Immunotherapy Safety for the Primary Care ... - U.S. Coast Guard

• Sulfites are added to all the bronchodilator solutions of the catecholamine class
to offset catecholamine susceptibility to inactivation by oxidation. Used primarily in the
multidose vials -- but not in MDIs, because fluorocarbon propellant replaces sulfite as
the preservative, and oxidation does not occur in these closed containers.
• Bronchodilator solutions: Bronkosol (the worst), Alupent, Isuprel
• Epinephrine
• Dopamine, norepinephrine
• Corticosteroids: Hydrocortisone, dexamethasone
Exercise-induced anaphylaxis. Recently a new group of patients have been described who
experience urticaria and anaphylaxis on vigorous exercise, an entity termed exercise-induced
anaphylaxis.
• This syndrome should be suspected in any person who collapses after exercise,
particularly if flushing, urticaria, or angioedema are evident.
• Most of these events occur only very sporadically, and it was this intermittent nature
that served as a clue that other associated factors may be responsible for promoting the
occurrence.
• Many of these individuals only develop symptoms in the post-prandial period.
In a survey of 199 patients, more than half of them felt that food ingestion 3 to 4 hours
before exercise significantly increased their risk for anaphylaxis.
• Others report that a specific food ingested prior to exercise was a major factor:
shellfish, celery, cabbage, chicken, or wheat products.
• Other associated factors: alcohol (5%)
aspirin (6%)
environmental factors (humidity: 63%)
menstrual cycle (25% of women)
Clinical manifestations of anaphylaxis
• Onset: usually begins within minutes after exposure to the causative factor, although the
onset may be delayed for several hours.
• Once under way, the reaction usually progresses in an explosive manner, reaching a
peak intensity within 1 hour.
• The primary anaphylactic shock organs in humans are the cutaneous, gastrointestinal,
respiratory, and cardiovascular systems, the latter two being the most critical.
• Respiratory events: accounted for 70% of the mortality in one series,
• Cardiovascular manifestations: accounting for an additional 24%
• Patients typically present with generalized pruritus (though often located to their
palms, soles, or groin area) They get hives, angioedema and frequently are noted
to have flushing.
• They often describe an immediate sense of impending doom - they know something is
wrong. Other neurologic symptoms: weakness, dizziness, confusion, LOC, or
seizures.
• Occasionally they complain of a metallic taste in their mouth, and are noted to have
swelling of the lips and tongue.
• They frequently develop typical allergic symptoms
• Itchy, watery, red eyes
• Nasal congestion/rhinorrhea or sneezing