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Sunday, February 8, 2009

Reason for why we put latex in common cause: Because there is a rapid increase problem due to the usage of latex rubber gloves in medical field and also increase in atopy. (Davidson College Biology, 2006) Mechanism of Anaphylaxis causation When re-exposed to a specific antigen which cross-links the antigen-specific IgE molecules that bound to the mast cells and basophils, leads to the occurrence of anaphylaxis, which will then undergoes activation and degranulation process. Histamine and tryptase, which performed as mediators, present within the mast cell and basophil will be released in degranulation. The arachidonic acid metabolism in cell membrane produces other mediators, prostaglandins and leukotrienes, which act on receptors to stimulate symptoms of anaphylaxis. This diagram illustrates each step of immunological mechanism for anaphylaxis and explanation is provided below the diagram. Diagram taken from Anaesthesia UK (2004). Explanation on Immunological Mechanism of Anaphylaxis: Step 1: Antigen-presenting cell internalizes antigen. Step 2: The APC processes the internalized antigen. Step 3: The APC presents the processed peptide to CD4+ T lymphocytes via MHC II. Step 4: After the peptide is presented, the T cell differentiates into TH2 lymphocytes and produces IL-4, IL-5, IL-9, and IL-13. Step 5: IL-4 and IL-13 cause B cell immunoglobulin isotype switching to IgE. Step 6: The circulating IgE binds to the IgE receptors on mast cells. Step 7: Antigen similar to the original antigen cross-links the mast cell surface-bound IgE, resulting in cellular degranulation. Degranulation releases histamine, tryptase, and other mediators that produce the symptoms of anaphylaxis (Anaesthesia UK, 2005). This diagram show how the mast cell is activated which leads to degranulation. (Adapted from Ewan, 1998) The Effect of Mast Cell Activation on Different Tissues This diagram illustrates how degranulation of mast cells affects various tissues in the body. (Adapted from Janeway, 2005) Reference: 1. Davidson College Biology (2006). Anaphylaxis. Retrieved on February 6, 2009. From http://images.google.com.sg/imgres?imgurl=http://www.bio.davidson.edu/courses/immunology/Students/spring2006/Witcher/pic1.jpg&imgrefurl=http://www.bio.davidson.edu/courses/immunology/Students/spring2006/Witcher/Anaphylaxis.html&usg=__8iH5oJtiulWaOzlrN8ZdCECmeG8=&h=222&w=312&sz=15&hl=en&start=6&tbnid=iBzFBj02mvPr3M:&tbnh=83&tbnw=117&prev=/images%3Fq%3DAnaphylaxis%26gbv%3D2%26hl%3Den%26sa%3DG 2. Anaesthesia UK (2005). Management of Latex Allergy. Retrieved on February 6, 2009. From http://www.anaesthesiauk.com/article.aspx?articleid=100086 3. Ewan,Pamela. "ABC of Allergies:Anaphylaxis" British Medical Journal 316 (1998): 1442-1445. 4. Janeway, C.A., Travers, P., Walport, M., Schlomchik, M. Immunobiology 6th Ed: The Immune System in Health and Disease. New York: Garland Publishing, 2005. BY KYM

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Friday, February 6, 2009

2. Causation of Anaphylaxis Antigens which are referred to allergens, are large molecules (usually proteins) that can be found on the surface of living organism (cells, viruses, fungi, bacteria) and non living substances (toxins, chemical, drugs and foreign particles). Anaphylaxis can occur in response to any allergen. When a patient is intact with an antigen, an allergic reaction will occur immediately. The body immune system recognizes these antigens, and will produce antibodies to destroy them. The common causes include foods, and drugs (e.g. penicillin) insect venoms, penicillin, horse serum (used in some vaccines), occasionally immunotherapy (i.e. injection of allergen to which a person is allergic, in order to treat allergic diseases). The rare causes are towards pollens and other inhaled allergens. Some people have an anaphylactic reaction with no identifiable cause (Idiopathic). Certain allergens stimulate production of IgE antibodies which binds to mast cells and basophils. These cells are activated by binding of antigen to the IgE, which results in release of cytoplasmic granules from mast cells and basophils (e.g. histamine). Mast cell products increase vascular permeability and constrict bronchial smooth muscle. In some unfortunate individuals, it may cause circulatory collapse and death. The main treatment is administration of adrenaline (epinephrine). Retrieved on Febuary 6, 2009 from Emergency Medical Secvices Agency, MET DST With references to: Lara. Hand & Jo. S, R. J. Mullins BY JESSLIN

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2. Causation of Anaphylaxis Anaphylaxis is commonly triggered by food, insect venoms or medication; with a variable proportion of patients experiencing idiopathic anaphylaxis (extensive evaluation fails to identify an underlying cause). In children, food allergy is the common cause, which is responsible for approximately 80% of anaphylaxis reactions identified by the emergency department studies conducted. However, when comparing to children, foods are only implicated in 20-30% of the adults’ anaphylaxis cases. This difference is reflected in mortality statistics: median ages for lethal reactions to foods and to insect venoms or medications are 22–24 years and 55–67 years, respectively (Simon, Raymond and Michael, 2006). Common causes leading to onset of anaphylaxis include: · Foods (e.g. peanuts, tree nuts, eggs, seafood, and dairy products) · Insect stings (commonly honeybee and wasp) · Medications (antibiotics, non-steroidal and anti-inflammatory drugs) · Latex Other causes that are less common include: · Physical triggers (e.g. exercise, cold) · Biological fluids (e.g. transfusions, immunoglobulin, anti-venoms, semen) · Tick bites · Hormonal changes: breastfeeding, menstrual factors · Dialysis membranes (haemodialysis-associated anaphylaxis) · Hydatid cyst rupture · Aeroallergens: domestic/laboratory animals, pollen · Food additives: monosodium glutamate, metabisulfite, preservatives, colours, natural food chemicals · Topical medications (e.g. antiseptics) BY TONG Reference: The Medical Journal of Australia

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3. Anaphylaxis management Acute management 1. Remove allergen (e.g. suspected medication or diagnostic contrast material from patient’s mouth) 2. Place patient in supine position (or left lateral position for vomiting patients) 3. Give intramuscular adrenaline (intramuscular dose can be repeated after 3-5 minutes if required) 4. Resuscitate with intravenous saline (20mL/kg body weight, repeated up to a total of 50 mL/kg over first half an hour) 5. Support airway and ventilation 6. Give supplementary oxygen by face mask at highest possible flow rate (>6L/minute) BY SIEW KIM ______________________________________________________________ Long term management 1. Specialist assessment 2. Provision of a written anaphylaxis action plan 3. Anti-histamines should be at hand for all patients 4. Avoid any medications that patient are at risk of that will complicate management 5. Patients are trained to recognize early warning symptoms and to carry self-injectable adrenaline (EpiPen) after being trained in its use 6. Identification and avoidance of triggers and cofactors, if possible. Common triggers of anaphylaxis include food, stinging insects and medication. While common cofactors are exercise, alcohol consumption and taking ~*NSAIDS ~*Non-steroidal anti-inflammatory drug BY KYM, TONG, JESSIN ______________________________________________________________ Food: Anaphylaxis patients should be referred to an allergist as detailed history needs to be taken to identify possible allergen. Skin prick tests is use for confirmation whenever there is doubt about the identity of allergen. Stinging insect: Venom immunotherapy can be carry out to reduce the risk of anaphylaxis from repeated stings and is also associated with an improved quality of life compared with carrying an EpiPen alone. Exercise: Patients whom exercise is a co-factor are best advised to premedicate with H1 and H2 antagonists, carry injectable adrenalin, not to exercise alone and consider carrying a mobile phone. BY KYM ______________________________________________________________ Retrieved on 01 Febuary 2009 from The Medical Journal of Australia Allergy Capital - Anaphylaxis With reference to National University Hospital

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When a patient faces with anaphylaxis reaction, there is a need of using injectable adrenaline (EpiPen) as their first aid because it helps to relieve by treating the symptoms. The use of epipen is shown in the video below.. It is to let you have a clearer view on how to use it when early symptoms are shown. Some early symptom warning includes: Sensations of warmth, itching especially in axillae and groins feeling of anxiety or panic When severe, hives, swelling, shortness of breath will occur. For more symptoms of Anaphylaxis, please go first entry for reference. BY JESSLIN Website: Youtube - Using Epipen BY JESSLIN AND KYM

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Clinical features of Anaphylaxis: Mucocutaneous:  Rhinitis  Conjunctival erythema and tearing  Flushing  Itch  Urticaria  Angioedema Abdominal/pelvic  Nausea*  Vomiting*  Abdominal pain  Pelvic pain (described as being “like uterine contractions”)  Delayed vaginal discharge Neurological  Vascular headache (typically described as “throbbing”)  Dizziness*  Collapse, with or without unconsciousness*  Confusion†  Incontinence* Respiratory/chest  Dysphagia and stridor due to upper airway angioedema†  Throat and/or chest tightness  Dyspnoea*†  Cough  Wheeze†  Cyanosis*† Cardiovascular  Palpitations  Tachycardia  Bradycardia (relative or absolute)  ECG changes (T and ST changes)  Hypotension*†  Cardiac arrest*† ECG = electrocardiogram. * These features are associated with hypotension.9 † These features are associated with hypoxia.9 Management: Anaphylaxis is usually a disorder for which the risk of relapse is chronic but the event itself is unpredictable. The mainstays of long-term management of anaphylaxis include: · Specialist assessment. · Identify and avoid triggering and cofactors, if possible. Common triggers of anaphylaxis include food, stinging insects and medication. Exercise, alcohol consumption and taking NSAIDS are common cofactors. · Avoid medications that may complicate management. · Train patients to look for early warning symptoms and to carry self-injectable adrenaline (EpiPen) (after being trained in its use). · Provision of a written anaphylaxis action plan. · Identify at-risk patients with a MedicAlert bracelet and entry of an allergy alert into hospital or health care network clinical information systems. References: -Simon G A Brown, Raymond J Mullins & Michael S Gold. (2006). MJA Practice Essentials — Allergy. Retrieved July 18, 2006, from http://www.mja.com.au/public/issues/185_05_040906/bro10212_fm.html#0_i1092246 BY XIAOTONG

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Thursday, January 29, 2009

In our first entry, we're going to tell you more about 1. with relation to the clinical features 2. the mechanisms involved in causation 3. and its management. Anaphylaxis is a serious, immediate and life threatening allergic reactions. The common causes of anaphylaxis are food, medication, insect stings and latex. These allergic responses includes swelling, lowered blood pressure, dilated blood vessel and hives. In serious cases, the person will go through a state of shock. If it is not treated immediately, it can be fatal. PS: Latex is the colorless or milky sap of certain plants, such as the poinsettia or milkweed, that coagulates on exposure to air. Hives also known as Urticaria, occurs when the body are in a state of hypersensitivity reaction. They are itchy, swollen, raised areas of skin (patches/ bumps). Anti histamine may suppress the effects of hives. Retrieved on Febuary 5, 2009 from MedicineNet, Inc. BY JESSLIN ______________________________________________________________ 1. Anaphylaxis clinical features There is variation in clinical presentation. Typically, symptoms develop within minutes of exposure to the allergen. Occaionally, the reaction comes on after a few hours. However, up to 20% of the patients develop a late response up to 24 hours after exposure. Clinical features of Anaphylaxis MILD: Flushing of skin Uticaria (Hives) Itching Watery, red eyes MODERATE TO SEVERE: Angio-edema Abdomnal pain and cramps, Nausea and vomiting Difficulty in breathing & swallowing Weakness Swelling of eyes, face, or tongue Hypotension Wheezing Dizziness, sudden/vascular collapse Retrieved on January 29, 2009 from National University Hospital, Australian Prescriber, Emergency Medical Services Agency BY JESSLIN ______________________________________________________________ Detailed research on clinical features of anaphylaxis was done and tabulated in table form as shown below (Click on the image for a larger and clearer image) Retrieved on 01 Febuary 2009 from The Medical Journal of Australia With reference to National University Hospital, Australian Prescriber BY SIEW KIM Terminologies ________________________ Mucocutaneous - relating to the skin and a mucous membrane Neurological - nerves and the nervous system - Angio-edema: an allergic skin disease characterized by patches of circumscribed swelling (similar to hives appear under skin) - Dysphagia: condition in which swallowing is difficult or painful Stridor: a harsh respiratory sound due to any of various forms of obstruction of the breathing passages Dyspnoea: difficult or labored respiration Cyanosis: A bluish discoloration of the skin and mucous membranes resulting from inadequate oxygenation of the blood. - Palpitations: Irregular, rapid beating or pulsation of the heart. Tachycardia: Excessively rapid heartbeat. Bradycardia: A slow heartbeat rate, usually less than 60 beats per minute. BY JESSLIN - _______________________________________________________ LAST UPDATED - 5th FEBUARY 09