chapter 25 immunologic emergencies. national ems education standard competencies medicine integrates...
TRANSCRIPT
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Chapter 25Chapter 25
Immunologic Emergencies
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National EMS Education Standard CompetenciesNational EMS Education Standard Competencies
Medicine
Integrates assessment findings with principles of epidemiology and pathophysiology to formulate a field impression and implement a comprehensive treatment/disposition plan for a patient with a medical complaint.
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National EMS Education Standard CompetenciesNational EMS Education Standard Competencies
Immunology
•Recognition and management of shock and difficulty breathing related to
− Anaphylactic reactions
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National EMS Education Standard CompetenciesNational EMS Education Standard Competencies
Immunology
•Anatomy, physiology, pathophysiology, assessment, and management of hypersensitivity disorders and/or emergencies
− Allergic and anaphylactic reactions
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National EMS Education Standard CompetenciesNational EMS Education Standard Competencies
Immunology
•Anatomy, physiology, epidemiology, pathophysiology, psychosocial impact, presentations, prognosis, and management of common or major immunologic system disorders and/or emergencies
− Hypersensitivity
− Allergic and anaphylactic reactions
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National EMS Education Standard CompetenciesNational EMS Education Standard Competencies
Immunology
•Anatomy, physiology, epidemiology, pathophysiology, psychosocial impact, presentations, prognosis, and management of common or major immunologic system disorders and/or emergencies (cont’d)
− Anaphylactoid reactions
− Collagen vascular diseases
− Transplant-related problems
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IntroductionIntroduction
• 1,500 Americans die of acute allergic reactions every year.− Be prepared to treat acute airway obstruction
and cardiovascular collapse.
− Be able to distinguish between a regular response and an allergic reaction.
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IntroductionIntroduction
• Immune response problems include:− Anaphylaxis
− Anaphylactoid reactions
− Allergic reactions
− Hypersensitivity
− Collagen vascular diseases
− Transplant-related disorders
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IntroductionIntroduction
• Allergen: Substance that produces allergic symptoms
• Antibody: Protein produced in response to an antigen
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IntroductionIntroduction
• Allergic reaction: An abnormal immune response− Local reaction: limited to a specific area
− Systemic reaction: occurs throughout the body
• Hypersensitivity: Inappropriate allergic symptoms from a substance
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IntroductionIntroduction
• Anaphylaxis: Systemic allergic reaction− No exact cause in up to two thirds of patients
− Allergy-related diseases increase the risk.
− Other major factors include:• The route of exposure
• The time between exposures
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IntroductionIntroduction
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IntroductionIntroduction
• Anaphylactoid reaction does not involve IgE antibody mediation.− May occur without previous exposure
− Patient presentation is the same.
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IntroductionIntroduction
• Collagen vascular diseases − Autoimmune disorders
− The body perceives its own collagen tissue as a danger and attacks that tissue.
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IntroductionIntroduction
• Collagen vascular diseases (cont’d)− Systemic lupus erythematosus (SLE or lupus)
• Multisystem autoimmune disease
• Often diagnosed in women of childbearing age
• Can attack multiple systems
• Survival rate is currently at 15 years
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IntroductionIntroduction
• Collagen vascular diseases (cont’d)− Scleroderma
• Autoimmune connective tissue disease
• Can be either localized or systemic
• Patients are at greatest risk of dying from organ damage during the first three years.
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IntroductionIntroduction
• Patients with organ transplants receive immune system suppression medications.− Be prepared to identify rejection, infection, and
medication toxicity signs.
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IntroductionIntroduction
• Infection is the greatest threat in an organ transplant.− Taking immuno-
suppressant medications is essential.
− Drug toxicity is also a danger.
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The Normal Immune ResponseThe Normal Immune Response
• Immune system protects body− Cellular immunity: T cells attack and destroy
antigens.
− Humoral immunity: B cell lymphocytes produce antibodies to attack foreign organisms.
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Routes of Entry for AllergensRoutes of Entry for Allergens
• Skin: injection or absorption
• Inhalation: patient breathes in allergens
• Ingestion: through the gastrointestinal tract
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PhysiologyPhysiology
• Primary response: Macrophages confront and engulf antigens.− Substances that cannot be identified are
recorded.• Antibodies are intended to match the antigen and
inactivate it.
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PhysiologyPhysiology
• The body develops sensitivity.− The body distributes details to the rest of the
body by placing the antibodies on:• Basophils
• Mast cells
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PhysiologyPhysiology
• Basophils and mast cells produce chemical mediators to fight antigens.− Summon white
blood cells
− Increase blood flow
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PhysiologyPhysiology
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PhysiologyPhysiology
• Vaccine administration sends a small amount of virus into the body.− Body produce antibodies to it
− If an immunized person is later exposed, the immune cells identify and kill the virus.• Secondary response
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PhysiologyPhysiology
• Acquired immunity: Vaccine allows the body to produce antibodies without becoming ill.
• Natural immunity: The body experiences the full immune response.
• Herd immunity: When a group is immunized
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Scene Size-UpScene Size-Up
• Assess the scene for safety issues.
• Determine the nature of the illness.− Check for potential exposure venues.
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Primary AssessmentPrimary Assessment
• Evaluate:− Level of consciousness
− Respiratory system
− Circulatory system
− Mental status
− Skin
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Primary AssessmentPrimary Assessment
• Allergic reactions can be local or systemic.
• Categories:− Mild: affecting a local area
− Moderate: mild signs spread through the body
− Severe: anaphylactic reactions
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Primary AssessmentPrimary Assessment
• Form a general impression.− Observe for indication of severity.
− If the patient cannot speak, assess the airway.
− Level of conscious indicates: • Severity of the reaction
• Oxygen and circulatory status
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Primary AssessmentPrimary Assessment
• Breathing and airway− A noisy upper airway may be a sign of
impending airway occlusion.• Check for stridor and hoarseness.
• The patient may report tightness in the throat.
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Primary AssessmentPrimary Assessment
• Breathing and airway (cont’d)− Lung sounds are a predictor of severity.
− As hypoventilation begins, there will be:• Diminished lung sounds
• Silence (ominous finding)
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Primary AssessmentPrimary Assessment
• Circulation− Evaluate skin for histamine release symptoms,
which may include:• Erythema
• Edema
• Pruritus
• Urticaria
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Primary AssessmentPrimary Assessment
• Transport decision− May include:
• Remaining on the scene
• Initiating treatment in the vehicle
• Beginning immediate transport
• Calling for air transport
− Determine which facility to transport to.
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History TakingHistory Taking
• Should be directed at the current complaint− Does the patient have allergies?
− Have they ever had an allergic reaction?
• Ask about medications.
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History TakingHistory Taking
• Intervention takes precedence over identifying antigen.− Determine if
treatment was administered:• EpiPen
• Benadryl
• Beta-agonist inhaler
• Aerosolized epinephrine
© Kumar Sriskandan/Alamy Images
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Secondary AssessmentSecondary Assessment
• Physical examinations− Evaluate the respiratory system.
• Assess breathing.
• Auscultate the trachea and chest.
• Wheezing may be present.
• Prolonged respiratory difficulty may lead to death.
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Secondary AssessmentSecondary Assessment
• Physical examinations (cont’d)− Assess the circulatory system.
• Hypoperfusion or respiratory distress indicates severe allergic reaction.
− A systemic reaction may present as:• Rash; red, hot skin; altered mental status
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Secondary AssessmentSecondary Assessment
• Vital signs− Assess baseline vital signs.
− Airway obstruction: rapid, labored breathing
− Respiratory distress or shock: rapid respiratory and pulse rates
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Secondary AssessmentSecondary Assessment
• Monitoring devices− Cardiac monitor for dysrhythmias
− 12-lead ECG for cardiac ischemia
− ETCO2 for bronchoconstriction
− Pulse oximetry for oxygen saturation levels
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ReassessmentReassessment
• Should be done en route − Focus on signs of airway compromise.
− Monitor the patient’s anxiety and the skin.
− Conduct serial vital signs.
− Reassess the chief complaint.
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ReassessmentReassessment
• Interventions− Identify the amount of distress.
• Severe reactions require epinephrine and ventilatory support.
• Milder reactions require supportive care.
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ReassessmentReassessment
• Interventions (cont’d)− Recheck the interventions.
• A second dose of epinephrine may be needed.
− Identify and treat any changes in condition.
− In anaphylaxis cases, check interventions.
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ReassessmentReassessment
• Interventions (cont’d)− Call in the patient report and include:
• The patient’s status
• Interventions completed
• The patient’s responses
• Estimated time of arrival
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Anaphylactic ReactionsAnaphylactic Reactions
• Pathophysiology− Immune system
becomes hypersensitive.• Identify harmless
substances as a threat.
Courtesy of Carol B. Guerrero
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Anaphylactic ReactionsAnaphylactic Reactions
• Pathophysiology (cont’d)− When an invading substance enters the body,
mast cells release chemical mediators.• In anaphylaxis, the effect involves more than one
body system.
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Anaphylactic ReactionsAnaphylactic Reactions
• Pathophysiology (cont’d)− Histamine causes:
• Vasodilation
• Vascular permeability
• Smooth muscle contraction
• Decreased effects of the heart
© Chuck Stewart, MD
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Anaphylactic ReactionsAnaphylactic Reactions
• Pathophysiology (cont’d)− Leukotrienes cause:
• Respiratory system becomes more dire
• Coronary vasoconstriction
• Increased vascular permeability
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Anaphylactic ReactionsAnaphylactic Reactions
• Clinical symptoms of anaphylaxis− Patient
experiences three types of shock:• Cardiogenic shock
• Hypovolemic shock
• Neurogenic shock
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Anaphylactic ReactionsAnaphylactic Reactions
• Assessment− It may be necessary to simultaneously:
• Assess the patient.
• Identify the problem.
• Intervene.
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Anaphylactic ReactionsAnaphylactic Reactions
• Management− Patients with allergic reaction signs but no
respiratory distress:• Diphenhydramine (Benadryl)
• Monitor for changes.
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Anaphylactic ReactionsAnaphylactic Reactions
• Management (cont’d)− If signs of allergic
reaction and dyspnea:• Deliver oxygen,
epinephrine, and antihistamines.
• Monitor for anaphylaxis.
− Remove offending agent.
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Anaphylactic ReactionsAnaphylactic Reactions
• Management (cont’d)− Maintain airway and prepare to intubate.
• Cricothyrotomy may be necessary.
• Assess for stridor and hoarseness.
• Administer supplemental oxygen.
• Early administration of epinephrine should be a priority.
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Anaphylactic ReactionsAnaphylactic Reactions
• Management (cont’d)− Administer epinephrine.
• Immediately stops the process
• Reverses the effects of the chemical mediators
• An EpiPen may have already been used.
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Anaphylactic ReactionsAnaphylactic Reactions
• Management (cont’d)− Maintain circulation.
• Administer 1 to 2 L of an isotonic solution.
• If there is no response up to 4 L may be needed.
• If there is still no response, consider a vasopressor.
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Anaphylactic ReactionsAnaphylactic Reactions
• Management (cont’d)− Initiate pharmacologic therapy.
− Be prepared to assist ventilation.
− Monitor for adverse effects to epinephrine.
− Reassess vital signs at least every 5 minutes.
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Anaphylactic ReactionsAnaphylactic Reactions
• Management (cont’d)− If not accompanied
by hypotension or airway compromise, treat with epinephrine.• Adults: 0.3 to 0.5
mg
• Children: 0.001 mg/kg
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Anaphylactic ReactionsAnaphylactic Reactions
• Management (cont’d)− Antihistamine administration should only be
considered after epinephrine.
− Corticosteroids may prevent late reactions.
− Consider glucagon if no response to epinephrine.
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Anaphylactic ReactionsAnaphylactic Reactions
• Management (cont’d)− Consider vasopressors if no response to fluids.
− If bronchospasm is present, consider inhaled beta-adrenergic agents.
− Psychological support is crucial.
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Collagen Vascular DiseasesCollagen Vascular Diseases
• Pathophysiology− Systemic lupus erythematosus (SLE or lupus)
• Multisystem autoimmune disease
• Monitor for life threats.
• Patients may be on immunosuppressive medications.
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Collagen Vascular DiseasesCollagen Vascular Diseases
• Pathophysiology (cont’d)− Scleroderma
• Presents with tightening, thickening, and scarring
• Often include symptoms of Raynaud phenomenon
• Damage to the heart muscle is a major complication.
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Collagen Vascular DiseasesCollagen Vascular Diseases
• Assessment− Rule out life threats.
• Management− Treat any life threats.
− Monitor for signs of infection.
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Organ Transplant DisordersOrgan Transplant Disorders
• Pathophysiology− Immune system tries to reject the organ.
− Patients are given antirejection medications.
− Address priorities in caring for specific transplanted organs.
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Organ Transplant DisordersOrgan Transplant Disorders
• Heart transplant− The recipient’s heart is usually removed, but
may be left in place.
− Atropine is not indicated.
− Sympathomimetic drugs work well.
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Organ Transplant DisordersOrgan Transplant Disorders
• Heart transplant (cont’d)− Signs and symptoms of infection may include:
• Shortness of breath
• Hypotension pressure
• Poorly controlled hypertension
• A new dysrhythmia
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Organ Transplant DisordersOrgan Transplant Disorders
• Liver transplant− The loss of function causes rapid deterioration.
− Watch for infection.
• Kidney transplant− Infection is a major concern.
− Recipients tend to develop hepatitis C and later liver disease.
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Organ Transplant DisordersOrgan Transplant Disorders
• Lung transplant− Usually performed unilaterally
− Signs of rejection may include:• Cough
• Dyspnea
• Rales
• Decrease in oxygenation
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Organ Transplant DisordersOrgan Transplant Disorders
• Pancreas transplant− More complications and a lower survival rate at
1 year than other transplants
− Exocrine component is usually drained into the bladder, along with the bicarbonate
− Infection and rejection are common problems.
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Organ Transplant DisordersOrgan Transplant Disorders
• Assessment− Be aware of subtle signs and symptoms.
− Signs and symptoms vary.
− Consider calling the transplant center for any questions.
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Organ Transplant DisordersOrgan Transplant Disorders
• Management− Priorities:
• Organ transplanted
• Medications
• Recognition of infection or rejection
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Organ Transplant DisordersOrgan Transplant Disorders
• Management (cont’d)− Understand how medications will interact and
how they will be metabolized.
− Monitor for infection or organ rejection.
− Consider transport to the transplant facility when possible.
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Patient EducationPatient Education
• Anaphylaxis− Avoid the antigen.
− Notify all health personnel.
− Wear identification tags or bracelets.
− Carry an anaphylaxis kit.
− Report symptoms early.
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Patient EducationPatient Education
• Collagen vascular diseases and organ transplants− Encourage self-monitoring.
− Consult a physician before taking a new medication.
− Comply with the immunosuppressive regimen.
− Know who to contact.
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SummarySummary
• An antigen is a substance the body recognizes as foreign.
• The immune system is responsible for the antigen–antibody response.
• An allergic response occurs when the body produces the antigen–antibody response when exposed to a normally harmless substance.
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SummarySummary
• Anaphylaxis is an extreme form of systemic allergic response involving two or more body systems.
• A person must be sensitized to an antigen before an allergic or anaphylactic response occurs.
• An anaphylactoid reaction may occur with no previous exposure of the allergen.
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SummarySummary
• Exposure can come from injection, absorption, inhalation, and ingestion.
• Mast cells release chemical mediators to stimulate the allergic reaction.
• Chemical mediators produce signs and symptoms on the skin, cardiovascular, respiratory, neurologic, and gastrointestinal systems.
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SummarySummary
• Skin effects include erythema, urticaria, and pruritus.
• Cardiovascular effects include vasodilation, hypotension, decreased cardiac output, cardiac ischemia, and dysrhythmias.
• Respiratory effects include upper airway edema and stridor, hoarseness, bronchoconstriction, increased bronchial secretions, wheezes, and hypoxia.
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SummarySummary
• Neurologic systems include altered level of consciousness, anxiety, restlessness, combativeness, and unconsciousness.
• Gastrointestinal symptoms include nausea, vomiting, diarrhea, and cramping.
• The assessment should include evaluating the scene, patient history, level of consciousness, upper airway, lower airway, skin, and vital signs.
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SummarySummary
• To treat anaphylaxis:− Remove the offending agent.
− Maintain airway.
− Administer medications.
− Resuscitate with IV fluids.
− Initiate rapid transport.
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SummarySummary
• Epinephrine is the first-line drug therapy.
• Patient education is essential.
• Collagen vascular and other autoimmune diseases may require medications to suppress the immune system.
• It is important to know the treatment priorities for patients with organ transplant disorders.
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CreditsCredits
• Chapter opener: © Jones & Bartlett Learning. Courtesy of MIEMSS.
• Backgrounds: Gold—Jones & Bartlett Learning. Courtesy of MIEMSS; Purple—Jones & Bartlett Learning. Courtesy of MIEMSS; Green—Courtesy of Rhonda Beck; Red—© Margo Harrison/ShutterStock, Inc.
• Unless otherwise indicated, all photographs and illustrations are under copyright of Jones & Bartlett Learning, courtesy of Maryland Institute for Emergency Medical Services Systems, or have been provided by the American Academy of Orthopaedic Surgeons.