Understanding and Treating Anaphylactic Shock

Emergency Medicine

Understanding and Treating Anaphylactic Shock

1. While I do have a fair amount of medical knowledge, I am not a medical doctor. You should not attempt self-medication or self-treatment when professional medical care is available. However, for the purposes of this post, it is assumed that professional medical care will be delayed or outright unavailable. The treatments I recommend are the treatments I would give to myself and my family if professional medical care were delayed or outright unavailable.

2. Anaphylactic shock is a life threatening condition that can kill in minutes. Never, ever attempt self-treatment or improvised treatment for this condition when professional medical care is available. However, for the purposes of this article it is assumed that professional medical care will be delayed or outright unavailable.

3. For those of you with professional medical training, you will notice that I have over-simplified some of the material in this article, as it is not written for medical professional but for those with little or no medical training.


Anaphylactic shock is a life threatening condition that can be described as a system wide type 1 allergic reaction. It is most commonly caused by bee stings. Without quick treatment, this type of allergic reaction can kill in minutes.

Symptoms-flushing and itching of the skin, hives, feeling of warmth, swelling of the tongue and throat making breathing difficult, nasal congestion, throat tightness, wheezing, shortness of breath, cough, hoarseness, dizziness, low blood pressure, weakness, fainting, chest pain, feeling of doom, heart palpitations, nausea, vomiting diarrhea, bloating and cramps

Common sensitizing antigens come from the following: Bee stings, wasp stings, hornet stings, yellow jacket stings, ant stings (especially fire ants), penicillin type antibiotics, peanuts and food containing peanuts, tree nuts and food containing tree nuts, fish and foods containing fish, shellfish and foods containing shellfish, eggs and egg products, soy and soy products, milk and milk products, aspirin, ibuprofen, and other NSAIDS (non-steroid anti-inflammatory drugs).

The insects listed above are Hymenoptera type insects and between 0.5 and 3 percent of the population experience system wide allergic reactions after being stung by these insects.

In the foods listed above, peanuts and foods containing peanuts are thought to be responsible for 62 percent of the deaths caused by anaphylactic reactions to food.

COMMENT: Even if you have been stung by one of the listed insects in the past and not had an anaphylactic reaction does not mean you cannot have an anaphylactic reaction the next time you are stung. The last time you were stung could have been the sting that sensitizes you immune system to that particular antigen.

TREATMENT-Most of the items for standard medical treatment are prescription drugs. We’ll look at the standard medical treatment, then address how you can get those prescription drugs, the look at over the counter items you can use for improvised treatment.

STANDARD TREATMENT FOR ANAPHYLACTIC SHOCK


1. The first line treatment for anaphylactic shock is epinephrine (also called adrenaline chloride) injected intramuscularly (into the muscle).

Adult Dose: 0.3 to 0.5 milliliters (0.3 to 0.5 milligrams) of 1:1000 epinephrine solution injected intramuscularly (IM). For more critical situations inject 1 to 2 milliliters (0.1 to 0.2 milligrams) of 1:10,000 epinephrine solution intramuscularly (IM).

Child Dose: 0.01 milligram of epinephrine solution per kilogram of body weight ? 1:1000 or 1:10,000

COMMENT: Epinephrine treatment of anaphylactic shock is essential. The injectable form of this drug requires a prescription. The inhaleable form of this drug is available over the counter in as Primeatine Mist. The tablet form of this drug, ephedrine, is available over the counter as Primeatine Tablets and as the white cross or mini-thin tablets in convenience stores. INHALEABLE EPINEPHRINE AND EPHEDRINE TABLETS ARE NOT A SUBSTITUTE FOR INJECTABLE EPINEPHRINE IN THE TREATMENT OF ANAPHYLACTIC SHOCK. However, we will look at how they can be used as an improvised treatment if standard treatments are delayed or outright unavailable.



There are three ways to get injectable epinephrine from your doctor.

1. The multi-dose vial-This is a good option to keep around the house IF you have medical training and are comfortable giving injections to yourself and others.

2. The Ana-Kit-This is a kit that you can keep at home or keep on your person. (You could probably keep it in your car in a small cooler. Heat causes epinephrine to deteriorate.) I like the Ana-Kit because it has enough epinephrine for a second injection if necessary.

3. The Epi-Pen-This is a good option for people with little or no medical training and for people who are not comfortable giving injections to themselves or others. The Epi-Pen is an auto injector. You simply place it against your skin and activate it. When activated a spring loaded needle deploys penetrating the skin and injecting the epinephrine. If your really afraid of shots, this is the best option.

If you have never had an anaphylactic reaction, tell your doctor you simply want to be prepared just in case. Some doctors will say yes and give you the prescription, others will not. If your doctor will not write the prescription, consider asking your dentist or veterinarian. (I often find veterinarians are some of the most down to earth medical professionals. It’s hard to develop a God complex working on animals. Many times veterinarians will give you prescriptions for drugs like this, if you only ask. However, for liability and legal reasons, the prescription will have to be written for a pet, real or made up.)

2. In addition to the epinephrine, treatment with an antihistamine that blocks histamine 1 receptors, while not absolutely necessary, is highly desirable. The best drug of this type to use is diphenhydramine (Benadryl). The adult dose is 10 to 50 milligrams injected intravenously (IV) or intramuscularly (IM) every 4 hours as needed. If injected intravenously (IV) the IV rate should not exceed 25 milligrams per minute. The child dose is 12.5 to 25 milligrams by mouth 4 times per day.

COMMENT: diphenhydramine (Benadryl) is available over the counter in the form of syrup, capsules, and tablets. The injectable form of this drug requires a prescription.

If diphenhydramine (Benadryl) is not available, other antihistamines can be used, such as:

chlorpheniramine maleate (Chlor-Trimeton)-over the counter
promethazine (Phenergan)-prescription only in U.S., over the counter in Great Britian
triloprolidine-over the counter
meclizine (Antivert)-over the counter, also sold as Dramamine Less Drowsy Formula
cyclizine (Marezine)-over the counter

3. If possible, in addition to epinephrine treatment plus an antihistamine that blocks histamine 1 receptors, treatment with an antihistamine that blocks histamine 2 receptors can be useful. A common drug of this type, available over the counter is ranitidine (Zantac). The dosage is 150 milligrams by mouth twice per day. Cimetidine (Tagamet) is another drug of this type.

COMMENT: In the professional medical setting these drugs are almost always given by the intravenous (IV) route for the treatment of anaphylactic shock.

Optional #1. For breathing difficulties caused by anaphylactic shock that do not respond to epinephrine, inhaleable bronchodilators are useful. Albuterol (Proventil, Ventolin) is a drug of choice for this. The adult dose is 1 to 2 inhaled puffs every 4 to 6 hours.

Optional # 2. For very severe anaphylactic reactions or for the treatment of delayed effects of anaphylactic reactions, corticosteroids can be used. Methylprednisolone (Medrol Dosepack) or dexamethasone (Decadron) can be given by mouth in the form of tablet. These drugs can also be given intramuscularly (IM) or intravenously (IV).

Optional # 3. The drug glucagon (GlucaGen) and dopamine (Intropin) also have use in treating low blood pressure caused by anaphylactic shock that does not respond to epinephrine treatment.


Glucagon (GlucaGen) is for use in anaphylactic shock patients who are taking the non-selective beta-blockers like propranolol (Inderall) for blood high blood pressure. In these patients, glucagon should be used in addition to epinephrine, not in place of epinephrine.

SUMMARY OF STANDARD MEDICAL TREATMENT OF ANAPHYLACTIC SHOCK

1. Injectable epinephrine solution-absolutely essential
2. Injectable or oral diphenhydramine (Benadryl) or other anti-histamine-highly desirable but not essential
3. Oral ranitidine (Zantac)-desirable but not essential
4. Inhaleable albuterol (Proventil, Ventolin) for breathing difficulties that persist despite epinephrine treatment.
5. Injectable or oral corticosteroid treatment for delayed anaphylactic symptoms.



IMPROVISED TREATMENT USING OVER THE COUNTER DRUGS

Anaphylactic shock is a life threatening condition that can kill in minutes. Never, ever attempt self-treatment or improvised treatment for this condition when professional medical care is available. However, for the purposes of this article it is assumed that professional medical care will be delayed or outright unavailable.

1. Epinephrine inhalers such as Primeatine Mist-These inhalers ARE NOT a substitute for epinephrine injection, however, if injectable epinephrine is delayed or outright unavailable, these inhalers are certainly better than nothing. Use according to directions on the box. The goal of this improvised treatment is to prevent airway constriction and to get some epinephrine into the bloodstream via absorption through the lungs.

2. Diphenhydramine (Benadryl) Syrup-Take 2 capfuls of diphenhydramine syrup and gargle for 1 minute then swallow. The goal of this improvised treatment is to keep the throat from swelling shut due to the anaphylactic reaction and to get the antihistamine into the bloodstream. If you do not have the syrup but have tablets or capsules, you can still make use of the drug. Chew the tablets and then put some water into your mouth and gargle the drug and water solution. If you have capsules, open them and mix them with water or any available liquid and gargle the solution.

3. Ephedrine tablets’ such as the white cross or mini-thin tablets sold in convenience stores. These tablets are also sold as Primeatine Tablets. Take 1 or 2 of these 25 milligram tablets. If ephedrine tablets are unavailable you can take pseudo-ephedrine (Sudafed) tablets or phenylephrine tablets (Sudafed PE). These are also beta-agonist like ephedrine and will give some degree of relief. The goal of this improvised treatment is to get epinephrine like oral drugs into the blood stream.

4. While not technically a drug, hot tea contains the drug theophylline, which is used to treat asthma and can be used to treat anaphylactic shock if other drugs are not available. If hot tea is available, drink two cups of it.

5. Mormon Tea is a herb that contains ephedrine. The seeds for it are available from Richters Herbs. The dried leaves make a good addition to a herbal medical kit. Drink the tea hot to release the ephedrine.