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| Anaphylaxis: Treating A Potential Killer |
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by Bob Blumm, MA, PA-C, DFAAPA - November 14, 2011
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Anaphylaxis is more than a medical term, but is a life changer and a very real medical emergency. I cringe when I consider that some of my colleagues have given a kid an injection of penicillin and have not waited 30 minutes for the possibility of a reaction. I saw my sister have this reaction when I was a kid, and her angioedema made her look like a Jack-o-lantern on Halloween night. She was fortunately brought to the hospital immediately and she responded to the epinephrine. It is important for us to consider the collateral damage done to the parents and siblings of someone that has an anaphylactic reaction to a medication or shellfish, iodine or any other agent including middle and upper aged people placed on an Ace inhibitor.
The pathophysiology of this problem is quite simple as a hypersensitivity reaction occurs when the normal immune system responds in an excessive manner. The type of reaction and the severity of the response will be the determining factor of life or death. Most reactions are Type 1 and happen immediately. I had the opportunity of seeing this as I was teaching at a PA program about five years ago as I watched a student bolt for the door. I followed her in a few seconds as I had seen a face that was filled with fear and saw her gasping for air. She was able to say that she had a peanut allergy and I looked in her pocketbook, found the Epi-Pen and wacked her immediately. When I returned to the class after escorting her to the program director, I discovered that one of the students was eating a bag of peanuts. Think of it, this can happen on a plane a train or an automobile. This can happen in a movie house, the theater or in church or synagogue, yet we don’t carry Epi-pens just like we don’t have defibrillators in the trunk of our cars.
I made one of the most stupid errors of my life, actually the epitome of poor judgment, when I went to dinner with some friends and he had a reaction (delayed) to shellfish and asked me to bypass the ER of a “dog and cat” hospital in our community and to treat him at home. I followed his suggestion out of temporary insanity or delusions of grandeur and gave him a shot of epinephrine, started a line, gave him an antihistamine and steroids and had a bag ready for him. He could have ended up in a body bag instead and he was not only running for Mayor but was an attorney. I was an ER PA at the time and had forgotten that the ER was well prepared, could have made him stay on a monitored bed for 12 hours after treatment and the ER had insurance, whereas I was working “commando” as my Doc is a Plastic Surgeon. I don’t think my liability policy would have covered this stupidity and assault. That is me standing naked in the front window of Macy’s and I hope that none of my colleagues ever have a thought process that was as damaged as mine on that evening.
The management of anaphylaxis is immediate concern for airway control and immediate injection of IM Epinephrine. In most cases you will not be dealing with a cardiac patient on five different cardiac meds but these may be the exception to the rule, which is why there is some security to that foolish term: “physician supervision.” That situation may signal that it is turf time for those with a weak stomach or who just wouldn’t know what to do next if there was a crisis from the injection. The average adult can receive between 0.3 to 0.5mg of Epinephrine 1:1000 IM depending on their individual weight. Since Americans seem to be so obese or overweight in this past decade, the higher dose may be more appropriate. Steroids have no use in the immediate care of this patient and 50 mg of Benadryl is a proper dose for an adult utilizing the IV route. Oxygen is always a perfect drug and should be placed on the patient immediately on presentation.
Hopefully you will not need to cope with this situation frequently but this small article is useful as a reminder of the acute care simply stated as well as a lesson on the stupidity of this caregiver at this time. By the way, he made it just fine and I gave him his steroids a few hours later since I couldn’t sleep anyway.
 Robert M. Blumm has received national recognition as a distinguished fellow of the American Academy of Physician Assistants (AAPA). He is the past president of the Association of Plastic Surgery Physician Assistants, and was past-president of the American Association of Surgical Physician Assistants, past president of the American College of Clinicians and NYSSPA, as well as Chairman of the Surgical Congress of the AAPA. In addition, Bob received the John Kirklin MD Award for Professional Excellence from the American Association of Surgical Physician Assistants. Along with his associate, Dr. Acker, Bob was the first recipient of the AAPA PAragon Physician-PA Partnership Award. He has been a contributing author of three textbooks, written 300 plus articles and is a sought out conference speaker throughout the United States.
The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.
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