PREVENTING DEATH FROM ANAPHYLAXIS
EpiPen on the Spot...When Bee Stings, Peanuts,or Other Allergies Cause Choking
by Helen Borel, RN,PhD
Recently, a young man asked about his possible allergy to yeast or barley because of a severe reaction he experienced while drinking beer. First, I advised him to stay away from beer altogether and also to avoid breads, soups, cakes, cereals and any other foods that might contain components of beer.
Common Allergic Reactions and Rare Allergic Anaphylactic Reactions
I also urged him to get examined and tested by an Allergist - a medical doctor specializing in immune system instigations of rashes, itchings, bronchospasms (asthmatic attacks), sneezing, wheezing, and laryngopharyngeal edema (swelling of the voice box and throat) due to allergens (substances that produce those allergic symptoms which can be life-risking).
The most extreme allergic response is ANAPHYLAXIS - complete airway impedence which prevents oxygen from reaching the lungs.
Why a Person in Anaphylaxis Needs an Immediate Epinephrine Injection
But the first-hand account of a woman with a peanut allergy who, upon eating some peanuts, experienced sudden itching and swelling in the facial area with tightness in her throat, sent shivers up my clinical nursing spine.
In response to this dire emergency, she did everything wrong and nearly died because she was totally unprepared for her sudden ANAPHYLACTIC REACTION. She had no emergency epinephrine (otherwise known as adrenalin) with her. Also wrong, she tried to swallow Benadryl ® (diphenhydramine), an antihistamine. Then she had someone drive her to an ER (Emergency Room) at a hospital some distance away.
That she survived is a miracle. The delay in adrenalin administration, the added delay while she tried to down the diphenhydramine, and the long time elapse while she was driven to the ER all could have killed her.
Don't Mishandle the Initial Manifestation of Your Choking Episode
As soon as swelling, itching and pharyngeal (throat) tightness intrude, take this syndrome very seriously!
When you know you are allergic to nuts, to bee or wasp stings, to shellfish, to strawberries, or to any other allergenic substances, you must have EpiPen ® (epinephrine, same as adrenalin) on hand with you at all times!
An Anaphylactic Reaction is Sudden, Alarming and Breath-Taking! That's how serious your condition is as soon as the swelling, itching and throat symptoms start!
So, I was horrified to hear that this peanut-allergic woman told her friends about her choking brush with death as though this were a humorous tale. "You nearly died," I told her. "You had an Anaphylactic Reaction. This is where the top of your airway literally closes so that no oxygen can get to your lungs. Death will be rapid in such cases unless the airway can be opened stat! (Immediately!)"
"Next time...and I pray there won't be a next time...you should not even consider walking to, or being driven to an ER. You need emergency treatment right THEN AND THERE! As soon as you notice the pruritis (itching), the edema (swelling) in your mouth and throat, the dyspnea (difficulty breathing), and BEFORE YOU START CHOKING TO DEATH!"
THE TREATMENT IS EpiPen ® (epinephrine, same as adrenalin) which, now that you know you are sensitized to peanuts, you absolutely must carry with you at all times.
Every allergic person should be aware of the availability of EpiPen ® . The unit is provided as a swiftly injectable single-dose-syringe which you must not even wait to drop your pants to take (that is how dire Anaphylaxis is). It is meant to be given right through your clothing because there isn't a moment to lose when an anaphylactic reaction begins. There are two versions: one for children under 12, the other (twice the child's dosage) for patients 12 and older.
Please also note: It is never wise to take Benadryl ® (diphenhydramine) in these circumstances. First of all, in anaphylaxis, you are in no condition to swallow anything. Not only is your throat rapidly closing and excluding oxygenation, the edema, inflammation and related symptoms of this severe, life-threatening allergic reaction also makes swallowing anything - a tablet, capsule, water - impossible and an added danger by further irritating the already inflamed pharynx (throat) and upper airway.
Not only that, no pill or capsule I know of works immediately, even if by some magic you managed to get it down. Most oral tablets or capsules will take approximately 30 minutes to even begin to take effect, some longer, rarely only 15 minutes. But even 15 minutes is too long to save the life of a person in Anaphylactic Shock.
Please remember: The brain cannot be deprived of oxygen for too long before you lose neurologic viability. After 8 minutes of respiratory-oxygen-lack, the brain suffers severely - a condition called hypoxia (decrease in, or lack of, oxygen). So even if the heart helps you survive, we'd not be able to revive the brain to it's pre-hypoxic state.
Important Lessons to Prevent Death from Anaphylaxis
(1) Never try to swallow anything during a choking allergic reaction!
(2) Never attempt to leave the place you're at during an Anaphylactic Reaction to get emergency care elsewhere! By the time you get to an ER, it is often too late. DEATH IS RAPID IN THESE CASES.
(3) Once you know you are highly allergic, ALWAYS CARRY AN EpiPen ® with you from then on! Your physician should prescribe this for you.
(4) Have several EpiPen ® units at home at all times. And teach whoever is with you (in case you are too incapacitated to perform the injection yourself...usually in the thigh) how to use the EpiPen ® . It comes with detailed instructions and is simple to use.
(5) NEVER, NEVER, EVER, EVER EAT PEANUTS or expose yourself to whatever you know you're allergic to ever again!
(6) You must follow these instructions to the letter to keep yourself safe from now on.
Allergies Run in Families...So be Prepared for Your Children's Sakes
Importantly, since tendencies toward allergies run in families genetically, one's children or grandchildren may be susceptible to allergic responses just like you...maybe not from peanuts but from shellfish, or strawberries, or something else, even from hymenoptera (bees or wasps) stings. Epipen ® - half the adult amount in your syringe for kids under 12 - would be appropriate if anyone in your family starts to choke after being stung by an insect or upon eating something.
Not from food caught in the trachea (windpipe); for that you do the Heimlich Maneuver.
When you suspect the inception of anaphylactic choking, don't wait more than a second or two to make the decision! Epinephrine won't kill anyone who isn't having an anaphylactic reaction, but it is life-saving for someone who is. Please take this condition seriously. Anaphylaxic Shock is life-threatening and never a laughing matter.
Remember: There is never enough time to travel or walk or be carried to the ER. EpiPen ® stat!!! No deviation from that prescribed protocol. Ever!
Only AFTER you've taken your epinephrine injection, should someone take you to the ER for follow-up monitoring and care.
Current Clinical Guidelines Support My EpiPen ® Protocol
According to Pediatric Professor F. Estelle R. Simons, M.D.,1 from the Faculty of Medicine of Canada's University of Manitoba at Winnipeg, recently updated guidelines by the United Kingdom's Resuscitation Council on "...emergency treatment of anaphylactic reactions....stress the importance of an early call for help from a resuscitation team or an ambulance. They introduce the ABCDE approach (airway, breathing, circulation, disability [level of consciousness], and exposure [of the skin]). They emphasise that prompt intramuscular injection of adrenaline (epinephrine) is the initial treatment of choice, along with other measures as indicated....They also advise subsequent referral to an allergy specialist for risk assessment and institution of long term measures to reduce risk."
She points out that "Few published [Canadian] guidelines are available on the treatment of anaphylaxis, but they all agree that adrenaline is fundamental for acute management."
Discussing the physiologic effects of epinephrine, Dr. Simons elaborates that "Adrenaline prevents and relieves laryngeal oedema and circulatory collapse through its alpha1 adrenergic effects. It provides bronchodilation and reduces the release of histamine and other mediators through its beta2 adrenergic effects. A brief window of opportunity seems to exist, during which even a relatively low intramuscular dose - such as 0.3 mg - is efficacious. Failure to inject adrenaline promptly increases the risk of a biphasic anaphylactic reaction, and death. Although adrenaline is sometimes blamed for causing myocardial ischaemia and cardiac dysrhythmias, anaphylaxis itself can cause these problems before adrenaline is given. Transient palpitations, tremor, and pallor after injection of adrenaline reflect the anticipated pharmacological effects of the drug."
Finally, warns Dr. Simons, "In community settings...even when [adrenalin is] readily available and affordable [it is] underused during anaphylactic reactions."
So please, allergic people, carry your EpiPen ® with you at all times. And USE IT SWIFTLY, ON THE SPOT. Don't let a sudden anaphylactic reaction catch you unprepared and choke the life out of you!
1. Simons, F. Estelle R.: "Editorials: Emergency Treatment of Anaphylaxis," British Medical Journal, No. 336 (May 24) 2008, pp. 1141-42.
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