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Anaphylaxis is a severe allergic reaction that involves airway compromise and cardiovascular collapse. It can be life-threatening and can occur within minutes of exposure to an allergen. Anaphylaxis is caused by an exaggerated immune response to an antigen, leading to the release of chemicals like histamines and leukotrienes that cause symptoms such as bronchial constriction, increased mucus production, and swelling. Anaphylaxis can be systemic and result in widespread symptoms throughout the body. It is important to recognize the signs and symptoms of anaphylaxis and seek immediate medical attention. involving allergic reactions. Allergic reaction emergencies always involve airway compromise and cardiovascular collapse. So the difference between anaphylaxis and a regular allergy is a regular allergy may cause like a cough or maybe a runny nose, watery eyes, maybe a little congestion, but not necessarily something like dreading. Anaphylaxis leads to acute airway collapse by constriction of the bronchioles and increased uterus production, and cardiovascular collapse as the blood vessels dilate and they become very permeable and fluidly in the blood pressure crashes. So it's the blood pressure crashing and acute constriction of the airway that causes the life-threatening condition. Anaphylaxis is a true anaphylactic shock. One of the shocks that I'm going to talk about is an anaphylactic shock. And it's one of the few shocks that can cause death within like 10 minutes. You can go from bee sting to death within 10 minutes in anaphylaxis. It can happen. It's like people carry epinephrine because epinephrine is the only true agent or medication that can reverse it. You must be able to treat these life-threatening complications and distinguish between a normal allergy and an allergic reaction, right, or a serious allergic reaction. Immunologists study the body's immune system. There are five categories of stimuli that may provoke an allergic reaction. We're going to talk about that. It's food, plants, and chemicals. We'll talk about that. The immune system protects the body from foreign substances and organisms. When a foreign substance invades the body, the body initiates a series of responses to inactivate the invader. It's not that I'm allergic. It's not that the bee venom is going to kill me. It's that my body's reaction to the bee venom is going to kill me. It's an exaggerated immune response to an antigen. An allergy is an exaggerated immune response to an antigen. Anaphylaxis is an exaggerated immune response to an antigen on steroids, right? It's really blown way out of proportion. An allergic reaction, again, is an exaggerated immune response to a substance not caused directly by the outside stimulus but by your body's reaction to it. What causes the body's immune system to release chemicals to combat the stimulus? It includes histamines, leukotrienes, and cytokines. You have basophils, neutrophils, and eosinophils. The basophils and the eosinophils are what we call granulocytes. They degranulize and they release histamines and leukotrienes and cytokines. The neutrophils actually absorb antigens after their, you know, through phagocytosis absorbs the antigen for destruction. So your eosinophils, which are involved in asthma, release histamine 1 and histamine 2. Histamine 1, one stomach, histamine 1 causes the increase of acid production in the stomach from the proton pulse. That's why you can take medications that are selective histamine 1 blockers and they're antacid, like Pepsi. And then you can also have histamine, and that causes GI motility, increased GI motility. And then histamine 2, two lungs, histamine 2 causes bronchial dilation or bronchial constriction and increased mucus production. And then leukotrienes released from the basophils cause vasodilation and increased vascular permeability, which means fluid leaves the vascular system and goes into the institution. Fluid, spaces. That's why we get that swelling. You see something with anaphylaxis, they get all the swelling, all the uric area, that's caused by the leukotriene. And cytokines also, cytokines cause a prostaglandin reaction that causes inflammation and discomfort. Some patients may not know what causes their reaction, so you must recognize signs and symptoms and maintain an index of suspicion. Some people know, I'm allergic to beans, I get stung by a bee. I'm allergic to tomatoes, I just ate a tomato. Eddie Murphy did a movie called Dr. Doolittle, and he was a doctor, and they had this woman that kept coming in, and she loved shellfish, and she'd come in her face and she'd be all swollen. Because she's allergic to shellfish, but she likes shellfish, and she'd keep eating it. And so she'd come in with an allergic reaction. That is funny, ha ha ha, but in real life, each subsequent anaphylactic reaction is generally worse than the one before. So something like that, no bueno, because eventually it's going to kill her. That's why you always ask a patient, you know, have you had an allergic reaction before? How did it result? What ended up happening? If the patient tells you that the last two anaphylactic reactions I had, I got intubated, you're like, oh shit, we've got to go to the hospital now, because you're probably going to get intubated again. So an allergic reaction can be mild and local, or severe and systemic. Mild and local would be like local swelling, scratchy throat, watery eyes, runny nose, sneezing, coughing, that kind of thing. That's localized. If my blood pressure starts dropping, my heart rate starts dropping, I start getting low widespread all over body swelling, that becomes systemic, that's anaphylaxis. So I like this slide here because it kind of shows everything. So this is kind of how it happens. So I get stung by the bee, ouch. The antigen, whatever it is. Now this is the thing, if I get, in order to be allergic to something, you have to be sensitized to it, right. So you have to have been exposed to it at one time or another. And that monster, hold that up for a minute, I want you to highlight the ingredients. Just point to them and show them. Look at the list of ingredients on the back of that. There's about 30 chemicals in that. And that's the problem today, is we are exposed to thousands of chemicals. We may be sensitized to it and not even know it. So I could be sensitized to a chemical three years ago, and then I come across it again, and that particular protein or enzyme causes an anaphylactic reaction. I don't know why, and I didn't do anything wrong. And it could be something that they were exposed to. Some chemical that was on something. It's such a doorknob. It can be, it can happen like that. Aren't some people allergic to things, like, I don't know, like, every day, kind of like water or something like that? Yeah, people can be allergic. Everybody, everybody on the planet is allergic to something. It's inherent in the body to be allergic to something. You just may never come in contact with it. But everybody's allergic to it. Some people are allergic to much more. My wife is allergic to chocolate. She sneezes. She likes chocolate, so she sneezes a lot. I've heard people have been able to outgrow, like, peanut allergies, like, from their childhood. Is that like... You can outgrow. Your body changes chemical, every seven to ten years, your body changes its chemical makeup. It is possible to outgrow an allergy. If you're a child, you have asthma or an allergy, you can outgrow it as an adult. If you have it as an adult, you're going to keep it. But you may not. It all depends. That's why, if a kid's allergic to peanuts as a child, I'm 18 years old, I'm going to go eat a peanut butter sandwich. I don't recommend it. So, anyway, so I get stuck by the B. The enzymes reach my body as antigens, and it causes my granulocytes to degranulize. And they release these chemical mediators. First of all, histamine 2 causes bronchospasms, constriction of the bronchioles, and increased mucus production, and basal constriction in the lung itself. The body says, whatever this chemical is, if I breathe it in, I don't want to get any more of it. I want to clear it out. So the mucus will clear it out, and I'll constrict the bronchioles so I don't breathe in anymore. The heart will slow down. That's that leukotriene, the cytokines. The heart will slow down and decrease pulmonary flow. What the body says, okay, whatever this chemical is, if it's in the blood, I want to slow down the circulation so it doesn't spread so quickly. Blood vessels. Blood vessels dilate. They become more leaky, more permeable, so fluid leaves. The body says, whatever this is, if it's in my skin, I want to clear it out. I want to rush chemical mediators to heal it, so it causes that widespread swelling. Then you can develop things like pruritus, which is a purpling blotching of the skin. You can get urticaria, which is hives, and edema. My mother, when I was 12 years old, she's allergic to tree nuts. It's funny because you can be allergic to peanuts and not tree nuts. Peanuts are actually a seed, not a nut. So you can be allergic to one and not the other, but she's definitely allergic to Brazil nuts. She won't eat any tree nuts, but especially not Brazil nuts. She had a pie that had just a little Brazil nut oil in it. She took a bite out of it, and within, I want to say, five to seven minutes, she looked like she was like six months pregnant. Her face was all bloated. She was all red, wheezing. Call the ambulance. They got there. EpiPen brought her to the hospital, and the doctor said if she had brought her to the hospital 20 minutes later, she would have been dead. So that's how quickly anaphylaxis can happen. So three common signs of anaphylaxis. So this is called a wheel, W-H-E-A-L, and it's a raised round area caused by edema or swelling. So if I get stung by a bee, I expect a wheel. I expect a raised, oh, that hurts. Oh, I just got stung by a bee. But if I get stung here and I start developing wheels here or on my leg or I start on my chest, that's systemic. That means that it's widespread. If it's just localized, okay, that's a localized issue. But if it's starting to spread like this, that's a potential for anaphylaxis. Now, I wouldn't hit this person with an EpiPen unless they had dropping blood pressure and respiratory compromise, but I definitely have it in hand. We don't use EpiPens anyway. We use the check and eject. How about that for angioedema? She probably ate something. Now, imagine trying to put an airway in that, right? And that's where you could get that. She could swell up like that in less than 10 minutes. They call that angioedema, swelling of the tongue, the face, the neck. You could get wheezes. Wheezes is that whistling sound in the lungs. You get that high pitched sound in the lungs of the patient. She would probably, if she were breathing, you could hear stridorous respiration, which is basically a wheezing in the upper, like in the throat, because the airway is closing off. So, you get that sound. Stridor due to uninspiration, hypotension due to vasodilation, nausea, vomiting, abdominal cramps. This is caused by the histamine 1. Histamine 1 causes increased acid production and increased GI motility. So, you get abdominal cramps, nausea, vomiting. A lot of times, patients with anaphylaxis will also have what they call a sense of impending doom. A patient will be like, oh my god, I'm going to die. If a patient tells you that, believe me. Food. Food is the most common allergy. 30 to 40% of anaphylaxis happens through food. May take up to 30 minutes to appear. Shellfish and nuts is most common. My wife is allergic to shellfish and I tell her that's very shellfishy for her because I like shellfish. The thing with food is anaphylaxis can have a delayed response up to six hours. So, we used to do all the calls at the colleges when we had bigger banks in Worcester. And so, I had done many calls over the years where you get the call for the allergic reaction and you arrive and the patient has no signs or symptoms. But the patient tells you, I'm allergic to tomatoes and there's tomatoes in the rice. Give them an IV and maybe give them some Benadryl and head to the hospital. In the hospital, we don't. They'll give them an IV and Benadryl and they'll sit on them for about four hours. And they'll allow the Benadryl to take effect. And then after that time, they won't just say, oh, we don't have a reaction so you're okay. No, because it can be having delayed reactions. Medications most common is penicillin or sulfa drugs. Sometimes you get them from non-steroidal anti-inflammatory drugs. What would be a non-steroidal anti-inflammatory drug? Adderall. Adderall. Acetaminophen. Aspirin. Naproxenazoleum. That is a medication allergy. Look at that. If medication is injected, the reaction may be immediate and severe. That's probably a... I mean, my mother kind of looked like that, but that would be... I would expect that to be like a medication reaction. Penicillin causes that. You're allergic to penicillin and you get penicillin. That's what you get. And it can be very dangerous. Plants. Dust, pollen, and other plant material. Ragweed, dry grass, maple, oak, poison ivy, poison oak, poison sumac. Those are all poison... Those are all anaphylactic reactions. Some people don't have them. Some people get them really bad. My father used to be able to eat poison ivy. Didn't bother. He would do that for kind of bad. Chemicals. The most common chemical allergen is latex. And sometimes latex can be very serious allergies. I used to teach a class on traumatic brain injury. And we used to practice proper ventilation of a patient. Not overventilating. We used to use balloons. A balloon, and that would act like the BBM. And they would squeeze it and we'd practice slowly ventilating a patient. And I can remember one girl came in one time. She had a latex allergy and I didn't know that. So I handed out the balloon. She kind of sat in the back. She didn't take a balloon. And they were just squeezing and she was practicing. And she didn't take a balloon. I said whatever. And all of a sudden she started wheezing and she ran out of the room. It was the molecules of latex from squeezing the balloon that got in the air that caused her to have an allergic reaction. Just breathing in the molecules from people squeezing balloons. Imagine that. So how serious that is. Imagine if she touched the balloon. Insect bites and stings. And venomation is the process of an insect injecting its venom. It is the reaction can be localized or systemic, severe and systemic. These ants and things like that. So like bot flies, is bot flying one of those things there? Is that an animation? Well, no. Bot flies don't envenomate you. They lay their eggs in you. Those are awesome. I love those. Approximately 2 million Americans are allergic to the venom of bees, wasps and hornets. And it's funny because each one has a different protein property. So you can be allergic to honey bees and not wasps or hornets but not get honey bees. Allergic reactions to stings cause at least 62 deaths in the United States per year. And why do most of those deaths happen? Because of shock, a delay in seeking care. Either they got stung as a kid, never been stung again, but their body sensitized. Then they get stung again, have an allergic reaction and they don't get care in time. Most of the time. 200 people a year die from snake bites. Most of the time it's because they have an allergic reaction and they don't seek care in time. About half of these deaths, the victims never experience the reaction to prior stings because they got sensitized by the first one or two stings. The stinging organ of most insects is a small hollow spine projecting from the abdomen. So, this is the honey bee. The royal honey bee who defends his family. He goes out and collects the pollen to make the honey. And he gives his life. He stings you and he's a barb at the end of the stinger. And he pulls on his abdomen and he dies and commits suicide to save his family. This little bastard right here, he just keeps stinging. They don't have a barb so they can just keep stinging. Some ants, especially fire ants, strike repeatedly. Fire ants are funny because they bite, they also sting. My experience with this was we went, I'll tell you a story, a little off track, when I was in the Army, did basic training down at Fort Jackson, South Carolina, and we did a 26-mile march out to the field for a seven-day field exercise, FDX. So, we got up at like 2 o'clock in the morning, packed our 70-pound ruck, and we started marching. I actually fell asleep marching. I was marching and I remember we were walking and I saw a sign on a pole with my unit's name showing this way. I just remember looking again and it was no longer there and I turned around and it was behind me like 50 feet. I walked like 100 feet asleep. So, anyway, we get there. We actually went to, we walked a 26-mile march and then we got Hatchow and then we went to the rifle range. Then we went to Bivouac at our first field Bivouac at night. And you have what they call a shelter house. It's half of the tent. So, I have a half and my buddy has one. And we made the whole tent together. We put our gear in it. Well, it was dark. We didn't really pay much attention to where we put it. It was so exhausting. We just made it anywhere and laid down. And about 2 o'clock in the morning, I woke up. Oh, my God, burning, scratching. What the hell is this? I get up yelling. My partner gets up yelling. My buddy gets up yelling. So, we had made our tent over a fire amp. And it was just all over screaming. And the drills, they were pissed because we were yelling. We broke sound silence and light silence. Oh, it was horrible. I had these bites all over me. It took two weeks for them to go away. Sucked. And then, then at the end of the FTX, they said to us, okay, we're going to run back. And we think it was seven compact, 26 miles. We're all going to die. We thought we're all going to die. We're going to die. Half mile back to the barracks. They marched us this way. We marched 26 miles doing this. We didn't even notice. Yeah. That's good training. Good training. This is a wheel. A wheel is not the thing that goes round and round on the bus. This is a raised, whitish, firm elevation of skin, usually from a sting or some kind of irritation. One item is a wheel. If you have multiple, it becomes high. It's what we call a unitary. In severe anaphylactic cases, patients may experience stridor. That's a high-pitched whistling sound from a constricted airway. Bronchospasms and wheezing in the lower airway. Chest tightness and cough, like an air hunger. Like some patients don't have wheezing. They have, my son, when he had asthma attack, he had a really dry, acting cough. And that's how he knew he had asthma. Shortness of breath, anxiety, that sense of impending doom. GI complaints, nausea, vomiting, GI cramping, as well as hypotension and bradycardia. These are all signs of anaphylaxis. This patient here is having an epidemic. Patients may occasionally experience respiratory failure, and they die. If untreated, anaphylactic will proceed to death fairly rapidly. More than two-thirds of patients who die of anaphylaxis do so within the first 30 minutes. Many die within less than 10. So, scene size-up, scene safety. Make sure the scene is safe, do your size-up. If you're going to an allergic reaction, or an anaphylactic reaction, and you're going to a park, most likely it's a bee sting, or some form of exposure. If you're allergic to things, be very careful. Patient's environment will tell you when you're going to a restaurant, probably a food allergy. Going to a manufacturing facility, probably a chemical allergy. Not always. Going to a home could be a medication allergy. Be mindful of other potential causes of respiratory distress. You can have asthma, you can have COPD. Traumatic injury may also be present. Follow standard precautions with a minimum of gloves and eye protection, right? You want to make sure the patient isn't coughing in your face. Who knows, maybe they got an infection. Call ALS right away, as soon as you recognize the potential for anaphylaxis. Yes, you can treat anaphylaxis, but call ALS. Quickly identify and treat any immediate or potential anaphylaxis. It may present as respiratory or cardiovascular distress, or the form of shock, anaphylactic shock. Patients will be very anxious, call ALS, and look for medical attention. Maybe they have a bracelet that says, you know, bee allergy, bee sting allergy, or, you know, medication allergy, food allergy, whatever. Airway and breathing, anaphylaxis can cause rapid swelling of the upper airway. You saw the angioedema, right? That woman's tongue. The whole airway can swell like that. You have only a few minutes to assess the airway and provide those life-saving procedures. Hit them with the EpiPen. Work quickly to determine the severity of symptoms. When in doubt, as long as the blood pressure is low, it's not bad to hit them with the EpiPen. Epinephrine sucks to get it, but it's not going to kill you, as long as you're not hypertensive. So, quickly assess the work of breathing, use of accessory muscles, head bobbing. You know, you'll get this. Patients will be sitting down, pulling down with their arms, trying to open up their airway, breathing with their nose. They'll be maybe head bobbing, grunting. You'll have that abnormal breath sounds, the wheezes. Assist the patient to sit up. They're going to want to sit up for best ventilation. It says, if in shock, place them supine and raise the legs in the Trendelenburg position, but if a patient's short of breath, they may not want to lie flat. So, you're going to have a hard time getting them into a flat position. Do not hesitate to give them hypo-oxygen. Can I bag a conscious patient? Can I ventilate a conscious patient? Yeah, absolutely. So, don't be afraid to ventilate them. Sir, I'm going to help you ventilate. I'm going to help you breathe. Patients may present with hypotension. That's one of the reasons we give them the EpiPen. Assess for rapid pulse rate, cool, cyanotic, reddish, moist skin. Now, the thing with anaphylaxis is it's going to cause the skin to have that urticaria. So, the skin may be cool, it might be cool and clammy, you know, diaphoretic, but it's going to be red because it's going to have inflammation. So, it'll be hot, moist skin, a warm, moist, flushed skin. You might not see cyanosis around the lips and the eyes and the fingernails, but you might not see it on the rest of the skin. Skin can be deceiving in anaphylaxis. The definitive treatment for anaphylaxis is FNS. So, always transport properly, call ALS for allergic reactions. And again, even if they have mild symptoms, if you know they were exposed to an allergic antigen that they were allergic to, call ALS. If you know they were exposed to an allergic antigen that they were allergic to, and they have severe allergies to it, transport high priority anyway, just in case. Investigate the chief complaint and the history of the present illness and their previous history. Find out if they were exposed to something. Have they had an allergic reaction before? How was it? Identify associated signs and symptoms. So, this table right here, 21-1, I'm not going to read through it because I've already covered all those, but I want you to read through it to kind of refresh your memory as to the things I've been talking about. Get your sample history. Things like, have any interventions been completed? Things like, have you taken any Benadryl or diphenhydramine? Say diphenhydramine slash Benadryl, because some people know it's Benadryl, some people know it's diphenhydramine. The thing with diphenhydramine is I keep children's Benadryl liquid at home. It's the fastest absorber. So, my wife, being allergic to shellfish, if she has one of those reactions, I'll give her 50 milligrams of Benadryl, it's like two cups full of Benadryl, and usually within 10 minutes that will take effect and she's asleep after that. But, I want to know if you've taken Benadryl, because I can give you guys, DLS can give Benadryl. You can give all Benadryl, children's Benadryl, you can give it all. So, let's say the patient's taking it, they don't tell you, so you give them Benadryl, and then you don't tell me, and I come in and I give them IV Benadryl. Now they've got 150 milligrams of Benadryl on board, and they can actually have a toxic effect to it. And it's a parasympatholytic, we're going to talk about it, and you can go from normal to seizure coma death in 30 minutes or less from an overdose of Benadryl. So, the last time I went into anaphylactic, I thought it was just like a regular, like I was breaking out, and I was like, oh, Benadryl will be fine. So, I went to take my Benadryl, and I'm sitting there, and then I'm starting to have trouble breathing. It's time for the Benadryl to take effect. Yeah, yeah. Was it pill or liquid? It was the pill. That could take up to 30 minutes. Yeah, but normally it goes away after that, and it never becomes anything super serious, but I guess when I touched whatever I touched, like I have an allergy to peanuts, so it just... Touched something with peanut oil. Touched something, and it just, I reacted to it. I ended up, immediately my hands ended up swelling up, so I couldn't grip onto my EpiPen. Oh. So, my manager actually had to do it, because like I couldn't, my hands were swollen up. And what happened when you got hit with the EpiPen? How did it feel? It was like relief. It was the weirdest thing, but it like, it actually acts so quickly. It's almost a disease. Yeah. And it like, I could, they noticed the difference, like my manager even said it, he was like, I noticed the difference. You got cool, pale, flaming skin. Yeah. So, this is what happens. So, she's got personal, first-hand experience with this. So, be alert for the statement regarding ingestions of food or allergic reaction, and ask about GI complaints, like nausea, vomiting. So, what the epinephrine does, is an epinephrine is a...