Treatment of Allergic Reactions and Anaphylaxis in Austere Conditions, by D.P.A., EMT

Tuesday, Jun 8, 2010

This article will provide background information on allergic reactions and anaphylaxis, and overview the initial management , or “buddy care”, of these conditions. Some of the procedures described in this article will require additional medical training in order for the provider to become proficient. These conditions range from mild to life threatening.

After a societal collapse which results in austere living conditions, definitive medical care would not be available. As a result most life threatening pathologies would not be treated. The good thing is that allergic reactions are readily reversible, in most cases, with prompt treatment. In these cases definitive care can be administered in the austere environment, so it is worth the expenditure of valuable medical supplies. Medical specialists cannot be everywhere, and some of these reactions must be treated immediately, so others should have some basic knowledge of how to treat severe allergic reactions.

Background and Signs and Symptoms of Mild Reactions

Allergic reactions are a hyper-stimulation of the body’s immune system to an antigen (foreign protein). The reactions range from mild signs and symptoms, such as with hay fever, to a life threatening condition called anaphylaxis, common with bee stings or specific medications. Both mild and severe forms require that the patient be sensitized (first exposure) to the foreign protein so that when exposed the second, and subsequent times, a response is mounted by the immune system. Allergies are very common in the general population. They include food, medications, soaps, insect bites and pollens.
The body’s reaction can begin as mild signs and symptoms and then progress to anaphylaxis. Mild allergic reactions usually manifest with urticaria (rashes, redness), hives (raised bumps in skin), edema (swelling), resulting in itching to the exposed areas of the skin. This is common with poison ivy, soaps and certain medication reactions. Itching and mild edema to the eyes lids, nose and throat, with rhinorrhea (runny nose) and lacrimation (tearing) can occur with pollens and inhaled antigens.

Although not life-threatening, mild allergic reactions are annoying and can disrupt activities of daily life. The ability to use scopes, night vision, binoculars and even maintain attention span can be limited by them. Rashes can worsen under hot, humid conditions and limit the ability to wear boots, protective clothing and remain outdoors for extended periods. Mild signs and symptoms also result in manual scratching as well as contact with mucus membranes, which can become sources of infection. This can be counter-productive and dangerous when living and operating in an austere environment such as a retreat, therefore justifying treatment and resources.

Treatment of Mild Reactions

Mild allergic reactions can generally be treated with antihistamine medications (oral and lotions) and oral over the counter (OTC) sinus medications. These are cheap, easy to store and have long shelf lives. Stockpiling these are easy and administering them requires no special training other than to know when to use them. Your medical specialist(s) will be able to handle the treatment of mild reactions as they are not time sensitive.
Benadryl (diphenhydramine) is an antihistamine and a mainstay of the treatment of allergic reactions. Histamine is a substance that is released by the body during an allergic reaction that results in the above sign and symptoms. Benadryl actively antagonizes the release of histamine providing relief. It is packaged in 25 mg tablets. The dose is 25-50 mg orally for mild allergic reactions every 4-6 hours. The chief side effect is drowsiness which can most easily be limited by drinking coffee.

There are several OTC medications for hay fever and the associated signs and symptoms to the eyes, nose and throat. The key ingredients to look for are pseudophedrine or chlorophrenamine. For those with high blood pressure pseudophedrine preparations should be avoided if possible as they can raise blood pressure (BP). Neosynephrine nasal sprays can aid in relieving nasal congestion and swelling. Loratadine and Zyrtec are two other popular long term antihistamines that do not have the side effect of drowsiness

Background and Signs and Symptoms for Moderate to Severe Reactions

More severe forms of allergic reactions, known as anaphylaxis, can manifest with itching, urticaria and hives that proceed from a local reaction to a systemic (body-wide)reaction with the addition of difficulty breathing (wheezing, increased work of breathing, increased respiratory rate); and difficulty swallowing.  Stridor is caused by edema (swelling) to the upper airway (inspiratory and expiratory noises when breathing, swollen tongue). Signs and symptoms of decreased BP (from dilated blood vessels) can also occur such as cool, clammy skin; decreased mentation; and weak pulses. This is a life threatening condition that can rapidly lead to death if not treated.
Anaphylaxis can be functionally divided into two forms in terms of signs and symptoms and treatment: moderate and severe. Both forms will require the provider to be able to administer intramuscular injections (IM); and the latter, potentially perform advanced airway maintenance as initial care for anaphylaxis.

: These procedures require hands-on training and initial instruction on how to draw up medications and inject them safely. These should ideally be performed by your group’s medical specialist if available, but could be considered buddy care in austere conditions. EMT and paramedic courses cover the treatment for this in comprehensive detail. Your medical specialist (paramedic or RN) can also teach these procedures and oversee practical training. Volunteers and oranges can be used for practice administration. Instructional videos can be found online. All medication doses are adult dosages. All pediatric doses should be weight-based and referenced prior to preparation. ]

Moderate anaphylaxis is characterized by a body-wide rash/urticaria as well as difficulty breathing; difficulty swallowing; but no signs of decreased BP. The patient will be in considerable distress but will be awake and conscious at this point but unable to exert themselves.
Severe anaphylaxis can occur within minutes of some exposures (such as with bee stings) or can be a continuation of mild anaphylaxis that does not respond immediately to treatment. This is the most lethal form of allergic reactions and results in a patient becoming unresponsive; severe difficulty breathing; failing respirations; bluish-color skin to the face and neck (cyanosis- lack of O2);  and low BP. These patients can die within five minutes without further, prompt treatment.

Initial Treatment for Moderate to Severe Reactions

These patients need two medications rapidly administered via intramuscular (IM) injection: epinephrine and Benadryl . If a patient is not responding to these medications quickly, they must be evacuated to more definitive care by your medical specialists. Those providers would establish IV access and may proceed with IV doses of these medications plus a steroid medication (anti-inflamatory) as available.
Benadryl is same as the oral version but in an injectable form for more rapid absorption. 50 mg is needed to be given via IM injection, between the hip and knee, in the outer aspect of the thigh of the patient. Drowsiness may still occur and may manifest more rapidly than the oral version.
Epinephrine is derived from the same adrenal hormone in our body. It caused blood vessels to constrict (raises BP); decreases swelling and edema (from vasoconstriction); and dilated bronchioles (eliminates wheezing). It is given IM in the deltoid muscle (anterior upper arm) or in the opposite outer thigh. The dose is 0.5cc of a 1:1000 preparation. This can be repeated once in young, otherwise healthy adults. It should be used with caution in older patients with cardiac disease. It does not have a long shelf life and if it turns brown in color it has expired.

Basic Procedure for Preparing IM Medications

1. Ensure the rubber-topped vial is epinephrine or Benadryl
2. Cleanse the rubber top of the medication vial
3. Use a 3cc syringe with a 22g needle and puncture the rubber top; keep the bevel of the needle in the solution to avoid drawing up air
4. Steady the vial upside down with your non-dominant hand and expel the medication into the syringe with your dominant hand. Draw up the necessary amount of medication; draw up slightly more than needed.
[Benadryl is usually packaged 25 mg / cc and epinephrine (1:1000) is usually 1 mg/cc- check all medication concentrations prior to use to know the dose/amount for what you have on hand]
5. Remove the syringe from the vial and push the plunger of the syringe up to expel any volume of air or large air bubbles, while ensuring the correct amount of medication is left in the syringe
6. Re-cap needle safely

Basic Procedure for Administering Epinephrine and Benadryl via IM Route
1. Expose the outer aspect of the patient’s thigh
2. Locate the site which is the outer aspect of the thigh mid way between the hip bone and knee
3. Cleanse the site with an alcohol prep in an up & down fashion and then with outward concentric circles
4. Re-check the that the medication is correct and amount drawn up is correct- usually this will be 50 mg Benadryl in 1or 2 cc and 0.5 mg epinephrine in 0.5 cc (depending on the concentration on hand)
5. Uncap the needle and inject it into the site at a 90 degree angle with your dominant hand
6. Steady the syringe with your non-dominant hand and pull back on the plunger with your dominant hand; and aspirate for blood (if blood returns this indicates you are in an artery- if so, withdraw the needle and re-inject about 1 cm away from it)
7. Inject the medication fully into the muscle and withdraw the needle
8. Apply pressure to the site with an alcohol prep for 1 minute to assist in absorption
Emergency Airway Management for Severe Reactions
If enough swelling and edema occurs in the upper and lower airway of a patient with severe anaphylaxis, emergent airway procedures may be needed. This will be evident in the patient by audible stridor and severe respiratory distress. Essentially the edema blocks off the larynx from its ability to exchange air and prevents ventilation. Death can occur in 4-6 minutes. The procedure of surgical cricothyroidotomy can be used to place an emergency airway for these patients. Basically this is putting a tube through the “Adam’s apple” of the patient below the level of the swelling.  This airway compromise may be present within minutes of the start of the reaction, or happen if the swelling is refractory to medications. Early epinephrine administration and Benadryl should begin alleviating s/s within a few moments so further interventions will not be necessary.
There are several ways to perform a surgical airway. Again, formal medical training is necessary for success and safety with this procedure. There are prepared kits as well as alternate methods to do this procedure. I will detail the latter later in the article. Although an advanced procedure, surgical airway insertion is very time dependent and more thoroughly trained personnel may not be immediately available, so it can be considered buddy care in austere conditions. This procedure should  be ideally performed by your medical specialist if available.
Caution: Movies and television show other heroic methods, such as using Buck knives and pens. These methods do not work and are dangerous. This is a procedure that must be kept as sterile as possible and be functional for 24- 48 hrs. Plus there are limited ways to treat infection and pneumonia in the austere setting, and saving a patient only to lose them to blood loss or infection is overtly counterproductive.]
 The key to this procedure is locating the cricothyroid membrane. You will need to look at anatomical pictures and find this location on live people plus use animals for further practice. Pig tracheas are very similar to humans and can aid in this process (they are also thrown out by butchers and can be harvested for training).
The larynx (“Adam’s apple”) is located to the front of the neck. It is the large, rigid structure sitting on top of the trachea. When palpating it, the superior hard ridge at the top is the thyroid cartilage (upper landmark). The next hard ridge blow the thyroid cartilage is the cricoid cartilage (lower landmark). Below that are the more pliable tracheal rings. The cricothyroid membrane is located between the thyroid and cricoid cartilages on the anterior aspect of the larynx. (It is the spot where if one presses on it, it feels like you will suffocate.) This is where an opening is made and an endotracheal (ET) or tracheostomy tube is placed in order to open an airway.
Note that locating the landmarks requires practice to be successful. The actual procedure is easy once the correct location of the cricoid membrane is made. A surgical airway should only be used in a last ditch effort to save a life after all other pharmacological options have been used and are not working. This cannot be over-emphasized.]

Basic Equipment Needed for Surgical Airway

Alcohol preps
Betadine preps
#6 ET tube (preferable- alternates will be discussed later)
4x4 gauze
1” medical tape
Adult bag valve mask (BVM) - if available

Procedure for Surgical Airway:

  1. Wash hands if at all possible or wipe with hand sanitizer; use gloves if available
  2. Determine need for procedure
  3. Place patient's head in the sniffing position (place rolled blankets under the shoulders of the patient and let his head hang dependent)
  4. Prepare all equipment(kits can be assembled ahead of time)
  5. Locate the cricoid membrane as previous
  6. Cleanse the site with alcohol prep in concentric circles moving from center of site to about 3 cm outside- repeat with Betadine prep
  7. Stabilize the  cartilage with one hand
  8. Puncture the cricoid membrane with the scalpel to approx 1 cm depth
  9. Remove the scalpel
  10. Insert the #6 ET tube through the hole into the trachea approx 4 cm
  11. Listen for air exchange and respirations through the tube plus chest rise
  12. Pack the edges of the site with 1-2 4x4s to control any bleeding
  13. Tape the tube in place by taping around the tube 1-2 times at the level of insertion in the larynx, and then by encircling the neck 1-2 times and finishing with tape to the tube
  14. Reassess for improvement in the patient
  15. Ventilate (breathe) for patient through tube PRN or at 10-12 b/min
  16. Move patient to more definitive care by your medical specialist

Caution- You must successfully identify the landmarks for the cricoid membrane. Any deviation can cause catastrophic bleeding (and death) as the carotid arteries and jugular veins lie on each side of the larynx. The thyroid gland also is present behind the thyroid cartilage (the upper landmark for the cricoid membrane) and is rich in blood supply.
There will be some bleeding but this should be minimal so long as you do not deviate from the landmarks for the cricoid membrane. Stridor should disappear after the tracheal tube is inserted and the tube should fog from the condensation from respirations. The cyanosis should also decrease and the patient’s respiratory distress should decrease as well.

Back-up Surgical Airway Methods
If a commercially made endotracheal tube or tracheotomy tube is not available then a barrel of a 1cc syringe can be used as the tube. This will need to be held in place after taping it like an ET tube, as it is shorter and non-pliable, until given to definitive care.

Another back-up method to do a surgical cricothyroidotomy is to use the drip chamber form a 10 drop IV tubing set. The barb from the drip chamber that is used to puncture the IV bag can be uncapped and used in lieu of a scalpel. You will need to cut the drip chamber in half in the middle of the chamber to act as a tube. Landmarks and procedure are the same as before, but here you use the sharp barb to puncture the cricoid membrane at a 45 degree angle towards the feet of the patient. The hole is large enough to allow for air exchange and standard BVM will fit the end of the drip chamber that was cut, in order to facilitate ventilation. It will also need to be held in place and taped as above, as it is also shorter than an ET tube.

The above two back-up methods are only for use if the standard equipment is unavailable. All medical kits should have a surgical airway kit set up from the supplies listed previously or have a commercially prepared cricothyroidotomy kit (that will have all supplies in it that are needed).Your medical specialist will know what the indications are for removal of the tube and the after-care that is needed for the site.

Although anaphylaxis can be successfully treated and all group members should know the buddy care for this condition. However, prevention is the best way to avoid death from anaphylaxis. All people who are allergic to known substances (foods, medications) should first, avoid them, and then advise all medical providers of their presence. Severely allergic people should have access to antihistamine tablets (Benadryl) and have access to Epi-pens (self-injectable syringes that contain 0.3 cc of 1:1000 epinephrine) for self-treatment. Anaphylaxis can have a high recovery rate but the treatment must be initiated early for optimum results.

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