questions, questions

Posted on: Fri, 09/22/2000 - 9:59pm
Teresa1's picture
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Joined: 09/19/2000 - 09:00

Someone once told me there's no such thing as a stupid question. I hope not because I have lots of them.

1. What do they give you in ER if you've already had an EPI and Benadryl?

2. Does liquid Benadryl work faster than pills? Do they even make pills for children?

3. Do they really keep you in the hospital for 8 hours (or more) observation like I read they're supposed to? Even if you're better in an hour?

4. After using an EPI, does the needle still stick out, or does it retract?

5. Why doesn't anyone make a heat and cold resistant EPI carrier?!?

6. Do skin test scores really tell you much about severity of attacks. My allergist says they don't mean much, but I'd like to hear from those of experience.

7. How can you tell a choking child from one in anaphylaxis?

8. My daughter's allergist said to use Benadryl for mild reactions and Benadryl plus Prelone syrup for moderate reactions. Should I even bother trying to determine a moderate one, or should I just use the EPI? I read an article that says to use the EPI in all instances before the symptoms get bad. Any advice?

I think that's it (for now). Any input is appreciated. Thanks.

Posted on: Sat, 09/23/2000 - 1:04am
Kathryn's picture
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Joined: 02/17/1999 - 09:00

I originally posted this August 9 in response to another question. I printed it out and carry it with my so that when we are in a rural area with a smaller non-teaching hospital I will have it available if needed:
Some of you may remember that I am a librarian/researcher. I found this somewhat technical article outlining the treatment of anaphylaxis at a hospital emergency room. It is from Consultant, April 1998 v38 i4 p851(9). It is titled Allergic reactions: 10 questions physicians often ask. It is by John F. O'Brien. I am picking it up in the middle of the article at the question that is relevant to this discussion.
I quote: "What is the current treatment protocol for hypersensitivity reactions? {question asked by doctors} The most useful agents for treating anaphylaxis are oxygen, epinephrine, and fluids.
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.
[Diphenhydramine mentioned above is the generic name for Benadryl.]
I found this article searching an Infotrac database of medical articles that is widely available in the US and Canada in public libraries. It is called Health Reference Center. Ask your local librarian for more information.

Posted on: Sat, 09/23/2000 - 1:57am
Kathryn's picture
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Joined: 02/17/1999 - 09:00

Hi here are some answers to some of your other questions.
I don't know of an heat and cold resistant pack but I keep watching the products section of this board in the hope of seeing a new product.
A choking child will grasp at his throat, his eyes may bulge and you will not see other anaphylaxis or allergy symptoms. It is pretty apparent immediately. I say this with some unfortunate authority as I had to perform the Heimlach manoevre on my son when he was choking. He survived but oh was it scary.
They may not admit you to hospital but will ask you to stay either in an emergency bed or in the waiting area.
The needle does not retract. Wait until you have counted to ten then pull it out. Take it to the hospital with you as they want to see it and can properly dispose of it for you.
RAST and skin tests do not predict severity but new research shows that in very young children with really small CapRAST levels there is a possibility that they will outgrow the allergy. Do a search on these boards to find more details.
Your allergist's advice is given by many. I am not a medical professional but after much research and reading about this issue I plan to use the epi-pen. Using it will not do harm but delay might. I have seen how quickly my brother's reactions have deteriorated sometimes. Most times he just gets hives, other times he gets hives and then quickly progresses to full blown anaphylaxis. I don't want to take any chances with my son. Remember I am not a medical professionaly just a researcher.

Posted on: Sat, 09/23/2000 - 2:09am
Teresa1's picture
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Joined: 09/19/2000 - 09:00

Thanks for all your info. I was trained on the Epi-Pen by a nurse at the allergist's office and she said nothing about holding it in for 10 seconds. That's probably a good thing to know! The more I read, the more I find out that I don't know. Let's hope we never have to put our knowledge to use.

Posted on: Thu, 09/28/2000 - 2:21pm
care's picture
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Joined: 09/21/2000 - 09:00

Has anyone heard about a new test that is done at the hospital.A PA individual is hooked up to an IV and then given a tiny amount of peanut butter. They keep giving them more until a reaction occurs . The idea is to see if they go into Anaphylaxis and if they do they are already hooked up to an IV and Drs and nurses are readily available. I have heard about this from one person and would like to know more, it sounds a bit extreme to me and they say that your reaction can differ each time so I'm wondering what the point is of this test.

Posted on: Fri, 09/29/2000 - 12:46am
lcyphers's picture
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Joined: 09/09/2000 - 09:00

Care,
This sounds to me like either some medieval torture or the closest thing to a "safe" way to determine whether the allergy's been outgrown. Reading these boards, it sounds like both skin and blood tests can come back positive for years (!) after the person would no longer react to peanuts. This just adds more uncertainty to this dreadful condition. What if the statistics on how many kids outgrow the allergy are so low because the tests still come back positive and nobody's about to feed what is essentially poison to their kids "just to see?" So even if our child hasn't had a reaction in years, we have to assume she's still allergic. It's a quandry, to say the least. They have to come up with a better diagnostic test - or a cure! - SOON!! Is there a national PA fundraiser, like a walkathon or something? We need more research money! Let's start one!!
Take care, Care!

Posted on: Fri, 09/29/2000 - 1:08am
jrizos's picture
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Joined: 05/30/2000 - 09:00

Hi,None of your questions are stupid. I am an RN and I knew have some of the same questions you have. I have never had to give the epi so I don't know if the needle goes back in. I don't think it will but the case the pharmacy gives should be used after and you can dispose of it at the hospital or the doctor's office. I was told by my allergist to give the epi right away because it is difficult to tell between a moderate reaction and a severe one and the epi will help even for the moderate allergy attack. I would love to see an insulated heat pack and cold pack on the market. I have a boy with an allergy to bees and he likes to play soccer. I need an insulated cooler at the games. It would be nice to have something smaller. My other son has the peanut allergy but he is younger so I put it in an insulated bottle pack. The reason for going to the hospital is to give further treatment. That may be an endotracheal tube or cpr. It would be difficult to come on to someone and see them gagging to decide what was wrong. Usually a choking victem will hold on to their throat. You can ask are you choking? If they nod yes do the heimleck meneuver. If the person falls down give a coulple of breaths. When someone is a choking victem air will not go in to the lungs.

Posted on: Fri, 09/29/2000 - 1:24am
anonymous's picture
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Joined: 05/28/2009 - 16:42

Hi Care - There is a thread under RESEARCH called "Tanox Announces Start of Anti-IgE Clinical Trial". This treatment involves IV and oral challenge until a reaction starts, in a hospital setting. I think this is probably what you heard about. The thread is very long and informative, so please check it out and let us know if it's what you have been hearing about. Take care. Carolyn

Posted on: Fri, 09/29/2000 - 3:11am
Tammy James's picture
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Joined: 06/01/1999 - 09:00

In reference to the CPR mentioned above...
I took an infant/child CPR class not long ago, thinking CPR would help my PA child. I was told it would not if his airway was swollen closed, and if he's not getting air, doing compressions is futile as well. I know this is distressing to hear. I'm just passing along what I was told. If anyone knows anything different, please do correct me!!

Posted on: Fri, 09/29/2000 - 4:18am
DMB's picture
DMB
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Joined: 02/22/2001 - 09:00

In regards to the needle--it does not go back in. After use of the epi-pen, just place back inside the plastic container and dispose of properly. Deanna

Posted on: Fri, 09/29/2000 - 8:05am
Triciasmom's picture
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Joined: 08/03/2000 - 09:00

As far as insulated packs are concerned, I carry my daughter's epi-pen in a soft-sided picnic cooler. They make insulated packs of all sizes for school lunches and picnics. I chose a larger model with a shoulder strap and use it as a carry-all diaper bag/food cooler/medicine carrier.
I wonder if they make insulated waist packs. That would easily fit a couple of pens, a bottle of benedryl, personal ID, etc. Has anyone checked at sporting goods supply stores like REI?

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