Anaphylaxis can certainly be fatal. Fortunately, as opposed to allergic reactions, they are far less common. Just to clarify terms for the sake of this post I posit the following. Anaphylaxis is life threatening systemic illness where an allergic reaction is more localized. Again, that’s for the sake of this post, not a scientific definition.
We get sent to a fair number of “Anapylactic Reaction” calls and an even larger number of “Allergic Reaction” calls. Fortunately, both are over triaged in our system and probably in most. I can’t give you even an estimate of the number of allergic reactions I’ve responded to and treated, mostly with Benadryl and Albuterol, but I can tell you how many true anaphylactic reactions I’ve responded to. Four. Over about 15 years working as a medic. Again, these are systemic, at least potentially life threatening, events that required the above mentioned drugs as well as Epinephrine (SQ) and IV fluid boluses.
From my memory, here they are with as many details as I can recall.
#1. 45 y/o male with anaphylaxis from eating Shrimp. He knew he shouldn’t as he had experienced reactions before and been hospitalized. In addition to hives and itching, he had profound hypotension. No airway compromise involved, which was a bit of a surprise. Benadryl, 0.5 mg Epi SQ, and 500ml of Normal Saline and he improved quite a bit.
Just based on his age and the fact that he got Epinephrine, he bought an overnight admission.
#2. 39 y/o female who decided that it would be a good idea to take Tetracycline that expired four years BEFORE she took it. Bad idea, that. Some antibiotics tend to become toxic after their expiration. Hives, itching, respiratory distress, essentially atensive. A very sick patient, one of the few times I thought a young, otherwise healthy, patient was going to die in front of me. We treated her pretty much as we did patient #1, and she lived. Which was fortunate because she was a single mom with a twelve year old daughter.
#3. 40 something y/o female that we were called to a reception hall to for. She too was pretty sick and had no history that she could tell us which would help us identify the allergen. To make matters worse, there was a drunk there claiming to be a doctor shouting contradictory orders to us. We ignored him as we tried to figure out what was going on, but it wasn’t easy as the “doctors” even more drunk wife was screaming at us that her husband was a “fucking doctor and you better do what he tells you”. Cooler heads (hotel security) prevailed and the would be helpers were escorted away. Oh, the patient was sick AND drunk, which was a pleasure as you can imagine. I forget the medical details of the call other than that we gave her some fluids and she got better.
#4. 30 something y/o female, of the very attractive variety. Sometime at 0-Dark-Thirty she and her boyfriend decided to experiment with intercourse in a “non traditional” orifice. Practicing safer sex they used a latex condom. Nature not exactly intending that particular orifice for penile insertion they decided that some form of lubrication was in order. Searching around the apartment they found a jar of a well known petroleum based lubricant. In case you were wondering use of petroleum based lubricants, either brand name or generic, is a bad idea. Rectal mucosa being what it is, the uptake was pretty quick and this is when the young lady discovered that she had an allergy to latex. Again, respiratory distress, hypotension, hives, and itching.
In case you’re wondering, she did fine.
As you can see, these are four cases that stick out in my ever so quickly aging brain. Which would indicate that it’s not very common, but is serious when it occurs.
The Cleveland Clinic has some very good information on the topic, but even they can only say that somewhere between 500-1,000 deaths occur nationwide yearly.
This brief page from Britain indicates about twenty deaths per year.
All of which has me wondering if schools, advocates, and parents are overreacting to peanut allergies in children. Maybe overreacting is the wrong word and overstating is the correct one. I’ll avoid using hysteria, though. I certainly don’t underrate the severity of particular incidents, but I have to question the rate of occurrence. Apparently, I’m not the only one. This article from the Boston Globe a couple of years ago seems to be asking the same question.
As the article states that about the same number of people die each year from lightening strikes as from peanut allergies.
It seems that there is more hysteria than fact around this topic and some schools and other organizations are in fact overreacting by banning anyone from having nut containing products on the off chance that someone does in fact have an allergy.
I have to wonder how many people have mistakenly treated themselves or someone else with an Epi Pen and if there is more danger from Epinephrine overdose than from peanut allergies.
Like any other medication, Epinephrine is not risk free although we don’t seem to hear about the risk, especially in people over 40, or those with cardiac history, some other factor that possibly could make the cure more dangerous than the illness.
Do any of my readers have any hard facts on this. Frankie, you’re a doctor, what do you think?
I don’t have any specifics to add except that I can’t remember a single true anaphylaxis case in my time in the field. Nor can I think of one who ended up as one of my donors.I do think you’re going to be savaged by the howler monk–er, I mean, doting parents, who will question your humanity as you compare their child’s very life with your ability to eat peanuts unfettered. Whether or not the little ankle biter has true anaphylaxis is beside the point, of course.
I can’t give you hard facts and data, but I can give you some subjective information. My brother is around 50. He’s severely allergic to bee stings. The last time he was stung, he spent time in the hospital, overnight if I recall correctly. That was at LEAST 18 years ago. He’s walked around for nearly 20 years without being stung, and he is constantly outdoors. He’s aware of the risks, and doesn’t antagonize bees, but he doesn’t spend a lot of time worrying about it. I think people have a tendency to over dramatize anything that happens to them anymore. It’s not a sunburn, it’s sun poisoning. It’s not this simple thing, it’s some other deadly disease. Part of it can be attributed to medical shows where the answer is always something way off the wall or exciting, and part of it is that people have started to believe that life can be lived without pain or discomfort, and anything that takes them out of their little pleasure land must be some horrible thing. Therefore, they’re willing to believe that the smell of a peanut butter sandwich can knock someone over dead from 100 feet away, and anytime they have a tingle in their mouth they must have eaten something that they’re allergic to. Forgive me if I rambled, it’s way too late to be up. (Oh horrors, I must have that rare disease that eats away at the part of your brain that lets you sleep!!!!)
PJ, you raise an interesting if obscure question. If someone does die from Anaphylaxis what effect does that have on organ donation? Phillip, welcome to the blog. I think you raise a good point regarding hyperbole about hypersensitivity. The case of the Canadian girl who died after kissing her boyfriend who had recently had a peanut butter sandwich is extreme, but it was presented as fairly typical of such allergies. My son has a severe allergy to bees as does your brother. We had Epi Pens in the house when he was young, just in case. What we didn’t do was restrict his activities to keep him away from bees. I do have to wonder if there has been a substantial increase in the use of peanut oil in commercial food preparation. Which might explain part of the reported increase in reactions.
I’ve had two sho nuff anaphylaxis cases in the field, and treated an untold number of lesser reactions.Both of my true anaphylaxis patients improved with Epi and fluid boluses.At PGHNSTRACH, they’d freak out at every little case of urticaria as if it were a dire emergency. We gave lots of SQ Epi, and I can’t honestly say that any of them really needed it. The docs seemed to think it was a dandy way to clear up a rash.Yeah, I know.They also seemed to think that SQ was a better route than IM, for some reason.I was not impressed.
Anaphylaxis has little effect on donation. Brain damage and/or brain death would be caused by hypoxia, but once the effects of anaphylaxis were reversed, the only concern would be the amount of hypoxia the organs suffered. We routinely recover organs from patients who suffered cardiac arrest and had a subsequent return of spontaneous circulation but suffered a severe hypoxic brain injury in the process. The degree of hypoxic injury is the determining factor in whether or not the organs are transplantable.
Thanks for the information PJ. AD, I’ve seen people overreact to minor allergic reactions by slamming Epi Pens into victims legs and other body parts. I heard a story last week about a person who jammed an Epi Pen into her own thumb. Now that hurts! Our general approach is to give Albuterol, followed by IV Benadryl. That’s for patients with some visible sign of a reaction.
I have seen one, true anaphylaxis in the field and one that wasn’t anaphylaxis, came into the hospital with an allergic reaction to substance unknown and was given Epi. She had a SEVERE reaction to the Epi…heart rate jumped to over 240, we really thought we’d lose her there for a minute. She happened to be a 24y/o OB nurse in our hospital. That was a bit scary…The one I treated in the field reversed rapidly with the epi and fluids….interestingly enough, it was a 90 y/o who had experienced a new onset of allergies and was under a doctors “elimination” care….as I was getting ready to give her the benadryl, her 70 y/o daughter began screaming..OH GOD NO…..that is what we think she is allergic to…After the elderly lady (90) was able to talk to me again, she said she had used this new cream on her bad, flaky skin (left over from a previous reaction causing rash and swelling). Come to find out, after I read it to them both, it was……benadryl cream…Had never seen anyone allergic to benadryl before or since.that’s my penny worth
“Elimination” care, huh? Sure sounds like it. I think Epi should be given only after a trial of Benadryl, Albuterol, and maybe some fluid. Most allergic reactions are scarier looking than they are serious.
I’m a 20 year old female. I had a true anaphylactic reaction a few months ago that required calling the paramedics. I had taken the drug several times before, but this time it caused trouble breathing, head to toe hives, swelling of my lips and severe abdominal cramping. I understand that a lot of people are paranoid about virtually any small allergy…but every time I start to swell or my skin gets irritated it’s extremely difficult for me not to worry about having another bout of anaphylaxis.
I’m one of those howler monkeys – er – concerned parents of a kid with PA, and my son did have a genuine anaphylaxtic attack – airway closing, bp drop, the works. We were lucky to get him to the ER in time – longest 5 min of my life. The thing is, his previous reactions were just a little redness around the mouth and a cough. (We didn’t have an epipen).I know that the overall rate of true anaphylatic attacks is very low in the general population, but I’m not really concerned about the general population, just my kid and those like him. And according to the conclusions of at least one study, “Dangerous anaphylactic reactions to food occur in children and adolescents. The failure to recognize the severity of these reactions and to administer epinephrine promptly increases the risk of a fatal outcome.”http://www.ncbi.nlm.nih.gov/pubmed/1294076?dopt=AbstractFrom what I’ve been told about epinephrine, overdose from the amount in an epipen in a healthy child is extremely unlikely. (Intrevenous is different). Does anyone know of any studies showing differently (not being snarky – I really want to know).Thanks!
Tracy, I’m not suggesting that if you have an anaphylactic reaction you can’t get seriously ill or die. What I am saying is that there is a fair amount of over reaction to the level of risk to the general population. Epinephrine is NOT the first line drug for a reaction. Benadryl and Albuterol would be the first drugs given in either an ED or by paramedics unless the patient initially presented with severe signs and symptoms. Reactions tend to, but don’t always, get more severe with each episode. My son has had several reactions to bee stings, so we had Epipens in the house in case something happened and I wasn’t around. That’s only prudent and you’re wise to have them.
“Epinephrine is NOT the first line drug for a reaction. Benadryl and Albuterol would be the first drugs given in either an ED or by paramedics unless the patient initially presented with severe signs and symptoms.”This makes sense for medical personel, who are trained to evaluate the severity of symptoms and also have access to resuscitation equipment, but the last part of your original post was aimed at the layperson trying to decide whether to use an epipen or not.We are NOT talking about the general population. These are folks who have already been determined by a doctor to be at risk for anaphylaxis and prescribed an epipen.Your claim that the epipen might be more dangerous than the reaction itself for these patients is just not supported by medical research. Delay in administrating an epipen has been a major factor in deaths from anaphylaxis. It just doesn’t do much good after cardiac arrest has occured.My biggest fear is that one of my son’s caregivers is going to “wait and see” whether his reaction is really bad enough to risk an epipen. In the meantime, his blood pressure will be dropping rapidly and his throat closing up. There’s only a small window that an epipen will help, and speculating about the “dangers” of using an epipen on a patient it was prescribed for is frankly irresponsible.Sorry for sounding so harsh, but as you acknowledge, it is prudent and responsible for an allergic person to have an epipen – but I would have to add – and to use it when needed.
FYI – here is an anaphylaxis grading chart that I’ve found useful. Based on my son’s history, I would give him an epipen for any of the bolded symptoms, or if any two body systems are affected immediately after food ingestion. http://pediatrics.aappublications.org/cgi/content/full/111/6/S2/1601/T2And for non-medical folks, here it is in English:http://the-clarkes.org/stuff/ana.html
Unlike non medical people, paramedics, doctors, nurses, etc., are accountable for their actions. You can give Epinephrine and if your son has an adverse reaction, people will feel sorry for you. If I give it and he has an adverse reaction, you’re going to sue me. One thing that all of us in medicine are taught (although some people don’t seem to learn it) is that every medicine we give has the potential to cause as much or more harm than it does to help. In the case of Epinephrine, young people have a fairly high tolerance for it’s side effects. As such the parameters for giving it are more liberal than for older people. You may consider not rushing to give Epinephrine irresponsible, but I consider giving a potentially dangerous drug when less dangerous drugs are likely to solve the problem malpractice.
I HAD an anaphylactic reaction to a wasp sting. It was in the 60s, I was a teenager on a pack trip in northern Washington. We were over a day’s hike from a phone. I had gone through multi-year desensitization for bee allergy, and was told that I no longer had to worry. That was fine until I got stung on the face walking along a brushy trail, and rapidly developed trouble breathing. Fortunately, there was an anesthesiologist along with a lot of wilderness medicine experience; he gave me Benadryl and started sharpening his pocket knife in case he had to do a tracheostomy. I guess seeing that worked to dump a bid more epinephrine in my bloodstream. Anyway, my airway stayed open enough. We stopped for a day and then we went on and completed the trip.After that I had a leather worker make up a belt case for a pre-loaded syringe of epinephrine.
i’ve had several anaphylactic reactions(which i would say were mild. i never went to the er, but i should have once or twice), according to the doctor. as of yet, it’s idiopathic. i was concerned that i wasn’t actually having anaphylaxis because the major symptoms i have are dizziness/fainting, nausea, very rapid heart rate (although it feels light… does that make sense?), feeling warm… but none of the typical hives or breathing problems. when it starts, i take a few benadryl because i’m scared to do the epi-pen. since i don’t have to worry about suffocating, i just focus on staying conscious. benadryl has always worked for me – and always within about twenty minutes. what scares me is that all of the side effects of epinephrine seem to be the same symptoms i have! at what point are you supposed to take the epi-pen? that thing scares the heck out of me. not the needle or anything, but the thought of using it when i don’t need it. my allergist literally told me to use it when i thought i needed it. what kind of a marker is that? no wonder people use them when they don’t need them.
Without knowing more details, it’s really impossible to render an opinion. I’d say if the Benadryl, which is the first line treatment we use, works for you, then stick with it.
2/29 anonymous -I’d talk your symptoms over with your doctor, including your fear that the epipen induces the symptoms you experience. Remember, there are two ways that anaphylaxis can kill. Most people know about the breathing problems when the airways swell shut, but for some people, anaphylaxis results in rapidly dropping blood pressure and cardiac arrest. In particular, if dizziness/fainting is a typical allergic reaction symptom for you, then I’d be concerned about the later.
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