Any treatment carried out including any drugs
  that were administered, including route, time and
  site of administration.
• Documentation should include the batch numbers,
  pack supplier and expiry dates on any drugs
  given.
• All observations made during treatment.
• Condition of the patient on transfer to another
  care provider e.g. the paramedics/AE, along with
  written details of drugs administered by them
  prior to transfer.
• Where the patient was transferred to and the time
  of transfer.
• Details of all staff present for all/part of the
  incident.
• 10.2 A incident Form should be completed for
  every administration of epinephrine and submitted
  as per PCT policy.
• 10.3 All adverse drug reactions should be
  reported using the yellow card system in the BNF.

Basic Life Support Anaphylaxis Policy Croydon
PCT
May 2005
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Consent

• 13.0 Consent
• 13.1 Ideally consent should be obtained prior to
  drug administration, but it is recognised that
  this may not be possible in the case of treating
  anaphylaxis.
• 13.2 Details of any consent obtained should be
  documented in the patients records and signed by
  the practitioner.
• 13.3 If the patient is not capable of giving
  consent practitioners should work in the best
  interests of the patient.

Basic Life Support Anaphylaxis Policy Croydon
PCT
May 2005
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Accountability

• As a registered nurse, midwife or specialist
  community public health nurse, you must maintain
  your professional knowledge and competence
• 6.2 To practice competently, you must possess
  the knowledge, skills and abilities required for
  lawful, safe and effective practice without
  direct supervision. You must acknowledge the
  limits of your professional competence and only
  undertake practice and accept responsibilities
  for those activities in which you are competent.

The Nursing and Midwifery Council Nov 2004
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ANAPHYLACTIC SHOCK SUMMARY

• Anaphylactic shock is caused bys severe allergic
  responses to an antigen, which sets off a release
  of chemicals in the body, causing life
  threatening symptoms.
• Treatment must be given quickly to prevent a
  cardiac arrest and death.
• Patients who have experienced a severe allergic
  reaction must be taught how to inject adrenaline
  via an Epipen or Anapen and wear a medical alert
  identification to alert any first aider.
• Nurses who administer vaccines should receive
  anaphylaxis training every 12-18 months.
• An anaphylaxis drug box should be easily
  available and checked regularly by a designated
  member of staff.
• The nurse and health care assistant should also
  be competent in basic life support.

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