After an Anaphylactic attack, what happens?

Posted on: Sat, 02/17/2001 - 3:48pm
redtruck's picture
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Joined: 01/23/2000 - 09:00

pFollowing an anaphylactic attack, and assuming you administer an epipen, and proceed to the hospital, what do you they do there? /p
pMonitor the condition i assume, but if the epi is not enough, what do they give you.br /
Since we have not had any reactions to date, i was wondering if,anyone who has gone through this, might explain what they would do at the hospital? Any detailed accounts would be welcome./p

Posted on: Sat, 02/17/2001 - 4:16pm
Kathy Spencer's picture
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Joined: 08/17/2000 - 09:00

I was so terrified when my son went to the hospital for anaphylaxis, I am not sure if I remember everything correctly. I know they immediately started an IV and gave him more epinephrine and cortisone. His heart, blood pressure, and other vital signs were closely monitored. The ER doctor called his allergist. The nurse stayed with him all the time, even after he became stable. We waited hours before it was safe to go home. And we left with a prescription for prednisone, which he took for two weeks.

Posted on: Sat, 02/17/2001 - 11:48pm
Anonymous's picture
Anonymous (not verified)

Great question, Redtruck! After we administered the Epi and he was in Rescue, the Paramedic notified the hospital in route that we had administered .015 mgs of the EpiPen Jr., and they relay vitals to the hospital as we are arriving. (This is why calling Rescue and not driving them yourself is very important...not to mention you get immediately into an ER bed and not sitting in the waiting room with Triage. They laid my son on the ER bed, immediately assessed him (hives, swelling, etc)., gave him Benadryl, Prelone, read his MedicAlert bracelet but I can't remember if they administered Epinephrine again or not. They hooked him up to the heart monitor and he was asleep within 20 minutes of them administering the antihistimine and the steroid. He was monitored on the heart machine and checked for any relapses for 4 hours and then was released. He was prescribed Prelone for 7 days.
I also brought with me in Rescue the Epi Shot we administered. They handed it over to the medical staff at the hospital for disposal of it.
Hope this helps!
------------------
Stay Safe.

Posted on: Sun, 02/18/2001 - 12:31pm
vic's picture
vic
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Joined: 11/30/2015 - 09:59

Hello Redtruck. We didn't know that our son was PA and TNA when he had an anaphylactic reaction so we did not have or use an Epipen.
The EMT's started an IV, gave him epinephrine and Benadryl in our driveway, then en route to the hospital, gave him a neb treatment, monitored his B/P, pulse, and heart rate. He was extremely groggy when we arrived at the hospital and fell asleep as soon as they transferred him to his hospital bed. The doctors and nurses continued to monitor his vitals, gave him Prednisone thru his IV. (They tried to give him the oral steroid, but he immediately vomited it as well as the entire contents of his stomach - which was probably a blessing in disguise! Let's get rid of that cashew!!) A little off the subject for a second, it angered me that the hospital staff thought they new my son better than me. I explained to them that the other 3 times someone had tried to give him oral Prednisone for asthma attacks that he vomited it immediately. But they insisted on trying anyway. Then when the nurse gave up on trying to force our sleeping son to drink it and had left the room to ask the doctor what to do next, he started choking on his vomit.
Anyway, back to your question. After a few hours, they sent us home with Prednisone pills for him to take for a few days and a prescription for EpiPens. He continued to have reoccurring symptoms for three days. Mostly just hives and itching. The doctors had us give him Benadryl for the hives and we had bumped up his asthma meds for 10 days. I hope this helps. Take Care, Victoria

Posted on: Sun, 02/18/2001 - 1:36pm
redtruck's picture
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Joined: 01/23/2000 - 09:00

Thank you Kathy, Connie, and Vic for all your wonderful and interesting responses. Pretty scary Vic.
Wonder why the kids felt sleepy...was it the benadryl or other medication or the anaphylaxis itself, i wonder!
Keep the responses coming, very interesting and informative for those of us who havent gone through this...kinda nice to have an idea of what to expect if it happens to us!

Posted on: Sun, 02/18/2001 - 9:37pm
Claire's picture
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Joined: 04/19/2000 - 09:00

I can't remember everything they gave to Christopher during the emergency room visits. I know that they gave him a lot more epinephrine,and oxygen, They also gave him mist treatments a few times. They called in a specialist to see is they were going to have to do a trachiatomy on him. Thing were so scarry that I was not really watching what steps they were taking as much as I was trying just to keep him relaxed. It is one of those situations that you totally forget what is going on and completly focus on the child and making them feel they will be o.k.,but in your mind you are so scared that it is one of the hardest things in the world. The doctors put me out of the room because they needed to have room for everything and all the machines and the room was small.They were very nice,but they were as worried at this point as I was. They said we were lucky he lived through this one. I must go now because this subject gets me so upset that I need to take a break. Have a good day. claire

Posted on: Mon, 02/19/2001 - 2:17pm
Anonymous's picture
Anonymous (not verified)

redtruck, Jesse's last reaction we administered an Epi-pen and two puffs of his asthma inhaler, Ventolin. We did not know, at this time, that it only bought you twenty minutes to get to a hospital. Twenty minutes later he started to "go" again, at which point we rushed him to the hospital, by car (I know, again, stupidly).
When we got there, Jesse was given another shot of the Epi-pen (I also gave the doctor the one I had used and he disposed of it) and some Benadryl via IV I believe. I know that it took 6 hospital personnel to hold him down while they put the IV in. It was awful.
He was crying quite a bit and then, I guess after the medication began to work, he was sleepy. I leaned over him, telling him stories and praying. We were still in emerg.
I thought it would all end there, but the nurses did keep coming in to monitor him and told me that no, I wouldn't be going home that night, we were being moved to intensive care.
We spent the night in intensive care. I can't remember if he had the IV in all the time or not. Then, we were only allowed to be released after he had been seen by his family doctor who was making rounds that morning. The doctor gave me a prescription for Pedi-pred and a renewal prescription for the Epi-pen.
I only hope that by telling this story over and over again, when someone asks, of course, that I will save another parent from the agony that I went through that night and from the guilt I will carry forever. I should have been better educated about this. He had already had one anaphylactic reaction. I should have known the Epi-pen wouldn't last.
However, when he had his first anaphylactic reaction, the Epi-pen was administered at the medical center next door to me and we were monitored for an hour and allowed to go home.
So, it was very different. This, does not excuse me.
I should have administered the initial Epi-pen right away. I should have known, by asking either the doctor or pharmacist that I only had twenty minutes to get to the hospital. And lastly, I should have dialed 911 when we administered the Epi-pen, in what I consider almost the middle of nowhere rather than driving in a car.
Jesse almost died that night.
Best wishes! [img]http://uumor.pair.com/nutalle2/peanutallergy/smile.gif[/img]
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Posted on: Tue, 02/20/2001 - 5:18am
Kathryn's picture
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Joined: 02/17/1999 - 09:00

I found this article and copied it. I am posting the most relevant parts here. I carry it with me always as we are often in areas with smaller rural non-teaching hospitals and medical staff who may not be as current with current treatment protocols. I shared it with my ds doctor who thought it was a useful tool. It tells you what treatment might be taken once at hospital. The info on treatment once at hospital is about half way through the information below.
From: Consultant, April 1998 v38 i4 p851(9)
Allergic reactions: 10 questions physicians often ask. (includes related articles) John F. O'Brien.
Abstract: The timely diagnosis and treatment of allergic reactions could prevent deaths associated with anaphylactic reactions that have been known to kill from 400 to 800 Americans annually. Doctors taking the history of patients with a suspected hypersensitivity reaction should ask key questions that would elicit the most useful information. They should also know the best way to detect dermatologic manifestations of an allergic reaction, its common causes and the best possible treatment.
Which signs and symptoms are the most useful predictors of an allergic reaction's severity?
1 Mild reaction. This consists solely of urticaria, which involves the superficial dermis. It presents as pruritic, well-circumscribed wheals that may coalesce. About 20% of Americans have had urticaria at some point in their lives.
If the urticaria is acute (of less than 6 weeks' duration), focus on treating the symptoms. Simple antihistamines, such as diphenhydramine or hydroxyzine, are usually effective, along with a 4- to 5-day course of prednisone. If the disorder lasts longer than 6 weeks, it may require work-up for unusual causes, such as collagen-vascular disease.
Moderate reaction. This is characterized by bronchospasm and angloedema, which is well-demarcated, localized edema that involves the entire dermis and the subcutaneous tissue [ILLUSTRATION OMITTED]. Commonly affected sites are the skin, gastrointestinal (GD) tract, and the upper airway. GI angioedema can produce cramping abdominal pain, nausea, vomiting, and diarrhea.
Severe reaction. Anaphylaxis is a severe systemic reaction of multiple organ systems to antigen-induced, IgE-driven mediator release in previously sensitized persons. Hypotension, bronchoconstriction, and/or upper airway obstruction are common. Be aware of atypical presentations, however, such as a patient who has only low back pain, syncope, or crushing chest pain (Box I).
Anaphylactoid reactions are "allergic-type" reactions that involve a nonimmune mechanism. The clinical manifestations of an anaphylactoid reaction are the same as those of anaphylaxis, but the reaction is not mediated by IgE.
Factors affecting severity. Even when a patient is exposed to the same antigen on different occasions, the severity of the hypersensitivity reaction may vary, depending on:
* The patient's degree of hypersensitivity, which is determined to a certain extent by the number of IgE molecules on the mast cells and basophils and their affinity for the allergen, as well as the number of mast cells and basophils in the target organs.
* The pattern and quantity of mediator release, which are unique to each person. Some persons produce more leukotrienes, others more histamine. Also, some mediators are more potent than others; for example, the leukotrienes are more likely than histamine to cause bronchospasm.
* The sensitivity and responsiveness of the target organ. For example, asthmatic patients do not tolerate allergic stresses to their lungs.
* The quantity, route, and rate of antigen exposure.
The timing of the reaction depends primarily on the route of exposure. If an antigen is given intravenously, it reaches target tissues quickly and in large quantities. If it is given orally, it is more slowly absorbed, and the reaction may be delayed for several hours.
The earlier a reaction occurs after antigen exposure, the more likely it is to be severe. Thus, parenteral exposure to an antigen poses a greater risk of a severe reaction than oral or topical exposure.
Late-phase reactions. In contradistinction to a delayed hypersensitivity reaction, a second "late-phase" reaction can occur about 4 to 12 hours after initial allergic manifestations; it may be severe and can last up to 48 hours. The pathophysiology of this stage involves infiltration with eosinophils, neutrophils, and mononuclear cells (such as macrophages and fibroblasts) as well as fibrin deposition and tissue destruction.
In my experience, such late-phase reactions are rare. In fact, a retrospective study of 1,261 patients with allergic reactions found that of 62 patients who had anaphylaxis, only 2 had late-phase reactions. These 2 patients had facial edema 20 to 40 hours after Hymen-optera stings to parts of the body other than the face.[1]
What is the current treatment protocol for hypersensitivity reactions?
The therapeutic goals are to eliminate the antigen or to delay its absorption. If the antigen was ingested orally, early administration of activated charcoal may reduce the antigen load. A 10:1 ratio of grams of charcoal to grams of antigen is recommended. [TABULAR DATA FOR TABLE 2 OMITTED] Usually, 30 g of charcoal is adequate.
If the antigen was injected into an extremity, loosely apply a tourniquet proximal to the injection site. If a stinger is present, remove it without compression. Ice may also delay antigen delivery centrally.
The most useful agents for treating anaphylaxis are oxygen, epinephrine, and fluids (Table 2).
Oxygen. The final common pathway of anaphylactic death is tissue hypoxia. Therefore, oxygenation and perfusion are critical. Give patients supplemental oxygen if any evidence of hypoxia exists. Monitor oxygen saturation (by arterial blood gas measurement or pulse oximetry); however, be aware that pulse oximetry may not be accurate in patients with severe hypoperfusion.
Endotracheal intubation with 100% oxygen may be required if the response to therapy is not rapid. Orotracheal intubation is usually best; the nasotracheal route may be difficult because of severe mucosal airway edema.
Epinephrine. A potent [Alpha]- and [Beta]-agonist, epinephrine is the drug of choice for severe reactions. Although severe hypertension and coronary artery disease are relative contraindications, especially in older patients, the bottom line is that there are no absolute contraindications in an anaphylactic emergency.
The dose and route of administration of epinephrine depend on the severity of the reaction:
* For a mild to moderate reaction, give 0.01 mg/kg (up to 0.3 to 0.5 mg) SC or IM.
* For a severe reaction, give 1 mL of 1:10,000 solution IV. Repeat the dose after 2 to 3 minutes if needed. Depending on the response, titrate the dose carefully (up to 5 mL may be given). You can also administer epinephrine intratracheally; however, this route may make titration difficult. If the patient is intubated, consider doubling the intratracheal dose. Use caution, since this drug is fairly well absorbed.
Once the symptoms are controlled, start an epinephrine drip (1 mg in 250 mL of 5% dextrose in water). Titrate the drip according to the signs and symptoms.
ECG monitoring for possible cardiac arrhythmias and hemodynamic monitoring for blood pressure control are required during epinephrine therapy. Inhaled epinephrine can be useful in patients who have severe laryngeal edema.
Barach and colleagues[9] studied patients with anaphylaxis who received intravenous epinephrine. The investigators reduced the dose to the point at which the anaphylactic symptoms just barely recurred. They found that 8 to 12 [[micro]gram]/min (or 2 to 3 mL) of epinephrine drip was sufficient to control symptoms in most patients with anaphylaxis.
While higher doses of epinephrine may be required to improve symptoms, low doses usually control them. Disaster may occur if too much is given. One milligram of epinephrine is a supraphysiologic dose as well as a tremendous pharmacologic dose.
Volume expanders. Leaking capillaries and venules are a prominent problem in patients with hypersensitivity reactions. Fluid shifts from the intravascular to the interstitial space.
Use crystalloids rather than colloids, since the latter are likely to leak out of vessels. In severe hypersensitivity reactions, several liters of isotonic saline or lactated Ringer's solution may be required to replenish intravascular volume. Avoid hypo-osmolar agents because they do not adequately restore volume. Also avoid dextrose-containing solutions because they can produce an osmotic diuresis in patients with high glucose levels.
Be aggressive in hemodynamic monitoring. Insert a pulmonary artery catheter if required. Urine production monitoring is also important in patients with severe reactions.
Antihistamines. These agents are effective in mild allergic reactions; however, they are inadequate in severe anaphylaxis because mediators that are much more potent than histamine are also involved. In a severe reaction, the role of antihistamines is adjunctive.
Commonly used [H.sub.1] antagonists are diphenhydramine and hydroxyzine (both are given at a starting dose of 1 mg/kg). Intravenous hydroxyzine is not recommended. Nonsedating antihistamines, including astemizole, cetirizine, and loratadine, may also be used for mild allergic reactions. Cetirizine and loratadine have much less cardiac toxicity than astemizole.
[H.sub.2] antagonists are useful in managing mild allergic reactions. The recommended dose of cimetidine in this setting is 300 mg IV. Cases have been reported of patients whose condition failed to improve after receiving epinephrine and diphenhydramine but who responded to cimetidine.[10]
Other drugs. Agents that may be useful in treating hypersensitivity reactions include:
* A mixture of helium and oxygen in patients with respiratory problems, because it decreases airway turbulence and reduces the work of breathing.
* Inhalational sympathomimetics (such as albuterol and metaproterenol).
* Other parenteral sympathomimetic agents (examples include dopamine and norepinephrine).
Under what circumstances would yea use corticosteroids to treat a hypersensitivity reaction?
6 Give corticosteroids to patients with severe laryngeal edema, bronchospasm, or hypotension. Consider administering them to patients with mild allergic reactions, such as urticaria.
Corticosteroids have a delayed therapeutic effect; they are not effective until 4 to 6 hours after dosing. Corticosteroids may attenuate the late-onset component of hypersensitivity reactions, but this remains unproven.
For most hypersensitivity reactions, a dosage of 1 to 2 mg/kg/d of prednisone for 4 or 5 days is usually appropriate. This regimen generally does not require tapering. Consider tapering if the patient has received corticosteroid therapy in the recent past or if you plan to continue therapy for more than 2 weeks. When given as short-term therapy, prednisone has fairly benign effects.
Pollack and Romano[11] examined the role of prednisone for simple urticaria of less than 24 hours' duration. To avoid adverse reactions from the corticosteroid, persons with diabetes mellitus or ulcer disease were excluded. Twenty-four patients received prednisone (20 mg bid) for 4 days, and 19 received placebo. All patients received hydroxyzine as needed for itching. At 2 and at 5 days, itching was much less severe in the patients who received prednisone.
What is the recommended treatment for a hypersensitivity reaction in a patient receiving [Beta]-blocker therapy?
7 Standard therapy for allergic reactions can be ineffective in patients who are receiving [Beta]-blockers. Such patients can have marked hypotension and bradycardia during a hypersensitivity reaction.
Glucagon and the anticholinergics atropine and ipratropium are particularly effective in this setting. Glucagon lowers intracellular cyclic guanosine monophosphate (cGMP) levels and inhibits mediator release. Give 1 mg IV, and repeat or increase the dose as needed. Since nausea and vomiting are common side effects of glucagon therapy, pretreatment with antiemetics is reasonable.
The anticholinergics also decrease intracellular cGMP levels. When delivered as inhalation therapy, they are useful for treating bronchospasm. Ipratropium may be particularly helpful in patients with bronchospasm.
Which patients with hypersensitivity reactions should I hospitalize?
8 Admit all patients with severe reactions - including airway angioedema; bronchospasm; hypoperfusion; and cardiac problems, such as serious arrhythmias or congestive heart failure - that do not resolve promptly with therapy. Also hospitalize persons with a significant allergic reaction who:
* Are receiving [Beta]-blocker therapy.
* Have a history of severe late-phase reactions.
* Have an inadequate support system at home.
Observe patients who have reactions associated with systemic toxicity for at least 4 to 6 hours (Box III). When patients are discharged, prescribe an [H.sub.1] and/or an [H.sub.2] antagonist for at least 24 to 48 hours. For most patients, 5 mg/kg/d of diphenhydramine is appropriate. Consider corticosteroids (1 mg/kg/d for a few days) to modify the inflammatory component of the allergic reaction. If the patient has significant wheezing, consider a [Beta]-agonist metered-dose inhaler.
[This message has been edited by Kathryn (edited February 20, 2001).]

Posted on: Tue, 02/20/2001 - 7:30am
Anonymous's picture
Anonymous (not verified)

Kathryn, excellent post, thank-you! Did you type that all out, or did someone teach you Control C, Control V, as I recently learned?
If you did type it out yourself, I really think you should be commended. That was a lot of work.
Best wishes! [img]http://uumor.pair.com/nutalle2/peanutallergy/smile.gif[/img]
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Posted on: Wed, 02/21/2001 - 6:57am
Anonymous's picture
Anonymous (not verified)

Redtruck, to answer your question regarding the sleepiness after a reaction...Benadryl knocks my son out! Each time he has had it (even just for environmental allergies, which now he takes Claritin Ready Tabs for his Allergic Rhinitis), he falls asleep. Like me, he has a low tolerance for meds.
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Stay Safe.

Posted on: Wed, 02/21/2001 - 12:52pm
Anonymous's picture
Anonymous (not verified)

redtruck, I have the same answer as Connie's re the sleepiness. Jesse was taking Benadryl for his environmental allergies but I switched him to Claritin because I didn't want him falling asleep during school. I just checked to make sure that they didn't add something to it to make it non-drowsy, which they don't. But definitely, I think it would be the Benadryl that makes the child sleepy and maybe their body is simply tired from what it has gone through.
Best wishes! [img]http://uumor.pair.com/nutalle2/peanutallergy/smile.gif[/img]
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