Friday, October 23, 2015

Anaphylaxis

Anaphylaxis is a very severe allergic reaction that can occur within moments of exposure to an allergen.  It can be triggered by an allergy to a particular food (peanuts or shellfish are among the most common), biting or stinging insects (like bees), medication (like antibiotics), latex (the type of rubber many balloons are made from) or a variety of other allergic triggers. Allergic reactions occur when the body mistakenly identifies something as harmful and over reacts. With anaphylaxis, this reaction can be life threatening. Symptoms usually start within seconds or minutes of the exposure, but there are exceptions. Rarely, a reaction can be delayed by several hours. This would make it much harder to figure out the culprit.

In an anaphylactic reaction there may be different parts of the body involved:

Mouth: itching or swollen lips or tongue
Lungs: cough, wheezing, shortness of breath
Heart: weak pulse, dizziness, fainting
Skin: hives, itching, redness, swelling
Face: flushed, swollen (eyes and ears common)
Throat: itching, tight feeling, swelling
GI system: vomiting, diarrhea, cramps, nausea

The first time that someone has a severe allergic reaction is very frightening. Unfortunately subsequent reactions can be even more severe. It is essential to recognize symptoms that need immediate attention.

Several years ago, a patient in our practice had been given yogurt for the first time. The child’s face began to swell and she started to have labored breathing. Mom’s first instinct was to call me, I redirected her to call 911 immediately. If it feels like an emergency situation, 911 trumps the advice nurse. Of course, we do want to be kept in the loop and help with any follow up. This child turned out to be severely allergic to milk. Interestingly she had no trouble with breast milk. It is very important that folks figure out what the trigger is so that the you can try to avoid future reactions, although there are cases that remain a mystery.

Avoid and educate
Knowing that your child is at risk for anaphylaxis is very unnerving to say the least. It is very important to educate your child (age appropriate) and all teachers and caregivers about how critical it is to keep your child from being exposed to the allergen.

One case comes to mind, of a school aged patient who was at Costco with some friends. The child was allergic to nuts. The friends parents allowed him to taste something from one of the samples. They had done a cursory check of the ingredients and thought it was safe. It turned out the the knife used to cut the samples had also been used to cut something with nuts, and the child ended up in the ER. Some kids are so sensitive that cross contamination (in this case, the knife) can cause a full reaction.

Talk to your child about the fact that just about everyone has a little something special going on, and it their case they need to be careful about whatever their trigger is. Check out this book, available on Amazon. It is a bit dated but still sweet and relevant, Perhaps pick one up for the class and make sure the teacher reads it out loud:


There is a new law, SB 1266 effective January 1, 2015, that mandates all schools keep an epinephrine auto-injector on hand and that someone on site be trained in its use. Check with your child’s school to make sure that they are complying.

Make certain that any babysitters or friends caring for your child know what allergens are potential hazards so that they can be certain to avoid them They should also have an injector handy just in case.

If you go to a restaurant, ask to speak to the chef so that you know the restaurant understands the importance of avoiding the ingredient in question. In serious cases, you might want to call ahead to make sure they are willing and able to accommodate you.

Just this week we had a patient with an anaphylactic reaction. To complicate things, this little 9 month old was already teething and fussy. She also is prone to eczema, so rashes are not unusual. The family had a recent checkup and had come home ready to increase solids and calories to fatten up their slender child. Dinner that evening was some Chinese take out. Our little patient was offered bits of foods from the various containers. They didn’t offer any foods that struck the parents as obviously new, but one of the containers was a shrimp dish. Although the baby didn’t actually eat any shrimp, she started to get very fussy and swiping at her face and ears. After several moments of excessive fussing from no overt cause, mom and dad opted to give her a bath and start the bedtime process.

When they removed her clothing they saw that she was covered with hives. At that point they wisely opted to go to the ER. It had been about 20 minutes since the food. The baby was fairly inconsolable and her face and ears were swelling. Luckily she did not appear to be having labored breathing (that would be a reason for a 911 call.) Once in the ER she vomited. She was given Epinephrine and kept overnight for observation. She was singing and happy the next morning with no seeming ill effects. The current plan is for to avoid any mystery foods and follow up with an allergist within a few weeks. The family will have an epipen or Auvi-Q on hand just in case.

Epipen and Auvi-Q are predosed epinephrine injections. They come in 2 strengths. The junior (.15mg)  is for anyone under 66 pounds. Anyone over 66 pounds gets the full adult strength (.30 mg.)

Epinephrine is the only first line treatment for an anaphylactic reaction. It relaxes the muscles in the lungs to improve breathing. To quote my go to allergist Dr. Fast, “Epinephrine is what saves lives. It is never wrong to give epinephrine.”

In the case of a severe allergic reaction, give the immediate dose of epinephrine but then head over to the ER for some observation. It is possible for the symptoms to rebound. This is called a biphasic reaction. Hours after a patient seems stable, the symptoms can flare up again. Since it is always better safe than sorry, keeping a close eye on the patient  is essential for the next 24 hours.

Epipens may be what most people are familiar with. The Auvi-Q is the new kid on the block. This little gizmo actually talks you through the injection. It also tells you that you need to get over to the ER for some follow up. This is great if a caregiver is giving it who is not as familiar with the procedure. Another plus for the Auvi-Q is that is it smaller and flatter, so it is easier to tuck into a purse.
Regardless of the brand, the autoinjector should be administered into the upper outer thigh. It can be given through thin clothing. New studies suggest that holding for 5 seconds is adequate. The leg should be restrained and the injector should be held against the thigh and then compressed, rather than jabbing it. The new recommendation comes in response to some rare lacerations from an epi pen needle given to an unrestrained leg.

Both the Auvi-Q and epipen have trainers available. Please ask your nurse or doctor's office to give you a demo and make sure you are comfortable using it.

The downside to both brands is that they are fairly temperature sensitive and should not be left in a hot car (keep in mind that they shouldn’t be left in the car anyway; they should be with you at all times!) They are also expensive if you don’t have good insurance. If you have a high deductible and you are close to meeting it towards the end of the year, this is an excellent time to get a refill.
Click the link for some Auvi-Q co pay assistance    auvi-q.com 
If you own an epipen or Au Vi Q, check the expiration dates. They don't usually have a shelf life of over a year or so because the rubber diaphragms can get dry and cracked.. If it is an emergency and the only one you have is expired, still give it...but you are are reading this go check right now and make sure yours is current.

Children with reactive airway disease and/or eczema are more at risk for allergic reactions, but they can happen to anyone. While it is essential to be vigilant, rest assured that most allergic reactions are mild to moderate and not life threatening. Benedryl liquid is an OTC antihistamine is something that every household should have on hand to help deal with mild reactions.

As a precaution, I recommend that all first time foods be tried when there is time to observe for a little while to make sure there is no reaction. Giving something brand new and then putting a baby straight to bed is not a good plan. This is especially important with high risk foods like nuts, milk, eggs, shellfish, and any medication.

While of course not everyone needs to carry around epinephrine, but it is so important to be able to recognize the symptoms and act quickly if you are concerned about the possibility of an anaphylactic reaction.


AS OF 10/27/2015 there is a recall on the AU VI Q due to some dosing issues.

http://www.empr.com/safety-alerts-and-recalls/emergency-med-recalled-due-to-potential-inaccurate-dosage-delivery/article/450199/?DCMP=EMC-MPR_breakingnews_cp&cpn=mnbped%2ctrumped%2cbexlm%2cnpizyr&hmSubId=p2t-h7PEL1Q1&hmEmail=1ULyjYi-Xg5E2NpzFd_agzIZDo7e_i8h0&NID=1215940762&dl=0&spMailingID=12813980&spUserID=MTcyMTIzNjAwMzgyS0&spJobID=641996003&spReportId=NjQxOTk2MDAzS0

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