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

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J ALLERGY CLIN IMMUNOL VOLUME 115, NUMBER 3 Lieberman et al S489 Management of anaphylaxis episodes should follow annotation 10 (see algorithm). Annotation 9: Diagnosis made of specific cause of anaphylaxis The diagnosis of a specific cause of anaphylaxis might be supported by the results of skin tests, in vitro IgE tests, and/or challenge tests (particularly double-blind, placebocontrolled challenge tests). Annotation 10: Management of anaphylaxis When anaphylaxis has occurred because of exposure to a specific agent (eg, food, medication, or insect sting), patients should be educated about agents or exposures that would place them at risk for future reactions and be counseled on avoidance measures that might be used to reduce risk for such exposures. Patients who have had anaphylactic reactions to food should be instructed on how to read food ingredient labels to identify foods that they should avoid. Patients with anaphylaxis to medications should be informed about all cross-reacting medications that should be avoided. Should there be a future essential indication for use of incriminated medications, it might be helpful to educate patients about applicable management options (eg, medication pretreatment and use of lowosmolarity agents in patients with a history of reactions to radiographic contrast media or desensitization for drugs, such as antibiotics). Patients who have had anaphylactic reactions to insect stings should be advised about avoidance measures to reduce the risk of insect stings are candidates for insect venom immunotherapy (see ‘‘Stinging insect hypersensitivity: a practice parameter update’’). Patients who have had anaphylaxis should carry self-injectable epinephrine for use if anaphylaxis develops. There might be exceptions to this (eg, anaphylaxis to penicillin). Patients should also carry identification indicating that they are prone to anaphylaxis and indicating the responsible agent. Patients taking b-blockers are at increased risk during anaphylaxis. ALGORITHM FOR THE TREATMENT OF ACUTE ANAPHYLAXIS (Fig 2) Annotation 1. Anaphylaxis preparedness It is important to stress that management recommendations are subject to physician discretion and that variations in sequence and performance rely on physician judgment. Additionally, a determination of when a patient should be transferred to an emergency facility depends on the skill, experience, and clinical decision making of the individual physician. Preparedness, prompt recognition, and appropriate and aggressive treatment are integral to parts of successful management of anaphylaxis. A treatment log will assist in accurately recording progress (Fig 3). Recommendations depend on practice resources and the proximity to other emergency assistance. Stocking and maintaining anaphylaxis supplies with regular written documentation of contents and expiration dates and ready availability of injectable epinephrine, intravenous fluids and needles, oxygen and mask cannula, airway adjuncts, and stethoscope and sphygmomanometer are bare essentials. (An example of a supply checklist is included in ‘‘Management of anaphylaxis’’ [Fig 4]. Not all items need to be present in each office.) Regular anaphylaxis practice drills, the contents of which are left to the discretion and qualifications of the individual physician, are strongly recommended. Essential ingredients are identification of a person who will be responsible for calling emergency medical services and the person who will document treatment and time each is rendered. The emergency kit should be up to date and complete. Everyone who will be directly involved in patient care should, for example, be able to easily locate necessary supplies and rapidly assemble fluids for intravenous administration. Annotation 2. Patient presents with possible-probable acute anaphylaxis Anaphylaxis is an acute life-threatening reaction, usually but not always mediated by an immunologic mechanism (anaphylactoid reactions are IgE independent), that results from the sudden systemic release of mast cells and basophil mediators. It has varied clinical presentations, but respiratory compromise and cardiovascular collapse cause the most concern because they are the most frequent causes of fatalities. Urticaria and angioedema are the most common manifestations of anaphylaxis but might be delayed or absent in rapidly progressive anaphylaxis. The more rapidly anaphylaxis occurs after exposure to an offending stimulus, the more likely the reaction is to be severe and potentially life-threatening. Anaphylaxis often produces signs and symptoms within minutes of exposure to an offending stimulus (see comments in text), but some reactions might develop later (eg, >30 minutes after exposure). Late-phase or biphasic reactions, which occur 8 to 12 hours after the initial attack, have also been reported. Protracted and severe anaphylaxis might last up to 32 hours, despite aggressive treatment. Increased vascular permeability, a characteristic feature of anaphylaxis, allows transfer of as much as 50% of the intravascular fluid into the extravascular space within 10 minutes. As a result, hemodynamic collapse might occur rapidly with little or no cutaneous or respiratory manifestations. Annotation 3. Initial assessment supports potential anaphylaxis Initial assessment should determine whether history and physical findings are compatible with anaphylaxis. The setting of the episode and the history might suggest or reveal the source of the reaction. Evaluation should include level of consciousness (impairment might reflect hypoxia), upper and lower airways (dysphonia, stridor, cough, wheezing, or shortness of breath), cardiovascular system (hypotension with or without syncope and/or
S490 Lieberman et al J ALLERGY CLIN IMMUNOL MARCH 2005 FIG 2. Algorithm for the treatment of acute anaphylaxis. ICU, Intensive care unit; CPR, cardiopulmonary resuscitation; ACLS, advanced cardiac life support. cardiac arrhythmias), the skin (diffuse or localized erythema, pruritus, urticaria, and/or angioedema), and the gastrointestinal system (nausea, vomiting, or diarrhea). In addition, some patients might have symptoms of lightheadedness, headache, uterine cramps, feeling of impending doom, and unconsciousness. The vasodepressor (vasovagal) reaction probably is the condition most commonly confused with anaphylactic and anaphylactoid reactions. In vasodepressor reactions, however, urticaria is absent, the heart rate is typically bradycardic, bronchospasm or other breathing difficulty is generally absent, the blood pressure is usually normal or increased, and the skin is typically cool and pale. Tachycardia is the rule in anaphylaxis, but it might be absent in patients with conduction defects, with increased vagal tone caused by a cardioinhibitory (Bezold-Jarisch) reflex, or who take sympatholytic medications. Annotation 4. Consider other diagnosis Other diagnoses that might present with signs and/or symptoms characteristic of anaphylaxis should be excluded. Like anaphylaxis, several conditions might cause abrupt and dramatic patient collapse. Among conditions to consider are vasodepressor (vasovagal) reactions, acute anxiety (eg, panic attack or hyperventilation syndrome), myocardial dysfunction, pulmonary embolism, systemic mast cell disorders, foreign-body aspiration, acute poi-
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Immunotherapy Safety for the Primar
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Welcome to “Immunotherapy Safety
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Immunotherapy at Remote Sites Stand
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What Immunotherapy Is Not • Not p
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How Does Immunotherapy Work? • De
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Who Benefits? •Those with… - Al
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Immunotherapy Efficacy • Effectiv
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Not Efficacious For… • Atopic d
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The Extracts/Vaccines • Bioequiva
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Immunotherapy Phases • Maintenanc
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Reaction Prevention - Avoidance •
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Reaction Therapy - BLS+ Level • T
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Treatment Guidelines • Treatment
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Frequency of Systemic Reactions •
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Immunotherapy Safety • To lessen
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Immunotherapy Safety • To lessen
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Immunotherapy Safety • After Inje
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Immunotherapy Safety • Equipment:
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What To Expect (Demand) from the Al
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Summary • Risk factors for advers
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• Allergen immunotherapy (allergy
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BEFORE EACH SHOT!!! • Screen pati
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instruct patient to report any abno
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Epi-Pen Adult Epi-Pen JR TwinJect
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Allergen immunotherapy should be gi
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a common practice to alternate the
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ALLERGY IMMUNOTHERAPY (AIT) PROBLEM
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10. Those patients having their dos
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SPECIFIC INSTRUCTIONS A. PHYSICIAN
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ALLERGY IMMUNOTHERAPY RECORD NNMC,
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Immunotherapy Pre-Injection Questio
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15. A 12 yo male presents for his a
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Site Under Construction
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Introduction • “Anaphylaxis”
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Revised Nomenclature For Anaphylaxi
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Anaphylaxis* Is Not Rare Estimated
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Pathophysiology
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Pathophysiology
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Original articles Evaluation of nea
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References Acknowledgment: Linda Co
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Immunotherapy Safety for the Primary Care ... - U.S. Coast Guard

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