Anaphylaxis Case Examination PDF

Anaphylaxis Case Examination – Diagnosis, and management of anaphylaxis in the pre-hospital setting Adam Khan MCoP Paramedic Clinical Tutor S  Aim: The student should be able to demonstrate a...

Anaphylaxis Case Examination – Diagnosis, and management of anaphylaxis in the pre-hospital setting Adam Khan MCoP Paramedic Clinical Tutor S  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 Table 1. Suspected triggers for fatal Nuts 32 anaphylactic reactions in the UK between 1992-2001 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.  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 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 Non life-threatening S Severe Asthma S Syncope (vasovagal S Sepsis (SIRS) episode) S Pulmonary Embolism (PE) S Panic Attack S Choking 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