Emergency - Allergic Reactions

8/8/2019 Emergency - Allergic Reactions

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ALLERGIC REACTIONSALLERGIC REACTIONS

in thein theDENTAL OFFICEDENTAL OFFICE



Allergic ReactionsAllergic Reactions

AllergyAllergy is defined as a hypersensitive stateis defined as a hypersensitive state

aquired through exposure to a particular aquired through exposure to a particular

allergen, reexposure to which produces aallergen, reexposure to which produces aheightened capacity to reactheightened capacity to react



Allergic ReactionsAllergic Reactions

Allergic reactions range from mild, delayedAllergic reactions range from mild, delayed

reactions occuring as long as 48 hours after reactions occuring as long as 48 hours after

exposure, to immediate lifeexposure, to immediate life--threateningthreateningreactions that occur within seconds after reactions that occur within seconds after

exposureexposure



Classification of AllergicClassification of Allergic

ReactionsReactions

Type Mechanism Time ExampleType Mechanism Time Example

II AnaphylacticAnaphylactic sec/minsec/min AngioedemaAngioedema

IIII CytotoxicCytotoxic ---- Transfusion rxTransfusion rx

IIIIII ImmuneImmune 66--8hrs8hrs Serum sicknessSerum sickness

complexcomplex

IVIV Cell mediatedCell mediated 48 hrs48 hrs ContactContact

dermatitisdermatitis



Most Common in Dental OfficeMost Common in Dental Office

Type IType I

Immediate Localized or GeneralizedImmediate Localized or Generalized

AnaphylaxisAnaphylaxis -- The Type I allergicThe Type I allergic

reaction is subdivided into several formsreaction is subdivided into several forms

based upon the response based upon the response

Type IVType IV

Contact DermatitsContact Dermatits



Type IType I

Immediate HypersensitivityImmediate Hypersensitivity

Generalized (Systemic) AnaphylaxisGeneralized (Systemic) Anaphylaxis

Localized AnaphylaxisLocalized Anaphylaxis

UrticariaUrticaria

Bronchial AsthmaBronchial Asthma

Food AllergyFood Allergy



AntigenAntigen

A substance that elicits an allergicA substance that elicits an allergic

reactionreaction



AntibodyAntibody

A substance in blood or tissue that respondsA substance in blood or tissue that responds

and reacts with the antigenand reacts with the antigen

(different in structure than the antigen)(different in structure than the antigen)



AtopyAtopy

Clinical hypersensitivity state, subjectClinical hypersensitivity state, subject toto

heredity (asthma, hay fever, etc.)heredity (asthma, hay fever, etc.)



UrticariaUrticaria

Wheals (hives)Wheals (hives)

Smooth elevated patches surrounded bySmooth elevated patches surrounded by

erythematous areaserythematous areas

Pruritus (itching)Pruritus (itching)



AngioedemaAngioedema

Non Non--inflammatory edema involvinginflammatory edema involving

skin, subcutaneous tissue, underlying muscleskin, subcutaneous tissue, underlying muscle

& mucous membranes.& mucous membranes.

Occurs in response to allergenOccurs in response to allergen

Most critical in the larynxMost critical in the larynx



Predisposing Factors in AllergicPredisposing Factors in Allergic

ReactionsReactions

Prior history of allergyPrior history of allergy

Genetic predisposition to allergyGenetic predisposition to allergy

-- atopic patientatopic patient

Patient with multiple allergiesPatient with multiple allergies

Drug that is utilizedDrug that is utilized



Drugs that Cause AllergicDrugs that Cause Allergic

ReactionsReactions

Up to 70% of Allergic ReactionsUp to 70% of Allergic Reactions

PenicillinPenicillin

MeprobamateMeprobamate

CodeineCodeine

Thiazide DiureticsThiazide Diuretics



Other Substances CausingOther Substances Causing

ReactionsReactions

IodinesIodines VaccinesVaccines

InsulinInsulin HeparinHeparin

SalicylatesSalicylates SulfonamidesSulfonamides

OpiatesOpiates Local AnestheticsLocal Anesthetics

Venom from stinging insectsVenom from stinging insects



Antibiotic AllergyAntibiotic Allergy

Highest incidenceHighest incidence

Penicillins (anaphylactic reaction mayPenicillins (anaphylactic reaction may

prove fatal in 15 minutes) prove fatal in 15 minutes)

SulfonamidesSulfonamides

Reactions to erythromycins rarely seenReactions to erythromycins rarely seen



Analgesic AllergyAnalgesic Allergy

Incidence of Incidence of truetrue allergy to narcotics is lowallergy to narcotics is low

"Allergy" is most often a side effect such as"Allergy" is most often a side effect such as

nausea, vomiting, drowsiness, dysphoria, or nausea, vomiting, drowsiness, dysphoria, or

constipationconstipation



Antianxiety Drug AllergyAntianxiety Drug Allergy

BarbituratesBarbiturates --most common but occur lessmost common but occur less

than aspirin and penicillinthan aspirin and penicillin

ReactionsReactions --hives, urticaria, blood dyscrasiahives, urticaria, blood dyscrasia

(agranulocytosis / thrombocytopenia)(agranulocytosis / thrombocytopenia)

Allergy occurs more frequently with a historyAllergy occurs more frequently with a history

of asthma, urticaria, and angioedemaof asthma, urticaria, and angioedema



Local AnestheticsLocal Anesthetics

Reactions occur most frequently with EstersReactions occur most frequently with Esters

Preservatives also cause reactionsPreservatives also cause reactions



Ester DrugsEster Drugs

ProcaineProcaine PropoxycainePropoxycaine

BenzocaineBenzocaine TetracaineTetracaine

Related compoundsRelated compounds

Procaine Penicillin GProcaine Penicillin G

ProcainamideProcainamide



Amide AllergyAmide Allergy

The amide type anesthetic are essentially freeThe amide type anesthetic are essentially free

of allergic reaction whenof allergic reaction when given in their puregiven in their pure

formform

Although true allergy to amide type anestheticAlthough true allergy to amide type anesthetic

is extremely rare, patients haveis extremely rare, patients have

demonstrated allergic reaction to thedemonstrated allergic reaction to the

contents of the dental cartridgecontents of the dental cartridge



IngredientIngredient -- FunctionFunction

Anesthetic AgentAnesthetic Agent -- Conduction blockadeConduction blockade

Vasoconstrictor Vasoconstrictor -- Decrease absorptionDecrease absorption

of local anestheticof local anesthetic

Sodium MetabisulfiteSodium Metabisulfite -- Preservative for Preservative for

vasoconstrictor vasoconstrictor

MethylparabenMethylparaben -- Preservative to increasePreservative to increaseshelf life; bacteriostaticshelf life; bacteriostatic

Sodium ChlorideSodium Chloride -- Isotonicity of solutionIsotonicity of solution

Sterile Water Sterile Water -- DiluentDiluent



Paraben ReactionsParaben Reactions

Preservative found in manyPreservative found in many nonnon--drug itemsdrug items

Allergic reactions to topical anestheticsAllergic reactions to topical anesthetics

are those of contact stomatitis;are those of contact stomatitis;

erythema, edema, ulcerationserythema, edema, ulcerations -- almostalmost

exclusively a dermatologic type reactionexclusively a dermatologic type reaction



Clinical OptionsClinical Options

Determine type of ³allergic´ reactionDetermine type of ³allergic´ reaction

Substitute different drugs for those whichSubstitute different drugs for those which

cause the allergic reaction.cause the allergic reaction.

Have patient evaluated by allergistHave patient evaluated by allergist



Management of AllergicManagement of Allergic

ReactionsReactions

Most severe allergic reactions are immediateMost severe allergic reactions are immediate

A number of organ oystems may be involvedA number of organ oystems may be involved

SkinSkin

Cardiovascular Cardiovascular

RespiratoryRespiratory

GastrointestinalGastrointestinal



Management of AllergicManagement of Allergic

ReactionsReactions

Generalized anaphylaxis involves all of theGeneralized anaphylaxis involves all of the

previously mentioned systems previously mentioned systems

When hypotension occurs, it is termedWhen hypotension occurs, it is termed

Anaphylactic Shock Anaphylactic Shock



Affected AreaAffected Area -- ManifestationManifestation

SkinSkin UrticariaUrticaria--Wheal & FlareWheal & Flare

pruritis, angioedema, erythema pruritis, angioedema, erythema

RespiratoryRespiratory Dyspnea,wheezing,flushing,Dyspnea,wheezing,flushing,

cyanosis,perspiration,tachycardia,cyanosis,perspiration,tachycardia,

increased anxiety,use of accessoryincreased anxiety,use of accessory

muscles of respirationmuscles of respiration



Affected AreaAffected Area -- ManifestationManifestation

GastrointestinalGastrointestinal Abdominal cramps,Abdominal cramps,

nausea, vomiting, diarrhea,nausea, vomiting, diarrhea,

incontinenceincontinence

Cardiovascular Cardiovascular Pallor, lightPallor, light--headedness,headedness,

palpitations, tachycardia, palpitations, tachycardia,

hypotension, dysrhythmias,hypotension, dysrhythmias,

loss of consciousness,loss of consciousness, arrestarrest



Sequence of ReactionSequence of Reaction

1. Skin reaction1. Skin reaction

2. Smooth muscle spasm2. Smooth muscle spasm

(GI, GU, and bronchial)(GI, GU, and bronchial)

3. Respiratory distress3. Respiratory distress

4. Cardiovascular collapse4. Cardiovascular collapse



Type of ReactionType of Reaction

Quick Onset==> Rapid Progression==>Quick Onset==> Rapid Progression==>

Intense ReactionIntense Reaction

Delayed Onset==> Slow Progression==>Delayed Onset==> Slow Progression==>

Less Severe ReactionLess Severe Reaction



Drugs Used in Allergic ReactionsDrugs Used in Allergic Reactions



EpinephrineEpinephrine

Has Alpha and Beta adrenergic effectsHas Alpha and Beta adrenergic effects

Acts as a physiologic antagonist to the eventsActs as a physiologic antagonist to the events

that occur during an allergic reactionthat occur during an allergic reaction




Actions IncludeActions Include

BronchodilationBronchodilation

Increased heart rateIncreased heart rate

Arterial constrictionArterial constriction

Cutaneous, mucosal, and splanchnicCutaneous, mucosal, and splanchnic

vasoconstrictionvasoconstriction

Reverses rhinitis and urticariaReverses rhinitis and urticaria




Risks of repeated use:Risks of repeated use:

Excessive elevation of blood pressureExcessive elevation of blood pressure

CVACVA

Cardiac rhythm abnormalitiesCardiac rhythm abnormalities



AntihistamineAntihistamine

Benadryl (chlorpheniramine) most often usedBenadryl (chlorpheniramine) most often used

HH--1 blocker 1 blocker

Inhibits action of histamine released duringInhibits action of histamine released during

reaction to allergenreaction to allergen



CorticosteroidsCorticosteroids

Hydrocortisone used most oftenHydrocortisone used most often

Stablilizes cell membranes against actions of Stablilizes cell membranes against actions of

histamines, bradykinins, and prostaglandinshistamines, bradykinins, and prostaglandins

Supplements adrenal steroid output duringSupplements adrenal steroid output duringstressstress



Treatment of Treatment of

Immediate Skin ReactionsImmediate Skin ReactionsObtain medical consultationObtain medical consultation

Observe patient for at least one hour Observe patient for at least one hour

Prescribe oral antihistaminesPrescribe oral antihistamines

Benadryl 50 mg PO Q6H for 3Benadryl 50 mg PO Q6H for 3--4 days4 days




Delayed Skin ReactionsDelayed Skin ReactionsAntihistamineAntihistamine

Diphenhydramine (Benadryl) 50 mg IMDiphenhydramine (Benadryl) 50 mg IM

Prescribe oral form Q6H for 3Prescribe oral form Q6H for 3--4 days4 days

Arrange medical consultationArrange medical consultation




Respiratory ReactionsRespiratory ReactionsBronchial ConstrictionBronchial Constriction

Terminate dental treatmentTerminate dental treatment

Sit patient uprightSit patient upright

Oxygen 6 L/minOxygen 6 L/min

Epinephrine aerosol or 0.3 mg IM or SCEpinephrine aerosol or 0.3 mg IM or SC

(0.3 ml of a 1:1000 solution)(0.3 ml of a 1:1000 solution)




Respiratory ReactionsRespiratory ReactionsBronchial Constriction (cont.)Bronchial Constriction (cont.)

Observe for at least 1 hr Observe for at least 1 hr

AntihistaminesAntihistamines -- Benadryl 50 mg IMBenadryl 50 mg IM

Obtain medical consulatationObtain medical consulatation

Prescribe oral antihistaminesPrescribe oral antihistamines

(Q6H for 3(Q6H for 3--4 days)4 days)




Respiratory ReactionsRespiratory ReactionsLaryngeal EdemaLaryngeal Edema

Sit patient uprightSit patient upright

Epinephrine 0.3 mg IM or IVEpinephrine 0.3 mg IM or IV

Maintain airwayMaintain airway

Summon medical assistanceSummon medical assistance




Respiratory ReactionsRespiratory ReactionsLaryngeal Edema (cont.)Laryngeal Edema (cont.)

Oxygen 6 L/minOxygen 6 L/min

CricothyroidotomyCricothyroidotomy

Additional drug therapyAdditional drug therapy

Diphenhydramine 50mgDiphenhydramine 50mg

&/or &/or Hydrocortisone 100 mgHydrocortisone 100 mg



Generalized AnaphylaxisGeneralized Anaphylaxis

withwith Signs of AllergySigns of AllergyPlace patient in a supine postionPlace patient in a supine postion

Basic Life Support (ABCs)Basic Life Support (ABCs)

Administer epinephrine 0.3 mg IM or SCAdminister epinephrine 0.3 mg IM or SC

(0.3 ml of a 1:1000 solution)(0.3 ml of a 1:1000 solution)

Summon medical assistanceSummon medical assistance -- call 911call 911




withwith Signs of AllergySigns of AllergyMonitor vital signsMonitor vital signs

Additional drug therapyAdditional drug therapy

AntihistaminesAntihistamines

CorticosteroidsCorticosteroids

Repeat epinephrine Q5min prnRepeat epinephrine Q5min prn




withoutwithout Signs of AllergySigns of AllergyPlace patient in a supine positionPlace patient in a supine position

Basic Life SupportBasic Life Support

Monitor vital signsMonitor vital signs

Summon medical assistance prnSummon medical assistance prn




withoutwithout Signs of AllergySigns of AllergyConsider possible causes of unconsciousnessConsider possible causes of unconsciousness

SyncopeSyncope

Overdose ReactionOverdose Reaction

HypoglycemiaHypoglycemia

CVACVA

Acute Adrenal InsufficiencyAcute Adrenal Insufficiency



Prevention of Allergic ReactionsPrevention of Allergic Reactions

HISTORYHISTORY -- a thorough, complete history of a thorough, complete history of

any previous allergic response or tendencyany previous allergic response or tendency prior prior to starting treatment will avoid mostto starting treatment will avoid most

emergenciesemergencies



Other Means of PreventionOther Means of Prevention

Medical consultationMedical consultation

Dental office skin testingDental office skin testing

(not foolproof and not advisable)(not foolproof and not advisable)



Take Home LessonsTake Home Lessons

All positive responses to an allergy history areAll positive responses to an allergy history are

true until exact nature is determined!true until exact nature is determined!

Patients reporting allergies should be criticallyPatients reporting allergies should be critically

evaluatedevaluated --refer for allergy testing if history,refer for allergy testing if history,

reaction, or management are suspect.reaction, or management are suspect.

Be prepared to manage difficulties! Always!Be prepared to manage difficulties! Always!

Emergency - Allergic Reactions

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