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AnaphylaxisCase Examination – Diagnosis, and management

of anaphylaxis in the pre-hospital setting

Adam Khan

MCoP Paramedic Clinical Tutor

Aim:

The student should be able to demonstrate a clear understanding of the safe approach, diagnosis and timely

management of a patient presenting with anaphylaxis in the pre-hospital setting.

Objectives:

S Understand the causes, prevalence & clinical

manifestation of anaphylaxis.

S Demonstrate a safe approach to a patient presenting with

anaphylaxis.

S Understand the diagnosis and management of a patient

presenting with acute life-threatening anaphylaxis.

S Understand the definitive management and referral

options to a patient suffering with anaphylaxis

Case Presentation:

you are dispatched to a 30-year-old female ‘Louise’ who is

complaining of acute onset of dyspnea.

S Acute onset of dyspnea, choking.

S Occurrence following what is described as a ‘Bee sting’

S Previous medical history: Childhood Asthma

Case Presentation: continued

Location:

S Louise is located in a busy public

park with her boyfriend.

S Warm, sunny and dry afternoon.

Case Presentation: continued

Patient Assessment Triangle (PAT):

S Marginally obstructed airway.

S resp. rate 32 resp/min. Shallow & laboured.

S Flushed in appearance, clear agitation, swelling around the

eyes and mouth.

S Palpable Radial pulses, bi-laterally rate of 133 b/min.

S Responding verbally in broken sentences – clear hoarse voice

Anaphylaxis: What is it?

S Anaphylaxis is a severe, life-threatening, generalised

or systemic hypersensitivity reaction

S Multisystem involvement, including the airway, vascular

system, gastro intestinal (GI) tract and skin and central

nervous system.

S Acute onset.

Anaphylaxis: What is it?

Patients who have anaphylactic reaction have life-threatening airway and/or breathing and/or circulation problems usually associated with skin and mucosal

changes

Resuscitation council UK (2012)

Causes: of anaphylaxis

Stings 47

Nuts 32

Food 13

Food Possible Cause 17

Antibiotics 27

Anaesthetic Drugs 39

Other Drugs 24

Contrast Media 11

Other 3 Figures taken from Resuscitaiton Council (UK) 2008.

Table 1. Suspected triggers for fatal

anaphylactic reactions in the UK between

1992-2001

Lifetime Prevalence:

S According to the Resuscitation Council (2008) approx. in

1 in 1,333 of the English population have experienced

anaphylaxis at some point in their lives.

S The current incidence rate suggests that between 30 and

950 cases per 100,000 persons per year present in the

ED with anaphylaxis

Anaphylaxis: Mortality

S Post Mortem Findings:

S Airway (laryngeal) and tissue (visceral) edema

S Gastrointestinal Hemorrhage

S Myocardial injury

Anaphylaxis: Risk Factors

S Fatal cases – 4%

S Risk factors

S Asthmatics

S Mast Cell Disease – (rare)

S Personal/Familial history of anaphylaxis

S Age

S Sex

Anaphylaxis – Clinical Presentation

S The Skin (Integumentary

System)

S Pruritus (Itching), Urticaria

(Hives), Angioedema,

Flushing

Example of urticaria (hives) presenting in a child

Anaphylaxis – Clinical Presentation

S Angioedema affecting

the eyes and mouth.

S If left untreated this can

develop into a life-

threatening airway

obstruction

Anaphylaxis – Clinical Presentation

S Respiratory System:

S Dyspnea, Tachypnoea, Universal Wheeze/crackles, Stridor and/or hoarseness,

throat swelling

S Cardiovascular system:

S Hypotension, Hypoxia, Tachycardia, arrhythmias

S Gastro-Intestinal system:

S Nausea, Diarrhea, Stomach cramp, Bloating and/or abdominal distension,

vomiting

S Central Nervous System (CNS)

S Confusion, Dizziness, Headache, agitation and/or anxiety

Case Presentation:

S Vital Signs:

S Angioedema, Dyspnoea & tachypnoea 32 r/min

S SpO2: 89% (air)

S Tachycardia: 133 b/min

S Blood pressure: 88/52 mm/hg

S Temperature: 37.1 degrees Celsius

S 12 lead ECG: Sinus Tachycardia

S Blood sugar: 6.6

Anaphylaxis: Initial management

S Should consist of:

S Removal of offending agent (if possible)

S Rapid primary assessment ABCDE

S Focused Secondary assessment which includes

S Head to toe physical assessment

S NIBP

S 12 Lead ECG monitoring

Anaphylaxis:

Initial

management

Algorithm to the right indicates

the steps required to

appropriately manage a patient

suffering with acute onset of

sever anaphylaxis

Algorithm taken from Resus Council UK 2012

Anaphylaxis: Treatment

S Joint Royal Colleges Ambulance Liaison Committee (JRCALC)

S ABC Assessment – Anaphylaxis

S OXYGEN – 15L if SpO2 <95%

S ADRENALINE (ADX) 1:1,000 Intra-muscular (IM) 500 mcgs

S HYDROCORTISONE (HYC) Intra-venous/muscular 200mgs

S SALBUTAMOL (SLB) Nebulised 5.0mg

Anaphylaxis: Treatment (cont.)

S CHLORPHENAMINE (CPH) Intra-venous 10mg

S SODIUM CHLORIDE (SCP) Intra-venous. 250 mL (titrated)

S NOTE:

S Establishing IV access should not delay transport to ED

S Adrenaline can be re-administered after 5 minutes if no effect

S Hydrocortisone is considered if transport time to ED is >30 mins

Transport Considerations

S Rapid Transport to Accident & Emergency

S ATMIST pre-alert en-route

S Consider HEMS if in a rural location or >45mins from hospital

Anaphylaxis: Temporal Pattern

S Uni-phasic:

S Singular allergic reaction, can be self limiting

S Bi-phasic:

S Initial allergic reaction

S Recurrence of same manifestations up to 8hrs later

S Protracted

S Up to 32 hours

S May not be prevented by glucocorticoids

Further treatment:

S ED will consider admittance if patient:

S Presents with biphasic or protracted reactions.

S If this is the patients first reaction.

S Age of patient – Risk management

S Children

S Elderly

S Referral onto an immunologist or allergy specialist will be required

Differential Diagnosis

S Life Threatening:

S Severe Asthma

S Sepsis (SIRS)

S Pulmonary Embolism (PE)

S Choking

S Non life-threatening

S Syncope (vasovagal

episode)

S Panic Attack

S Idiopathic Urticaria

S Isolated Angioedema

Summary:

S Anaphylaxis is a life-threatening condition.

S Prompt identification, assessment and management is

vital for positive outcomes.

S Rapid transport is key to definitive treatment. Do not

delay on scene time

S Be aware of future treatment options