ANAPHYLACTIC REACTION

An anaphylactic reaction is an acute systemic hypersensitivity reaction that occurs within

seconds or minutes after exposure to certain foreign substances, such as medications (eg,
penicillin, iodinated contrast material), and other agents, such as insect stings (eg, bee, wasp,
yellow jacket, hornet) or foods (eg, eggs, peanuts).
Repeated administration of parenteral or oral therapeutic agents (eg, repeated exposures to
penicillin) may also precipitate an anaphylactic reaction when initially only a mild allergic
response occurred.

Common Causes of Anaphylaxis

Foods
Peanuts, tree nuts (walnuts, pecans, cashews, almonds, etc.), shellfish (shrimp, lobster, crab,
etc.), fish, milk, eggs, soy, wheat
Medications
Antibiotics, especially penicillin and sulfa antibiotics, allopurinol, radiocontrast agents,
anesthetic agents (lidocaine, procaine), vaccines, hormones (insulin, vasopressin, ACTH),
aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs)
Other Pharmaceutical/Biologic Agents
Animal serums (tetanus antitoxin, snake venom antitoxin, rabies antitoxin), antigens used in
skin testing
Insect Stings
Bees, wasps, hornets, yellow jackets, ants, including fire ants
Latex
Medical and nonmedical products containing latex

An anaphylactic reaction is the result of an antigen–antibody interaction in a sensitized

individual who, as a consequence of previous exposure, has developed a special type of
antibody (immunoglobulin) that is specific for that particular allergen. The antibody
immunoglobulin E (IgE) is responsible for most of the immediate type of human allergic
responses. The individual becomes sensitive to a particular antigen after production of IgE to
that antigen. A second exposure to the same antigen results in a more severe and more rapid
response.
Anaphylactic reaction produces a wide range of clinical manifestations, especially respiratory
symptoms (difficulty breathing and stridor secondary to laryngeal edema), fainting, itching,
swelling of mucous membranes, and a sudden drop in blood pressure secondary to massive
vasodilation.
Signs and Symptoms of Anaphylaxis:

Respiratory Signs
• Nasal congestion
• Itching
• Sneezing and coughing
• Possible respiratory distress that progresses rapidly (caused by bronchospasm or edema of
the larynx)
• Chest tightness
• Other respiratory difficulties, such as wheezing, dyspnea, and cyanosis
Skin Manifestations
• Flushing with a sense of warmth and diffuse erythema
• Generalized itching over the entire body (indicates developing general systemic reaction)
• Urticaria (hives)
• Massive facial angioedema possible with accompanying upper respiratory edema
Cardiovascular Manifestations
• Tachycardia or bradycardia
• Peripheral vascular collapse as indicated by
• Pallor
• Imperceptible pulse
• Decreasing blood pressure
• Circulatory failure, leading to coma and death
Gastrointestinal Problems
• Nausea
• Vomiting
• Colicky abdominal pains
• Diarrhea

Preventing Anaphylactic Reactions

 Be aware of the danger of anaphylactic reactions and the early signs of anaphylaxis.
 Ask the patient about previous allergies to medications, foods, stings, latex, pollen, and so
on.
 Before giving a foreign serum or other type of antigenic agent, ask the patient or caregiver
whether the agent was received at some earlier time.
 Ask about allergies to eggs.
 Avoid giving medications to patients with hay fever, asthma, or other allergic disorders
unless absolutely necessary.
 Avoid giving parenteral medications unless absolutely necessary, because anaphylactic
reactions are more likely to occur when the agent is given parenterally.
 Perform a skin test before administration of certain materials known to produce
anaphylactic reactions (eg, horse serum).
 Remember that negative skin test results do not always indicate safety and that skin testing
can precipitate anaphylaxis in highly sensitive individuals. Have epinephrine, intravenous
infusions, and intubation and tracheostomy equipment available as precautionary
measures.
 If the patient is an outpatient, keep him or her in the office, hospital, or clinic for at least 30
minutes after injection of any agent. Caution the patient to return if symptoms develop.
 Caution patients who are highly sensitive (eg, to insect bites and stings) to carry kits
equipped to treat insect stings (epinephrine). Instruct the patient, family, and significant
others in the use of the emergency supplies.
 Encourage patients with allergies to wear medical identification tags or bracelets.

Management
With an anaphylactic reaction, establishing a patent airway and ventilation is essential. (This is
performed while another person administers epinephrine.) Early endotracheal tube intubation
is essential to avoid loss of the airway, and oropharyngeal suction may be necessary to remove
excessive secretions. Resuscitative measures are used, especially for patients with stridor and
progressive pulmonary edema. If glottal edema occurs, a cricothyroidotomy is used to provide
an airway.
Simultaneously with airway management, aqueous epinephrine is administered as prescribed
to provide rapid relief of the hypersensitivity reaction. Epinephrine may be administered again,
if necessary and as prescribed. Judgment is used in choosing the route of administration, as
follows:
• Subcutaneous injection for mild, generalized symptoms
• Intramuscular injection when the reaction is more severe and progressive, and with concern
that vascular collapse will inhibit absorption
• Intravenous route (aqueous epinephrine diluted in saline solution and administered slowly),
used in rare instances in which there is complete loss of consciousness and severe
cardiovascular collapse. This method may precipitate cardiac dysrhythmias. ECG monitoring
with a readily available defibrillator is necessary. This method is controversial and is not usually
recommended because it can lead to more distress than is initially present. An intravenous
infusion of saline solution is initiated to provide for emergency access to a vein and to treat
hypotension.

Additional treatments may include

• Antihistamines to block further histamine binding at target cells.
• Aminophylline by slow intravenous infusion for severe bronchospasm and wheezing
refractory to other treatment
• Albuterol inhalers or humidified treatments to decrease bronchoconstriction; crystalloids,
colloids, or vasopressors to treat prolonged hypotension
• Isoproterenol or dopamine for reduced cardiac output; oxygen to enhance tissue perfusion
• Intravenous benzodiazepines for control of seizures, and corticosteroids for prolonged
reaction with persistent hypotension or bronchospasm
After the acute symptoms have been treated, the patient is usually admitted to the hospital for
observation.