19: Don't Mess Around With Anaphylaxis

[Music] Welcome to the Rapid Response RN podcast, helping you keep your finger on the faults of your patient's condition. With real-life stories from the front lines of nursing, this podcast can help you sharpen your assessment skills, improve your ability to recognize the signs and symptoms of your patient's decline. Be inspired to speak up and advocate and know how to jump into action to promote the best outcome for your patients. Hey everybody, I'm your host Sarah Loranzini, a rapid response nurse and educator who loves telling stories to teach critical thinking. On today's episode, I'm actually going to share two antifiloxic cases to highlight how it can present differently for different patients. I think because of the movies, we have all come to think of antifiloxic as hives and angiodema, but there are several possible symptom combos that antifiloxic can induce. Before we dive into these stories though, I wanted just to take a moment to thank everyone who has shared my podcast with friends or family and a special thank you to those who have taken time to write a review. You are the reason this podcast has grown so quickly. I feel very honored that people I have never even met in countries I've never been to are listening to my stories. Thank you so much. I hope that you're learning knowledge from them that will help you the bedside and inspiration to keep you showing up for your patients. Now that our COVID numbers are improving, at least in my hospital, I'm no longer working crazy hours and I have more time to invest in the podcast and I'm really excited about the direction that is heading. So if you haven't followed me on Instagram, please do. They'll find more educational content and updates about the show. I just ordered some rapid response. Our instickers that I'll be giving away via Instagram. I really love chatting with all of you via the DMs. It's just been a great opportunity to have a visual arm to support the audio platform of this podcast. So you can find me at the rapid response RN. I look forward to meeting you there. Okay, now let's dive into these cases. So the first one was a rapid response on our behavioral health unit or the psychiatric floor. Let me back to the intake room and there's this probably six and a half foot tall young man in his early 20s and he's pacing and kind of hyperventilating. I get the story from the nurse that he was admitted for suicidal ideation with some new onset hallucinations and erotic behavior. He basically just had his first psychiatric break and in the stress of it all, forgot to tell anyone that he was allergic to nuts. He had just finished breakfast and included a muffin with nuts. And now he says he's itching is having a hard time swallowing and that he left his epic head at home. So even though he looks okay now, I don't mess around or are way too run to see what's going to happen with anaphylaxis. Our hospital has an anaphylaxis kit like already profiled in every medication machine. So I send the nurse to the pool the anaphylaxis kit. I prepare the patient for what's about to happen. Hi sir. My name is Sarah. I'm from the rapid response team. I hear you accidentally ate something with nuts in it and that you have an allergy to nuts. I just wanted to give you some medication to prevent that reaction from becoming severe. There are about to be a few more doctors showing up from the ICU but don't be afraid. We'll just be working together to get everything you need to help you through this reaction. Have you ever had to use your epiphen before? He noted yes. Okay, I just sent the nurse to grab our epi and I'd like to give it to you in your thigh. Will you let me do that? He noted yes again. About that time the ICU residents arrived and got the story and I told them that I had the epi drawn up and ready to administer. They hesitated initially to give it for a few reasons. First, his vatls were fine. He was a little techicardic like in the 120's but his blood pressure and oxygenation were perfect. Additionally they were concerned about how to monitor him after the epinephrine on the behavioral health unit that has no monitors. But I explained, he is a history of antifilaxis. We don't know how this will evolve. He needs to be monitored on a medical floor either way. Whether I give epi and we have to monitor for the side effects of the epi or I don't give it and we just need to watch him for signs in his anaphylactic shock. As I'm talking through all of this though his eyes and lips are becoming more and more swollen and he says he's having a harder time swallowing so they agreed and I proceeded to give the epinephrine in his thigh. I then started an IV and gave him some IV diphenhydramine or benedrial and IV pepsid which is an H2 blocker and an IV steroid. He did really well and his symptom started resolving within minutes honestly. We moved into the progressive care unit for 24 hours just to closer monitor him and then he was able to go back to the behavioral health unit to finish out his BAKER Act and received the mental health treatment that he came to hospital for in the first place. Easy peasy, classic antifilaxis. He even has a history of it so that really helped point us in the right direction as far as his diagnosis goes. I mean who knows what would have happened if we had not given the epinephrine early but I did not want to find out. Especially on the behavioral health unit where you have no access to anything. I'm really lucky that I've never had a patient die from a allergic reaction. Now I've had something that had really close run into the death but of all the antifilaxis patients I have ever cared for we have always had access to epinephrine and the doctors I've worked with have always been able to get an airway either via endotracheal tube with an intubation or crycothyroidotomy which we'll talk about later. So now let's talk about a less obvious and much more severe case that I encountered. Now you all have the benefit of knowing the ultimate diagnosis is antifilaxis but try to listen to this case unfold as if you didn't know the source with antifilaxis. Alright so I get paged a cat scan for a rapid response. The patient has passed out per the cat scan staff. This is a 60-year-old female and all the CT staff knows is that she's here in their department for an abdominal cat scan which they haven't even started yet. The patient was stable enough prior that the transporter brought her down in a wheelchair. She's currently on the CT table and barely irausible. I quickly put the patient on the monitor showing the following battle signs. Blood pressure of 79 or 40, heart rate of 75, respiratory rate about 35, oxygen saturation 92%. So I quickly delegate. I need you to get the primary nurse and physician on the phone. I need to know what led up to her coming down here. I need you to get me the crash cart so I can get a liter of fluids on her pressure bag and a non-rebrita mask please. The ICU residents arrived and are looking through the chart and call the primary doctor to get the back story. I hang a liter of ibifluids and start mixing up some norepinephrine just in case while I talk the primary nurse on the phone. So I'm just trying to rule out all the possible causes. Like what drugs were given today? Any nausea, vomiting, diarrhea, what was her blood pressure? Been running. Any cardiac history has she got a plane of chest pain today? Has she had any visitors that could have slipped or something? Because you just never know. Anyway, so we get enough information and we, you know, compare findings together. Here's the summary. This patient was admitted for abdominal pain. Hence the CT scan. The primary nurse of the patient was very stable, walkie-talkie. He had administered the patient's usual PO beta blocker in statin and had just given an IV push up antibiotic and then transport came to pick the patient up for her cat's scan. Now mind you, this patient had no hives or facial edema. She looked pretty normal except she was kind of pale looking more diaphragtic by the minute. At this point, she had received about 700 ml of fluid bolus and her blood pressure had not responded at all. So I'm not sure this is anaphylaxis. Like, she could have perfed something in her gut. She does have a abdominal pain that we have it nailed down the source. But the very important detail of the nurse had just pushed an IV antibiotic. That was a big clue for me. I mean, I'm used to anaphylaxis shock presenting tachycardic, but now I know she's on beta blockers chronically. Anaphylaxis could still explain her vitals and her clinical presentation. About this time, I hear faint, high-pitched breathing sound. They get closer to her neck and it's definitely strider. So I'm going to try to play you guys an audio clip of what strider sounds like from my phone. Let's see if I can pull this thing up. All right. [Breathing] So strider is very high-pitched and different than any other lung sounds because usually you don't even need to set this up. You can hear it from a few feet away. I've heard some pediatric patients from like a few doors down, but I would encourage you to check out several auto clips yourself so you can kind of train your ear to it because whatever I just played you probably did not come out as far as audio quality. But when you you hear that, it's time to move. This is the sound of a narrowed airway and what can cause a narrow airway? You guessed it, anaphylaxis. So that's when I said, "Do you guys hear that? This is anaphylaxis." So I get an order for intra muskier epinephrine. I tell the respiratory therapist to call him back up because we're probably going to be intubating him urgently. I jab the epine her thigh and then proceed to get steroid and antihistamines on board. I'm really hoping this is going to turn around, but like five minutes go by and she's still not looking good. I'm now starting to a second liter of IV fluids on her pressure bag. Her blood pressure is still in the 70s systolic. Her strider is getting louder and louder. The physicians and respiratory therapists are working to set up her intubation and that's when the doctor orders IV epinephrine, but in the form of what we call pushdose pressers. So I grabbed the cardiac 1 milligram per 10 ml's epinephrine off the crash cart. Not the little vial. The one that comes in the tan box packaged as a two piece, some assembly required syringe kit. I mix one milliliter of that epinephrine with nine milliliters of saline and now that gives me a concentration of 10 micrograms of epinephrine per milliliter of fluid. So every milliliter I give, the patient gets 10 mics of epi. Now I've already given her 500 mics of epi intramuscularly, but that did not take enough effect. So I gave her 50 micrograms or 5 milliliters of the pushdose epi per the MD order. I recycled a blood pressure like a milliliter and it had already improved to 160. They proceeded to successfully intubate her and we brought her to the ICU for an epinephrine drip and monitoring into all the anaphylactic shock symptoms subsided. But that was a close one. She looked bad. It's so crazy to me that she went from a patient who was able to emulate into the wheelchair to hear what I am of the unstable and unresponsive within a few minutes and then within maybe 15 minutes she was striderous and pale and diaphoretic and at death door. But a little with the epinephrine and a tube in her airway and a lot of teamwork and we turned her around. So each of these patients had very different presentations. Our psych patient had a nut allergy. He had the muco-cutaneous symptoms. Itching, swollen lips and began to develop difficulty swallowing. But he had no shock symptoms yet. But our beta blocker taking abdominal pain patient had no rash, no facial edema. If she had itching, I wasn't aware because she wasn't able to tell me about it. She had a shocky blood pressure but her heart rate was fine. Thanks beta blockers for making things confusing. She ultimately developed airway edema that we could hear called strider. Okay, so let's start with the basics. Anvilaxis is the body's multi-system response to an allergen. Be it environmental, foods, medications, etc. It can evolve into shock. The body recognizes the allergen and triggers mast cells to release a bunch of chemicals into the system like histamine and triptase. These chemicals induce a variety of responses from several organ systems. This skin can become flushed or break out in hives, notice ear to carry out. Patients can experience itching and angiodeema can develop. Angiodeema is like swelling kind of deep underneath like deep in the skin. Angiodeema is most easily seen around the eyes and the lips. It almost looks like the eyes are closed shut and the lips are about to burst open. But nobody dies from itchy swollen skin. Anvilaxis can also affect the digestive system. Some patients have sudden onset nausea vomiting or diarrhea, abdominal pain, saying "Oh, must have been something that I ate." Well, yeah, maybe it was. Maybe you are allergic to that something. But it's not the digestive system's response to anvilaxis that will kill your patient either. When anvilaxis takes someone's life, it is either from a human anemic collapse or loss of their airway. In layman's terms, their blood pressure drops to nothing and their throat closes off and they cannot breathe. Those chemicals dumped from the mast cells are also responsible for bronchoconstriction and laryngeolodema that can lead to a fixation. The same thing chemicals can also cause systemic vasodilation that drops the blood pressure. They increase vascular permeability, which causes fluids to shift out of the bloodstream, which drops the blood pressure even more. It also induces tecacardia, which drops the blood pressure even more because of decreased cardiac output. Ultimately, the body is unable to circulate blood to the tissues because the pipes have malfunctioned. We call this shock and it can lead to death. But the great news is, there is a drug that can halt this out of control reaction of the respiratory and cardiovascular system. It's called epinephrine. Let me see that again with more emphasis. The only life-saving drug that can actually have an effect on whether your patient lives or dies is epinephrine. Yeah, there are other adjunctive therapies like antihistamines that might help the rash or steroids that take forever to work, but will help with the whole inflammatory cascade. But epinephrine, vasoconstricts to improve blood pressure and makes the heart squeeze more effectively, hence helping cardiac output. Additionally, it bronchidylates via the beta-turi-septars and reduces airway edema. It even stabilizes the mast cells to stop this anaphylactic reaction in its tracks. Epi is the only cure. The other stuff is just supportive. So that is why it is the first line therapy for anaphyloxis. Always prioritize getting the epine first and then draw up the other drugs. Now I'm sure you're thinking. But Sarah, epi is kind of big guns and could have some major consequences. We don't want to just be jabbing every itchy patient with epinephrine. And you are correct. So let's talk about making the diagnosis of anaphyloxis. Unfortunately, there is no diagnostic test to quickly differentiate anaphyloxis from some other ideology. Yeah, there's a tripthase level, but by the time it results, your patient may be dead. And it would be a waste of time to try and draw blood right now when your patient could potentially crash any second. Treat first, tripthase level, later. According to the American Academy of Allergy, Asma, and Immunology, anaphyloxis symptoms typically begin within five to thirty minutes from the exposure to the allergen. But to diagnose some of the anaphyloxis, you must have two organ systems involved. For example, skin rash and difficulty breathing, or nausea vomiting and itching, or low blood pressure and angiodeima. If someone just has itching, which is a common reaction to many of the drugs that we give, just give them an antihistamine. But someone who reports sudden onset vomiting and they are itching everywhere, well, now we have a problem that needs epinephrine. And here's the thing. Reactions to allergens often worsen with each exposure. So just because last time they had a rash and a little difficulty breathing, doesn't mean that this time that's all they're going to have. In fact, the likelihood that this time they will go into shock is even higher. So we don't wait it out to see what happens with anaphyloxis. We don't give binedrill and see that'll just take care of it. Binedrill cannot cure anaphyloxis. The patient can still die with binedrill pumping through their veins. And it is impossible to predict the course of anaphyloxis. Like, my patient who ate a nut muffin, he did not have any shock symptoms, but he had two systems involved, eucocotaneous or his facial lipidema, and difficulty swallowing or respiratory, like, airway involvement. And especially with his known history of anaphyloxis, I did not want to take any chances. So now let's talk about how to give anaphyloxis. The intramuscular dose of anaphyloxis is 0.01 milligrams per kilogram, which comes out to about 0.5 milligrams, which is conveniently 0.5 ml of the 1 milligram to 1 ml concentration. All right, before I go any further, there is huge potential for met errors with anaphyl administration, because it comes in two different concentrations. We used to use this complicated ratio to differentiate epi concentrations, and I think some places still use it. But, oh, so we used to have 1 to 1000 epi, which is the little vial of 1 milligram in 1 ml, and that's the one for anaphyloxis. There is also the one in 10,000 epi, which comes in a box with with a pre-filter wrench of 1 milligram per 10. hen MLs. That's the one we use for cardiac arrest. So to clarify, if it's going to go in the muscle, you don't want to be giving multiple MLs into the muscle. You want to reach for the little vial, not the big box. And while the deltoid is a muscle, the vastness lateralis is an even bigger, more vascular muscle. So injection into the vastness lateralis results in faster and more effective absorption of the epinephrine. So if you haven't given an eye injection a while, here's the easiest way to remember. Imagine the patient is wearing a really starched pair of pants with a nice ironed increase down the front. The needle should go about halfway up the thigh and midway between that invisible crease and the seam down the side of the pants. The antelateral aspect of the thigh. That is where patients are taught to place their epiphen when they're discharge home. So you give your epinephrine and the side of the thigh, you can repeat the dose up to two more times every five minutes. But with the intramuscular absorption rate, you worry about stacking the dose because about 20 minutes in, they're all going to be kicking in at the same time. I am epinephrine is the standard because it's very easy dosing. It has quick and easy administration. You don't have to wait for an IV or deal with the complicated dosing of ibinephrine. But if you are an experienced critical care nurse or provider, you deal with ibinephrine every day. And the benefit of ibinephrine administration is that you can taper the dose and give more or back off a little bit based on your patient's response. So what's great about IV is you can actually give less dose and it works immediately and it wears off pretty fast too. But when you give a medication I am, it takes time to absorb and it will keep absorbing for a while. So if you overshot, well, it's in there now. IV dose so you can give smaller little doses and titrate until you get the effect that you want. If you have an epinephrine drip readily available, go ahead and start it. In our patient's case, it was faster for me just to quickly mix up push to a sepia and give her a little bolus. Then once I got her blood pressure up, I was able to mix up and start the epinephrine infusion. For those of you that I have totally lost with all of the epi concentrations and the dosing and the math, I feel you. I hate math and I'm a visual learner too. So I'm going to post a couple of visuals on Instagram to help make this all a little clearer. In addition to the epi, if your patient isn't shocked, you will also need to be replacing volume as fast as they can third space it out. So expect to give several leaders of isotonic crystalloid to ensure adequate preload for your patient. The final drug to mention in this discussion of anaphylaxis is beta blockers. No, we do not give beta blockers to patients anaphylaxis. In fact, that would be the last drug you would want to give. But many of our patients come to us with beta blockers already on board. So here's the deal with beta blockers and anaphylaxis. First, it might make it more difficult to identify anaphylaxis because it might mask the body's tachycardic response and the patient might present in shock with a normal heart rate. Second, beta blockers might make the epineference bronchidilating effects less effective. And finally, and this is rare, some beta blockers, when mixed with epinephrine, could cause an unopposed alpha adgenurgic effect. And the vessels, vasoconstrict like crazy, resulting in dangerous hypertension. But even that would not be a reason to withhold epinephrine in the face of anaphylaxis. Give the epi, save their life, and deal with the beta blocker afterwards if you have to. You can always give lucagon if you feel the epi isn't working because of their beta blockers on board, or if you're concerned about unopposed alpha. But if you're giving lucagon, be prepared for puke. We actually call it pucagon when I worked in the ER because I swear every time I gave it, the patient would start vomiting. So to summarize the pharmacological management of anaphylaxis, epinephrine. That's it. That's my summary. That's all you need to know. If you want to be extra like in a good way, go ahead and give the antihistamines for their itching, some steroids, maybe a bronchidilator. You might need some IV fluids if they get a little shocky, but epi is your first line intervention for anaphylaxis. If you're giving it I am, grab the little vial, not the big box, draw 0.5 milligrams, dip in anorepations weight, and administer it without delay into their antilateral lateral thigh. The final thing to discuss is airway compromise. Patients probably won't tell you, "My airway is closing!" But they may say, "My voice sounds different," or, "I'm having a hard time swallowing." Those words should make your sphincture tighten a little and put some hustle behind your actions, because next comes strider, and next comes airway obstruction, and then death. It is better to intubate early than to wait too late. No matter how badly your patient doesn't want to be intubated, I guarantee they would rather have an endotracheal to a placed than a crycothyroidotomy. It is just what it sounds like. We bypass the swollen airings and cut open the crycothyroid membrane and place an air raid directly into the neck. It is bloody, it leaves a scar, and I imagine it is not very comfortable. But, it makes for great medical TV dramas. I'm pretty sure every medical TV drama has an episode where they have to emergency cry some patient, and the real exciting episodes are when they have to use a ballpoint pen, because that's all there is. You know what, with as many episodes as I've seen of ballpoint pen cryics, I was sure I would have a chance to have done that by now in my career, but the opportunity just has not presented itself. So I can only think of two cases actually where we had to cryic and anaphylaxis patient. The first was a cancer patient who had an anaphylactic reaction to his chemo. The infusion clinic was literally across the street from the hospital, and his airway had already closed by the time he got to us. It was so fast, but the doctor was able to place the cryic before he coded. The second was a 16 year old with known shelf as allergy that forgot her epiphen when she went to a sleepover. By the time she got to us, she was blue. But with cryctor gave epi, and she escaped death that day. I think that about covers it. So now for a quick bullet point summary of managing anaphylactic shock. If your patient has a potential exposure to allergen and two organ systems that have decided to freak out about it, you're pretty safe to call anaphylaxis and treat it as such. The doctor may order a whole cocktail of medications, but epi should be the one you reach for first. administer it in the outer thigh as soon as possible. Continue to closely monitor for signs of shock and/or airway compromise. So have ibifluid infusing and a pressure bag just in case you have to slam those fluids in and have intubation and crycothyroidautomy supplies close by. Anaphylaxis evolves quickly and the severity of the reaction is difficult to predict, so be prepared for the worst and act fast. Remember that even though it is important to hustle and to convey a sense of urgency, there is still time to explain what you're doing to the patient and prepare them for what to expect. Sometimes when I respond to emergencies, it can feel like a pit crew at NASCAR, like everyone passing on the patient all at once as fast as possible. But there's not a car in the hospital bed. It's a human, a human who is probably scared. So taking the time to provide comfort and support can make all the difference in the world and your patient's memory of a very scary event. Well that's it for today's episode. If you like this podcast, I'd love to hear from you. You can shoot me an email with questions or comments and it would mean so much if you could take a moment to write a review on iTunes as this helps more listeners find this podcast. Thanks for listening and I hope you learned something that will save a life. Remember, nursing is a team sport, so trust your intuition and don't give up advocating until you are confident you've done what's right by your patient. You've been listening to the Rapid Response RN podcast, the views and opinions expressed on this show by that of Sarah Loranzini and her's alone. They are not intended as medical advice and should not take the place of your institution's policies or procedures. Evidence based practices ever changing and your patient's care should reflect the current best practice. If you want to get in contact with Sarah, you can find her at rapid response RN podcast at gmail.com or on the Rapid Response RN podcast Facebook page as well as the podcast website rapidresponse RN dot com. (upbeat music)