Alexander ch27 lecture

Copyright © 2017, 2012 Pearson Education, Inc. All Rights Reserved.
Advanced EMT
A Clinical-Reasoning Approach, 2nd Edition
Chapter 27
Immunologic Disorders

• Applies fundamental knowledge to provide basic
and selected advanced emergency care and
transportation based on assessment findings for
an acutely ill patient.
Advanced EMT
Education Standard

1. Define key terms introduced in this chapter.
2. Explain the importance of being able to recognize and
treat anaphylactic reactions.
3. Describe the pathophysiologic process by which
exposure to an antigen results in anaphylaxis.
4. Recognize the signs, symptoms, and history associated
with anaphylaxis.
Objectives (1 of 4)

5. Explain the life-threatening mechanisms of anaphylaxis,
including airway compromise, impaired ventilation and
oxygenation, and impaired perfusion.
6. Describe the effects of excessive histamine release on
the body.
7. Describe the difference between an anaphylactic and an
anaphylactoid reaction.
8. Apply knowledge of substances that commonly cause
anaphylactic and anaphylactoid reactions to develop an
appropriate index of suspicion for these conditions.
Objectives (2 of 4)

9. Discuss each of the ways that an antigen can be
introduced into the body.
10.Differentiate between patients who require prehospital
treatment with epinephrine and those who do not.
11.Explain the importance of limiting exposure to the antigen
as a step in the treatment of the patient with an allergic or
anaphylactic reaction.
12.Describe the roles of airway management, fluid
administration, and medications in the treatment of
allergic and anaphylactic reactions.
Objectives (3 of 4)

13.Given a variety of scenarios of patients with allergic and
anaphylactic reactions, implement an appropriate
treatment plan for each.
14.Explain the necessity of ongoing evaluation of the patient
having, or at risk for, an anaphylactic reaction.
15.Recognize conditions that compromise immunity.
16.Describe the basic pathophysiology of common
autoimmune/collagen vascular diseases.
17.Describe considerations for patients living with
transplanted organs or tissues.
Objectives (4 of 4)

• Nonspecific and specific defenses against disease
• Protects from multitude of pathogens encountered
every day
• When protection against disease fails, illnesses
that normally would not pose serious risk can be
life threatening.
Introduction

Think About It
• What should Erin and Dale consider in the scene
size-up for this situation?
• What findings would confirm an allergic reaction?
• What findings would differentiate a mild allergic
reaction from an anaphylactic reaction?
• How would the treatment for a mild allergic
reaction differ from that for an anaphylactic
reaction?

Anatomy and Physiology Review (1 of 3)
• Nonspecific defences
– Skin and mucous membranes
– Antimicrobial substances (blood, interstitial fluid)
– Natural killer cells
– Phagocytosis
– Inflammation
– Fever

• Specific resistance (immunity)
• B lymphocytes
• T lymphocytes
• Antigens
• Antibodies
– IgA, IgD, IgE, IgG, IgM

• When an antigen is recognized, histamine,
heparin, and other chemical mediators of
inflammation are released.
• Inflammatory response to histamine and heparin
usually localized and beneficial. In anaphylaxis,
responses are systemic and exaggerated.

Figure 27-1
Life-threatening responses in anaphylactic reaction: bronchoconstriction, capillary
permeability, vasodilation, and an increase in mucus production.

Assessment and Management (1 of 4)
• Scene size-up
– Do not enter area with swarm of bees or wasps.
– Determine number of patients.
– Request resources.
– Ensure patient no longer in contact with allergen.

• Look for clues to anaphylactic reaction.
– Swelling of face and tongue, hives, stridor, and
wheezing
• Nature of illness and chief complaint
• Onset of anaphylaxis usually begins
in 30–60 seconds.
– More rapid the onset, the more severe the reaction.

• Primary assessment
– Assess airway.
 Stridor
 Swelling in airway
– Use manual maneuvers and bag-valve-mask.
– Sign of respiratory distress
– Observe for hypoperfusion.
 Urticaria

Figure 27-2
(A) Urticaria (hives) on a patient's neck. (SPL / Science Source)

• Anaphylaxis treatment
– Albuterol
– Assisted ventilation
– Administration of epinephrine
 Duration of action is short: 10 to 20 minutes
 Powerful effects on cardiovascular system
– Intravenous fluids

Think About It
• Anaphylaxis is life threatening.
• Patient will have a problem with airway, breathing,
and circulation.
• Mental status may be altered, and hypotension
and tachycardia are likely.
• Often, history of anaphylaxis and known history of
exposure

Allergies and Anaphylaxis (1 of 7)
• Hypersensitivity reactions: allergic and
anaphylactic reactions
– Body exposed to antigen (allergen)
– Sensitization
• Common causes of immediate hypersensitivity:
– Drugs, foods, insects

Figure 27-3
Angioedema of the tongue. (© Edward T. Dickinson, MD)

• Antigens enter body in a variety of ways.
– Ingestion (foods, medications)
– Inhalation (pollen)
– Injection (insect venom, medications)
– Skin contact (poison ivy, latex)
• Similar types of reactions
– Anaphylactoid
– Angioedema

• Signs and symptoms of anaphylaxis
– Peripheral vasodilation; increased vascular
permeability
– Constriction of bronchiolar/gastrointestinal muscle
– Itching, hives, edema
– Distributive and/or hypovolemic shock
– Airway obstruction (hoarseness, stridor, complete)

• Medical identification jewelry that identifies
allergy
• May carry epinephrine autoinjector for
self-administration of epinephrine

Figure 27-4
Epinephrine autoinjectors. (A) EpiPen autoinjectors for infant/child and adult. (B) Twinject
autoinjectors for infant/child and adult.

Table 27-2
Signs and Symptoms of Allergic Reactions
Mild Allergic Reaction Anaphylaxis
Onset Usually slower and more gradual than
anaphylaxis
Usually rapid, often within 30 to 60
seconds of exposure, but up to one
Hour
Skin Itching, hives Itching and hives, may be
widespread; diaphoresis, may be
flushed; cyanosis with severe
respiratory Involvement
Angioedema Mild May be severe enough to cause
airway obstruction; stridor indicates
significant partial airway obstruction
Mental status Normal, may be anxious Anxiety, confusion, decreased
responsiveness
Lungs May have mild or scattered wheezing May have significant wheezing in all
lung fields
Vital signs Normal Hypotension, tachycardia, weak
peripheral pulses, tachypnea,
respiratory distress
Gastrointestinal system Nausea, increased peristalsis Nausea, vomiting, diarrhea

• Assessment and management
– Nonrebreather mask (ventilations adequate)
– Bag-valve-mask (ventilations inadequate)
– Epinephrine by protocol

• Assessment and management (continued)
– Start IV.
– Nebulized albuterol (levalbuterol) treatment should be
administered to treat bronchospasm.
– If protocols allow, diphenhydramine (Benadryl) can
be used.

• Signs and symptoms of allergic reactions—body’s
attempts to rid the antigen/prevent further
exposure
– Coughing, sneezing, and watery eyes work to remove
the antigen.
– When antigens are ingested, increased peristalsis,
vomiting, and diarrhea can occur.
– Respiratory exposure—slight bronchoconstriction

Immunocompromise
• Immunocompromised patients are at risk for
infectious diseases and cancers that are normally
rare.
• Assess for signs of infection
– Fever, cough, unexplained weight loss, night sweats

Think About It
• Patients can be immunocompromised for a variety
of reasons:
– Cancers that affect the bone marrow
– Medications
– Recipients of organ transplants
– HIV/AIDS
– At risk for infectious diseases and cancers that are
normally rare

Autoimmune Diseases
• Immune system fails to recognize molecules in
body as “self” and destroys them, affecting
function of tissues involved.
• Treatment: suppress immune system
• Rheumatoid arthritis, psoriasis, systemic lupus
erythematosus (SLE), Graves’ disease, Crohn’s
disease, multiple sclerosis (MS)

Table 27-3
Selected Autoimmune Diseases
Disorder Description
Rheumatoid arthritis A collagen vascular disease that affects the joints. Smaller joints, such as those in
the hands, usually are affected first, but other joints are affected with time. There is
joint pain, swelling, and stiffness with eventual deformity and loss of use. The
patient also may experience fatigue, weight loss, and fever.
Other organs can be affected. The disease is progressive, but patients can have
long periods of remission with flare-ups from time to time.
Psoriasis Rapid cell reproduction results in patches of scaly, thick skin with periods of
worsening and improvement. Common areas affected include the elbows, knees,
and scalp, but the lesions can be widespread in severe disease.
Scleroderma Involves inflammation of the skin and blood vessels with formation of scar tissue.
The skin and other organs become fibrotic from scar tissue.
Patients have flare-ups and periods of remission.
Systemic lupus
erythematosus
(SLE)
More common in women (90 percent of patients). Signs and symptoms include
fatigue, fever, joint pain, and rash. The disease can also affect the kidneys, heart,
and lungs.

Chapter Summary (1 of 4)
• Anaphylaxis: severe hypersensitivity reaction
– Vasodilation
– Increased capillary permeability
– Bronchoconstriction
– Increased gastrointestinal motility

• Anaphylaxis: severe hypersensitivity reaction
(continued)
– Urticaria
– Airway edema
– Wheezing
– Hypovolemia

• Patients with anaphylaxis may require advanced
airway management.
• Airway and ventilation can deteriorate quickly.
• Primary treatment: epinephrine
• Patients may require fluid resuscitation.

• Patients with immunosuppression are at increased
risk for infectious disease and cancer.
• Patients with autoimmune diseases have
condition in which immune systems fail to
distinguish between self and nonself molecules;
results in destruction of affected tissues.

Alexander ch27 lecture

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