What is anaphylaxis?

Anaphylaxis is a severe allergic reaction to an allergen (a substance

which causes an allergic reaction); it is life threatening systemic reaction that
can affect all ages. The defense system or immune system is over reacting
to irritant or allergen. When a person is allergic to something, the body
makes antibody against the allergen. This antibody is called
(immunoglobulin E) IGE. IGE is a special antibody that coats cell called
mast cells. Mast cells line nose, lungs, skin and digestive tract. For example
when bee sting injects venom, the venom connects to IGE molecules
surrounding the mast cells. The mast cells then rupture, releasing their
granules which contain histamine and inflammatory substances. These
granules burst open, the histamine and inflammatory substances are released
to body tissues. The histamine seeks out antihistamine receptors in the skin,
respiratory tract, blood vessels and stomach. Histamine attaches itself to
receptors like lock and key, this causes the plasma to leak out of the blood
vessels. The tissue around the blood vessels absorbs the plasma causing
swelling of the skin tissues, vocal chords and even a drop in blood pressure.
This reaction might happen in the nose and eyes causing what we know as
hay fever; in the lungs, causing asthma, but when a massive release of
histamine occurs and affects multiple parts of the body, that is called
anaphylaxis. It is rapid onset of increased secretion from mucous
membranes, increased bronchial smooth muscle tone, decreased vascular
smooth muscle tone, and increased capillary permeability occur after
exposure to an inciting substance.
 Charles Robert Richet was the 1913 recipient of
the Nobel Prize for physiology or medicine, "in
recognition of his work on anaphylaxis", his term for
the some times deadly reaction in a sensitized
individual against a second injection of an antigen.
The word anaphylaxis was coined when scientists
tried to protect dogs against a poison by immunizing
them with small doses. Far from being protected, the
dogs died suddenly when they got the poison again.
The word used for protection by immunization is
'prophylaxis', so the scientists coined the word
'anaphylaxis' to mean the opposite of protection.
What the scientists saw in the dogs helped them to
understand that the same can happen in humans. This
helped us to understand asthma and other allergies
too, because they work in a similar way.
• Food Allergy
Symptoms usually are mild and limited to the GI
tract, but full-blown anaphylaxis can occur.
Fatalities are rare compared to number of
exposures; however, the number of exposures is so
high that foods may be the commonest cause of
anaphylaxis. Seven out of one hundred people are
known to have food allergy. Anaphylaxis due to
foods may be an underrecognized cause of sudden
death and an unappreciated cause of diagnosed
anaphylaxis. Commonly implicated foods include
nuts (especially peanuts), legumes, fish and
shellfish, milk, and eggs. Symptoms usually begin
five to thirty minutes after ingestion, occasionally
after one to two hours, but rarely any longer.
• Latex Allergy
It is an increasingly recognized problem in
medical settings, where use of gloves and
other latex products is universal. Most
reactions are cutaneous or involve the
mucous membranes. Anaphylactic reactions
occur and have been reported with
seemingly benign procedures (e.g., Foley
catheter insertion, intraperitoneal exposure
to gloves during surgery).
 • Drugs
Parenteral exposures tend to result in faster and more
severe reactions. Most severe reactions occur soon
after exposure. The faster a reaction develops, the
more severe it is likely to be. While most reactions
occur within hours, symptoms may not occur for as
long as three to four days after exposure.
Penicillin and cephalosporin antibiotics are the most
commonly reported medical agents in anaphylaxis.
Reports often assert that ten percent of patients
allergic to a penicillin antibiotic are allergic to
cephalosporins. Reactions tend to be more severe
and rapid in onset when the antibiotic is administered
parenterally. Anaphylaxis may occur in a patient
with no prior history of drug exposure.
Another type of drugs that cause anaphylaxis are
Aspirin and nonsteroidal anti-inflammatory drugs
(NSAIDs).
• Hymenoptera stings
Hymenoptera (highly specialized insects with
complete metamorphosis that include the bees, wasps,
ants, ichneumon flies, sawflies, gall wasps, and related
forms, often associate in large colonies with complex
social organization, and have usually four
membranous wings and the abdomen generally borne
on a slender pedicel) stings are a common cause of
allergic reaction and anaphylaxis. An uncertain but
enormous number of exposures occur; accurate
reaction rates are difficult to estimate. In the United
States, Hymenoptera stings result in fewer than 100
deaths per year. Local reaction and urticaria without
other manifestations of anaphylaxis are much more
common than full-blown anaphylaxis. Generalized
urticaria is a risk factor for subsequent anaphylaxis;
but a local reaction, even if severe, is not a risk factor
for anaphylaxis.
• Exercise-induced anaphylaxis

It is a distinct form of physical allergy and

rare. This disorder is classically
characterized by spectrum of symptoms
occurring during physical activity that
ranges from mild cutaneous signs to severe
systemic manifestations such as
hypotension, syncope and even death. In
susceptible persons, ingestion of certain
foods or medications before physical
activity maybe a predisposing factor for
exercise induced anaphylaxis. Aspirin and
NSAID have been the most frequently
involved medications and seafood, celery,
wheat and cheese have been involved.
• Idiopathic anaphylaxis

This term is used when the cause of

anaphylaxis is unknown. Signs and
symptoms in patients with idiopathic
anaphylaxis do not differ from patients with
other forms of anaphylaxis. Idiopathic
anaphylaxis is a diagnosis of exclusion.
Only after a thorough history, physical, and
review of the medical record that this
diagnosis is considered. Known causes of
anaphylaxis that must be considered in every
patient with a possible diagnosis of
idiopathic disease include food, medications,
insect stings, latex, radiographic contrast
media, and exercise.
• Post Vaccination anaphylaxis

Reaction to childhood vaccines is extremely rare.

According to the research that was done on over
two million individuals from birth to age
seventeen vaccinated between 1991 and 1997.
Only five subjects with possible or probable
anaphylaxis were identified. Out of five, only
one child had a reaction associated with a single
vaccine (MMR-measles, mumps, and rubella).
The estimated risk of post vaccination
anaphylaxis ranges between 0.26 to 1.53 cases
per million.

The study pointed out that allergic reactions may

be related to vaccine antigen, animal protein, or
latex used in vial stopper and syringe plunger.
Signs and symptoms:

The clinical manifestations of anaphylaxis can vary in onset,

appearance, and course.

• The skin frequently shows symptoms first. Hives, itching,

swelling, redness or a stinging or burning sensation may
develop
• The loss of fluid from blood vessels causes a drop in blood
pressure and the individual may feel light-headed or even lose
consciousness.
• Anaphylaxis can cause obstruction of the nose, mouth and
throat. Individuals may first notice hoarseness or a lump in the
throat. If the swelling is very severe, it shuts off the air supply
and the individual experiences severe respiratory distress
• The airways in the lungs can constrict, causing chest
tightness, shortness of breath and wheezing - the classic
symptoms of asthma
• The person may experience nausea, vomiting, cramping and
diarrhea.
• The gastrointestinal tract often reacts, especially if the
allergen is something that was swallowed.
 • Women may experience pelvic cramps due to contractions of
the uterus.

Treatment:

The backbones of treating anaphylaxis are avoidance of the allergen when

possible and emergency administration of adrenaline (epinephrine) when necessary.
Adrenaline (epinephrine) is a natural hormone released by adrenal glands in
response to stress. It is a natural antidote to the chemicals released during severe allergic
reactions. Anaphylaxis is an emergency condition requiring immediate professional
medical attention. The emergency medical system should be contacted immediately.
Adrenaline is the recommended first line treatment in anaphylaxis. Assessment of the
ABC's (airway, breathing, and circulation from Basic Life Support) should be done in all
suspected anaphylactic reactions. Cardio pulmonary resuscitation (CPR) and other
lifesaving measures may be needed.
Since there is no way to predict the severity of a reaction, and because
anaphylaxis can progress so rapidly, waiting for the paramedics or ER staff to administer
epinephrine may greatly increase the risk of death. Epinephrine should be administered
as soon as practical while assessing and supporting vital functions. It is usually given
intramuscularly but may be given subcutaneously in mild cases. In clinical setting,
intravenous administration is only indicated in severe cases because of the risk of
ventricular dysrhythmias. In the intubated patient, endotracheal installation is possible if
intravenous access is unavailable. When injected, it rapidly reverses the effects of a
severe allergic reaction by make blood vessels contract, preventing them from leaking
more fluid, thus maintaining blood pressure. It also relaxes airways, opening the airways
by reducing throat swelling, helping the individual breathe easier. It relieves cramping in
the gastrointestinal tract and stops itching and hives.
Even if the individual responds to the epinephrine, it is vitally important to go
to an emergency room immediately. Other treatments may be given such as oxygen and
medications to improve breathing. Intravenous fluids may be necessary to restore
adequate blood pressure. Additional medications may be given to counteract the effects
of histamine and to help prevent a delayed allergic reaction. When administered as
directed, the risks of not giving adrenaline far outweigh any potential side effects of the
medication.

School Nurse Role

In a school setting, it is important that not only

the school nurse be able to recognize the signs and
symptoms of this condition and its medical
requirements but also the entire school personnel.
The school nurse is responsible for educating the
school staff regarding anaphylaxis, its emergent
nature and its treatment. The school nurse can also
be instrumental in helping the allergic child feel
accepted by making other children aware of how it is
to have allergies. The parents count on not only the
nurse but the rest of the school staff to lessen the
possibility of allergic reaction and to deal with
reaction if it occurs. The school nurse develops an
individualized emergency care plan (IECP) in
consultation with the student’s parents and health
care provider. The school nurse can also promote the
use of medical identification bracelet.