Anaphylaxis The Killer Allergy

1. AnaphylaxisThe Killer Allergy How to recognize and care for severe allergic reactions

2. Objectives in Anaphylaxis Education • What is it? • Who is at risk? • When can it happen? • How do we know it is anaphylaxis? • Where can it happen? • What should we do? • Why is follow-up needed?

3. Anaphylaxis A serious allergic reaction that is rapid in onset and may cause death Each year in the U.S., anaphylaxis to food causes an estimated 14,000 to 90,000 emergency room visits1,2 Individuals with food allergy plus asthma are at greatest risk for this life-threatening reaction • Ross MP et al. J Allergy ClinImmunol. 2008; 121:166–171. • Clark S et al. J Allergy ClinImmunol. 2011;127: 682-3.

4. Allergen (Food, Drug or Insect) IgE antibody Mast cell granules Mast Cell Immediate reaction Wheeze Urticaria Hypotension Abdominal cramping Late-phase reaction Anaphylaxis: Mechanism Lieberman. Clinician’s Manual on Anaphylaxis. 2005.

5. Warning Signs

6. Anaphylaxis: Signs and Symptoms • Mild to Moderate • apprehension, uneasiness, weakness • redness, itching, hives, swelling • abdominal cramps, vomiting, diarrhea • urinary incontinence, uterine cramps • These symptoms can occur as initial signs of severe anaphylaxis • Severe • chest tightness, cough, wheezing, difficulty breathing • Lightheadedness, fainting, low blood pressure • Death Lieberman et al. JACI. 2005

7. Anaphylaxis is highly likely when any one of the following three criteria are fulfilled: • Acute onset of Symptoms (minutes to a few hours after ingestion or sting) with: a). Skin - redness, hives, swelling, itching. b). Swelling of lip, tongue and/or other mouth tissues c). Breathing difficulties, d). Dizziness/faintness or shock due to reduced blood pressure. Sampson HA et al. J Allergy Clin Immunol 2006;117:391-7

8. Anaphylaxis is highly likely when any one of the following three criteria are fulfilled: 2. Symptoms involving two or more organ systems that occur rapidly after exposure to a likely allergen for that patient. 3. Reduced Blood Pressure: Dizziness/Faintness, Shock following exposure to a known allergen for that patient. Sampson HA et al. J Allergy Clin Immunol 2006;117:391-7

9. Most deaths from anaphylaxis, especially from food allergy, are due to obstruction to airflow in the upper and/or lower respiratory tract that result in respiratory failure. Bock et al. J Allerg Clin Immunol 2007;119:1016-1018.

10. Fatal Food Anaphylaxis • Fatal Anaphylaxis • Clinical features: • Biphasic reaction can contribute –initially better, then recurs • Cutaneous symptoms may not be present • Respiratory symptoms prominent • Risk factors: Underlying asthma Delayed epinephrine Symptom denial Previous severe reaction Adolescents, young adults Increased platelet activating factor

11. Triggers of Anaphylaxis: Overview • The most commonly identified triggers are: • Food • Insect stings and bites • Medications • Idiopathic anaphylaxis (no cause found after extensive evaluation). Lieberman P. Ann Allergy Asthma Immunol 2006;97:39-43

12. Fatal Anaphylaxis Cases • Food induced anaphylaxis: An estimated 150 fatalities from per year in the US: • Peanut and tree nuts account for 94% of fatalities reported to a national registry • Antibiotics: 400-800 fatal episodes of anaphylaxis per year worldwide • Insect Stings: An estimated 50 fatalities in the US per year. However, the true incidence is unknown. There is evidence from autopsy studies suggesting the true incidence might be higher.

13. Food Allergy Facts 1. Almost everyone knows someone with a food allergy. 2. About 1 in 13 children have food allergies. 3. 12 million Americans have food allergies1 4. 5.9 million of those with a food allergy are under the age of 182 5. Perceived food allergy is greater than True food allergy 2 2 • Sicherer SH, Sampson HA.J. Allergy Clin Immunol2006;117:S470-475. • Gupta R., et al. Pediatrics 2011;Vol. 128, No. 1.

14. What foods cause allergic reactions? People can be allergic to almost any food, but 90% of food allergic reactions are caused by 8 foods: • Milk • Peanuts • Eggs • Tree Nuts • Wheat • Fish • Soybean • Shellfish

15. Anaphylaxis Syndromes • Food-Induced Anaphylaxis • Food allergy is the #1 cause of ER anaphylaxis • Rapid-onset, up to 30% biphasic • May be localized (single organ) or generalized • Any food, highest risk: • Peanut, tree nut, seafood (cow’s milk and egg in young children) • Food-dependent, exercise-induced: 2 forms • Specific foods (wheat, shellfish, celery most common) • Any food (after eating) • Severity increased with alcohol and ASA/NSAIDs Bock SA, et al. J Allergy ClinImmunol2001 and 2007.

16. Triggers of Anaphylaxis: Insect Stings and Bites COMMON: • Bees • Wasps, Hornets, Yellow Jackets • Fire ants and other ants RARE: • Scorpions • Deer & horse flies • Mosquitoes

17. Classification of Insect Sting Reactions

18. Medication Triggers of Anaphylaxis • Diagnostic agents • X-ray Contrast • Medications • Antibiotics • Aspirin and other NSAIDs • Biological response modifiers • Anti-venoms • Monoclonal antibodies • Blood transfusions • Allergy shots Joint Task Force on Practice Parameters: AAAAI, ACAAI, and JCAAI. J Allergy Clin Immunol 2005;115:S483-523

19. False Assumptions in Anaphylaxis • Anaphylaxis is always preceded by mild symptoms • There is no need to rush because there is always time to get to a medical facility • Epinephrine is always effective • A mild reaction will not progress and will go away • Antihistamines are effective by themselves in the treatment of anaphylaxis • Don’t worry about giving antihistamines initially in treatment: Secondary therapy

20. ANAPHYLAXISTreatment

21. BE PREPARED!!!

22. 3 R’s of An Anaphylaxis Emergency Action Plan • Recognize symptoms early • Respondquickly • Review what caused the reaction

23. For Patients and Providers • Anaphylaxis Tool Kit, including epinephrine device • Wallet Card • Emergency Action Plan • Educational Material Available At • www.aaaai.org • www.foodallergy.org

24. Identification Jewelry From www.foodallergy.org www.medicalert.org

25. Action Plans

26. Wallet Card Simons FER. J Allergy Clin Immunol 2006;117:367-77

27. Accidents Are Never Planned Emergency medications and a treatment plan must be immediately available and accessible at all times!

28. Treatment • Epinephrine is the drug of choice for all anaphylactic episodes. • 911 must be called afterwards for treatment of possible biphasic or second reaction. • Flexibility in dosing needed to treat effectively. - Many patients require more than a single injection. - Lower dose for children under 50 lbs. (50% - 7 yr old) • Early and aggressive use to maintain breathing, blood pressure. • Severe side effects are rare with SQ or IM epinephrine

29. Epinephrine Is Under-Utilized for Acute Treatment • Only about 30% of individuals requiring epinephrine during a reaction actually received it. • Fatal food-induced reactions: • Failure to use, delayed use, or inappropriate dose of epinephrine increase the risk of death from anaphylaxis. Gold MS and Sainsbury R. J Allergy Clin Immunol 2000; 106:171-6; Sampson HA et al.N Engl J Med 1992; 327:390-4; Pumphrey RS. Clin Exp Allergy 2000; 30:1144-50

30. Outdated Epinephrine Loses Efficacy • As time passes, percent of labeled dose and epinephrine bioavailability are reduced. • Improper storage and exposure to sunlight and heat increase degradation. • Degradation often occurs without a color change in the epinephrine solution. Simons FER et al.J Allergy Clin Immunol2000;105:1025-30

31. Which epinephrine auto-injector dose is appropriate – 0.15 mg or 0.3 mg? Recent guidelines suggest a 50 lb cutoff for the 0.15 dose devices. >50 lbs, use the 0.3 ml dose devices. This is the weight of 1 )An average 7 year old (2nd grade) 2) Pudgy 5 year old – highest 10% on growth chart. 3) Thin 9 year old. When in doubt use higher dose. Simons FER. J Allergy Clin Immunol 2004;113:837-44

32. Epinephrine (adrenaline) Prompt administration of epinephrine is key to surviving anaphylaxis Prescribed as auto-injectors (such as EpiPen® or Auvi-Q®) or generic epinephrine

33. EpiPen® Use Online video at www.epipen.com Epipen is a registered trademark of Dey Pharmaceuticals

34. Auvi-Q® Overview www.auvi-q.com 3) Seek medical attention immediatelyReplace the outer case and take used Auvi-Q™ with you to a healthcare professional for proper disposal and a prescription refill.

35. Generic Epinephrine Place RED tip on the middle of the outer side of the thigh. Press down hard until the needle penetrates the skin and slowly count to 10 Remove the GRAY cap labeled "1". Never put thumb, finger, or hand over the RED tip Remove the GRAY cap labeled "2" Call 911 after administering to get medical attention. After injection, the injector needs to be properly discarded.

36. Food Allergy in Schools Once a reaction begins, there is no way to know how severe it will become Take all food allergy-induced allergic reactions seriously Every school should have a plan for managing food allergies

37. TX State Guidelines for Students with Food Allergies at Risk of Anaphylaxis 1. Food allergy management plan 2. Food allergy management team • Works with parents in supporting students with food allergies on the campus and assist campus staff in implementing administrative procedures and student specific strategies 3. Environmental controls in the school setting 4. Training of school personnel on food allergy awareness 5. Recommend that epinephrine be readily accessible in a secure, but unlocked area Department of State Health Services local policies to implement by August 1, 2012

38. The Food Allergy Management Plan The plan to manage a student’s food allergies should take into account: Unique needs of the child School environment (size, staff, etc.) Goal of equal participation in all school-related activities

39. The Food Allergy Management Team Developing the plan is a team effort involving: School staff Child’s family (parents/guardians) Child’s physician The child who has allergies, as age-appropriate

40. School’s Responsibility Create an environment where children, including those with food allergies, will be safe Employ prevention and avoidance strategies Be prepared to handle an allergic reaction Address teasing

41. Environmental Controls in School Careful Food Preparation;- Wash hands, cooking utensils, and food preparation surfaces to avoid reactions from trace amounts of proteins left behind. Liquid soap, bar soap, or commercial wipes for hands, not antibacterial gel sanitizers Dishwashing detergent and hot water for cooking utensils and cutting boards Common household cleaners for counters, tables, and other surfaces

42. Vigilant Label Reading Read every label every time • Formulations can change without warning Don’t rely on “safe lists” Allergens can be in non-food items • Soaps, shampoos, skin products, medications, pet foods

43. Strategies to Minimize Risk of Reactions Clean hands before and after eating or handling food Plan for safe parties/celebrations Avoid using foods in classroom art/craft projects or as incentives Prohibit food trading and sharing

44. Family’s Responsibility Provide written medical documentation Work with the school to develop a plan Provide properly labeled medications and replace after use or when expired Keep emergency contact information up-to-date Teach the child age-appropriate self-management skills

45. Key Points for Schools Reactions can occur anywhere in school Early recognition and treatment of anaphylaxis is imperative and life-saving Education of all staff is important

46. Objectives in Anaphylaxis Education • What is it? A severe allergic reaction that can cause death • Who is at risk? People with food, drug or insect allergies • When can it happen? Anytime • How do we know it is anaphylaxis? By the classic symptoms • Where can it happen? Anywhere • What should we do? Treat with epinephrine and call 911 • Why is follow-up needed? To treat “second” biphasic reactions and prevent future reactions

47. Anaphylaxis Summary • Anaphylaxis is a life-threatening allergic reaction and should be treated promptly with epinephrine. • Food, medications, insects and unknown factors can all cause anaphylaxis. • Careful preparation and precautions are required at home, schools and workplaces for allergic people to avoid exposure to allergens and prevent severe allergic reactions.