Anaphylactic Shock

med surg, medical surgical, shock

Video Transcript 

Hey everyone. So in today's video, we're going to be talking about anaphylactic shock. So anaphylactic shock is a systemic type one hyper-sensitive reaction that often has fatal consequences. If untreated the causes are the immune system releases a flood of chemicals that can cause a person to go into shock.

So the pathophysiology of anaphylaxis is when an individual after a re-exposure to an antigen, to which they have a specific IgE antibody. This happens because of the re-exposure. So they, the sensitivity allergen may cross the mass cells or basophil surface bound allergy specific IgE resulting in cellular degranulation as well as a synthesis of mediators, then binding occurs and binding happens at the immunoglobulin E and it binds to the antigen, which provokes the allergic reaction.

Then activation occurs. So the antigen bound to IgE activates certain receptors on the mass cell and basophils, which then leads to inflammatory mediator release, which leads to the release of things such as histamine. Once histamine is released many of the signs and symptoms of anaphylaxis occur. And this happens because histamine binds to its receptors. At the H1 receptor mediated, pruritis, tachycardia, and Bronciospasms can occur. Then prostoglandin D2 mediates, bronchiospasm, and vascular dilation and manifest as anaphylax. And leukotriene and C4 is converted to LTD four and LTE, which are the mediators of hypotension and Bronciospasm, and mucus secretion during anaphylaxis.

In addition to acting as a chemotactic signal for eosinophils and neutrophils, that's a lot of information, but pretty much in summary, you have a re-exposure to an allergen, which binds at the IgE receptor sites and activates certain receptors on mast and basophil cells, which causes this inflammatory mediator release, leading to histamines, releasing and binding at H one receptors.

And that leads to things such as the Bronciospasm, vascular dilation, and runny nose.

All right. So what are some statistics? And that we see worldwide is that 0.05 to 2% of the population is estimated to experience anaphylaxis at some point in life. And it most often happens in young people and females and of people that go to the hospital. 0.3%. Do you die? And. It occurs one in 50 Americans and they found that 13% of the cases of anaphylaxis occur at hospitals or clinics 6.4 at a relative or friend's home, 6.1 in the workplace and 6.1 in restaurants and 2.6 at school.

All right. Let's get into the different causes. So these are all things that can cause allergies and people. We have food allergies, medication allergies, insect allergies, latex allergies, the most common. Type that is triggered in children is food allergies. These are things such as peanuts, tree, nuts, fish, shellfish, and milk.

When we have medication allergies, these can include antibiotics, aspirin, different over-the-counter pain relievers. Also seen with, contrast in the hospital for imaging. Insect bites can be stings from bees or wasps, Hornets or bites from fire hands. And also people can have latex allergies, which can develop after an exposure to latex

so the clinical manifestations of anaphylaxis is the person is going to experience anxiety. This is usually a feeling of impending doom or fright. You might've heard about this when your teachers are in nursing school, they talked about giving IVs blood products or any type of high risk for reaction IV medication.

This is a usual. First warning sign the feeling of impending doom or fright. So if you see that in a question on your test or on NCLEX, that is important to keep in mind too, that a reaction may be coming. So then also you can have skin reactions such as hives, itching, flushing or peril. Shortness of breath, which is from constriction of the airways, a swollen tongue or throat could also be causing wheezing and trouble breathing.

You may also see hypotension so low blood pressure that occurs is one of the major symptoms of shock tachycardia because the heart is compensating through pumping faster, to try to deliver that blood to the organs within the body and dizziness. They may feel like they are going to faint. So how can we prevent anaphylaxis shock from occurring in patients that are already exposed to an antigen or who have developed antibodies to it?

Is to avoid exposure to allergens. So teach patients to avoid foods that they may have allergies to or certain drugs or certain insects bites. They also use Desensitization. If a patient has to receive a drug to which they are allergic, they can prevent the reaction by making sure the patient receives careful desensitization with a gradual increase dose of the antigen or an advanced administration of steroids. So they'll give the steroids before monitoring so they can closely monitor a patient undergoing diagnostic tests that use radioactive contrast media such as a cardiac catheterization.

So complications of anaphylaxis shock, our respiratory obstruction. The trachea may close up due to severe inflammation, which could result in respiratory obstruction, or they can have systemic vascular collapse, which is sudden loss of blood flow to the brain and other organs, which can cause systemic vascular collapse.

So as the nurse, we are going to focus on assessment and diagnostic findings. So because anaphylaxis is primary, a clinically diagnosis, laboratory studies aren't usually required and they're not really helpful. They can do a histamine and tryptase assessment. If the patient is seen shortly after an episode this is a plasma histamine, or a urinary histamine, metabolites, or serum.

Tryptase measurement, which may be helpful in confirming the diagnosis. They can also check 5-hydroxyindoleacetic acid levels. That's a tongue twister. So this is a urinary level that they will measure the amount that is in the urine. They can also test for food allergies. And if they want to identify maybe what is causing these reactions in somebody they'll take a patient medical history and physical exam, and they will do a puncture of a food allergen specific skin test or an in vitro specific IgE test.

And this can be performed and there's an understanding that both false positives and false negatives may occur during this test. So they pretty much just prick your skin and then look for some type of reaction. If you have a reaction that could indicate a possible allergen, then they can also do testing for medication allergy.

So if the patient's history suggests. Penicillin allergy they can do skin testing for this. If they find that it might be appropriate and they can test for suspected insect bites or stings. So if the patient has a history that suggests an insect sting or allergy specific skin test they can perform these as well.

So medical management. So in treating anaphylaxis, who shock, we want to remove the antigen. So removing the causative, antigen, such as discontinuing an antibiotic, this could help to stop the progression of shock. So that is why when you know, you're giving a patient, an IV medication, and, in the question that the patient gets a feeling of impending doom or you're seeing rash or seeing some type of reaction that could be occurring. The first thing you do is stop the medication. You can also administer other medications that will help to restore vascular tone and provide emergency support such as basic life function. You can also do cardiopulmonary resuscitation.

If cardiac arrest does occur or respiratory arrest occurs then you will do CPR. There's also endotracheal, intubation, or a tracheostomy. If you need to establish an airway and IV lines can be placed to provide access to administering fluids and other medications. So pharmacologic therapy, there are two drugs that we use for patients that are having Anaphylactic shock.

And that is epinephrine. It's given for a vasoconstriction reaction in emergency situations an immediate injection of one to 1000 aqueous solution, 0.1 to 0.5 mil liters is repeated every 5 to 20 minutes. Then there is Benadryl, which is administered to reverse the effects of histamine, thereby reducing capillary permeability, and also albuterol.

If there is a bronchiospasm due to a histamine induced bronchiospasm, we can give the patients albuterol. So that's not on the slide. Make sure to add that to your notes. So nursing assessment, we are going to assess for any kind of allergy. This is why, when we do our admission assessments, we are asking, do they have any previous reactions to medications?

Do they have any allergies that they know of? Cause that can help us to prevent these kinds of reactions. We assess the patient's knowledge so we need to know if the, what the patient's baseline level of understanding to previous reactions and the steps that them and their family can take to reduce these exposures in the future.

And also new allergens when they are identified, we want to advise the patient either wear or carry identifications, that name, these specific allergens or antigen. So our nursing diagnoses for patients undergoing anaphylactic shock is impaired gas exchange related to ventilation profusion and balance altered tissue per operation related to decreased blood flow, secondary to vascular disorders due to anaphylactic reaction, inactive breathing patterns related to the swelling of the nasal mucosa wall.

Acute pain related to gastric irritation, impaired skin integrity related to change in circulation. So these are all different diagnoses you can use when you're coming up with your nursing care plans and goals. So these are our goals for the patient. Client will maintain an effective breathing pattern as a evidenced by relaxed breathing at a normal rate in depth. In the absence of adventitious breath sounds, the client will demonstrate improved ventilation as evidenced by absence of shortness of breath and respiratory distress. Client will display hydrodynamics stability as evidenced by a strong peripheral pulse.

With a rate of 60 to a hundred beats per minute with regular rhythm systolic BP within 20 of the baseline urine output greater than 30 milliliters, an hour, warm, dry skin and alert, responsive mental status, the client and significant others will verbalize an understanding of allergic reactions. It's prevention and management client insignificant.

Other will verbalize understanding of need to carry emergency components for intervention. I need to inform healthcare providers of allergies and need to wear a medical alert, bracelet, or necklace, and the importance of seeking emergency care. So nursing interventions, we want to monitor the client's airway and assess for sensation of a narrowed airway.

Are they having trouble breathing? Assessing. Do we hear anything when they breathe in and breathe out, we want to monitor their oxygen nation status. So we can do this with arterial blood gas values, or we can just use an O two sensor when a focus on breathing, instruct the client to breathe slow and deeply.

Like we said, the first sign, you may see some anxiety and when people experience anxiety, they're taking those. Short, like chest breaths, the are not deep breaths. So we want to remind the client to be breathing slowly and deeply positioning. We want to make sure the client is sitting upright. Any question that you get on an exam that is to improve breathing.

Positioning is a big one to remember you want to have the patients sitting up that is going to be the easiest way to breathe. And it provides the maximum amount of chest expansion when they're sitting up. So if they're in respiratory distress, you want them sitting up good way to remember.

This is if we see a patient in respiratory distress, a lot of times they might be in a tripod stand. So that's like they're sitting up, they have their arms on a table or open, and that's they're trying to really like breathe in. So that's how I always remembered that sitting up helps people breathing.

Cause when people struggle to breathe, that's the position their body wants to get in because it allows the biggest amount of chest expands. We want to promote activity, although we do want to encourage adequate rest. We want to make sure to limit activities within the client's tolerance.

So of course, we know that we want patients to get up and move in the hospital to, increase the blood flow and help, with clots and DVTs and things like that. But they're really having trouble breathing. We don't want to encourage too much activity because that's going to require more oxygen for them.

We can also look at hemodynamic perimeters. So monitor the client's central venous pressure, pulmonary artery, diastolic pressure, pulmonary capitally, wedge pressure, and cardiac output and cardiac index. A little bit of a tongue twister. We also want to monitor urine output. The renal system compensates for low blood pressure by retaining water and decreased urine output is a classic sign of inadequate renal perfusion.

So want to make sure that we have that 30 milliliters per hour of urine output, if not, that is a sign of an adequate renal perfusion. So as the nurse, our evaluation is going to look at. Client maintained an effective breathing pattern. They demonstrated improved ventilation. They displayed hemodynamic stability.

They verbalized understanding of allergic reactions and prevention and management, and they verbalized understanding of the need for emergency components for intervention need to inform healthcare providers of allergies, where medical bracelets and the importance of seeking emergency care. So our evaluation is really based on.

Diagnosis and interventions, this may not be what your evaluation is. You can take certain interventions, maybe they don't work. So now our evaluation is, the client hasn't been maintained, effective breathing. So now we're going to do something else. Our interventions are going to change based on our evaluation, but these are just some suggestions.

So discharge and home care guidelines. We want to teach the patient about emergency medications. We want to offer these medications to them. So they may have a prescription for an epi pen and. We want, or maybe an albuterol inhaler, just so they have some tools. If the crisis does reoccur and we want to assist the client and family to identify factors that may lead to a crisis.

So this could be does everyone understand the type of foods that this patient is allergic to, that they shouldn't be around those food foods? Do they understand that. Say for example, it's a peanut allergy that if they're on a plane and somebody opens up a bag of peanuts that could stimulate a anaphylaxis reaction.

And it's not necessarily that the patient needs to eat peanuts. So just teaching like this, because people don't understand this stuff normally. And that is why nurses come in as educators to help them understand inevitably save someone's life because who wants to go on an anaphylaxis reaction on a plane?

That would be horrible. So these are important things to know. So then our documentation. We are going to include our assessment findings of the respiratory rate, the character of the breath sounds. What did they sound like? The quality of the breath that the patient is taking the frequency amount and appearance of secretions, the presence of any cyanosis laboratory findings and mental status.

We also want to indicate any conditions that may interfere with oxygen supply. We want to include the pulse, the blood pressure. We want to document the client's description of pain evaluation or expectations of pain management and what they identify as an acceptable level of pain. One indicate prior medication use.

We want to indicate our plan of care specific interventions who's involved in planning our teaching plan, the client's responses to the treatment teaching and actions performed. We want to indicate our progress towards the desired outcome, what modifications we may have made to this plan and the long-term needs of the patient.

All right. So that is it for this video on anaphylaxis shock. If you guys liked this video, make her make sure to subscribe to the channel and give this video a thumbs up and that's all. Thank you. Bye.