2. Allergy and Anaphylaxis

Question 1

Allergy

This is more likely to occur with medicine given by ____, since its direct in the body and doesn’t need to be absorbed in gut. This is overall cascade that occurs and this allergies can be anything: topical anesthetic, dental material, medication, local anesthetic. Want to know this process as a concept!

This tells us we are seeing more and more allergens. Lots of theories behind this. There are many new molecules, material and things today that our body is being exposed to. Our immune systems are constantly challenged in today’s time

Answer 1

IV

Question 2

Allergy

This is the schematic, for you to understand what is happening with the immune system. Lets look at an allergen.

The most common medication allergen is ____. This picture shows penicillin.

When patients get wisdom teeth out may get pre operative dose of amoxicillin and/or dose after they get them removed. After taking penicillin for the firs time, immune system will see the beta lactam molecule that makes up penicillin. The B cells, which are responsible for making antibodies, will see the beta lactic ring from penicillin, will mature and stimulate a plasma cell, So direct B cell progenitor will release ab against penicillin. They will be IgE mediated. The different type of IgGs have a pneumonic GAIN –> IgG, IgA, IgM, IgG IgE will be released. The same Ig as person exposed to a protozoa worm. That Antibody will float around body. In Px you with take penicillin every 8 hours. Once they take their next dose 8 hours later. The process is reinitiated and the IgE receptor are mounding up. The IgE molecules are going to find a mast cells, the same ones involveed in asthma. Mast cells are circulating around, and will connect with IgE.

Answer 2

Pencillin

Question 3

Allergy

~____% of children have a food allergy in the US

8% of children are going to go on to have a food allergy in US. Most common is ____ allergy. Selfish: iodine, shimp based, selfish is popular as well

Answer 3

8

peanut

Question 4

Allergy
RISK FACTORS

• ____
• ____

The concept is that they have an immune system that is ____ to things when it doesn’t need to.

Answer 4

asthma
atopic dermatitis
sensitive

Question 5

Allergy 
RISK FACTORS (Host Factors)
• Gender (\_\_\_\_ > Female) 
• \_\_\_\_ predisposition 
• \_\_\_\_/Ethnicity

There is NO real known risk factor aside from a person having multiple previous ____ or having ____ or ____. No factors that you can say a person is of high risk category. If a person has many Antibiotics allergies should be nervous prescribing them more antibiotics cause may be allergic to them.

Answer 5

male
genetic
race

allergies
asthma
contact dermatitis

Question 6

Allergy

RISK FACTORS (Environmental Factors)

• ____ smoke
• Air ____
• ____ infections
• ____ factors
• ____
• Indoor/outdoor ____

Answer 6

tobacco
pollution
respiratory
socioeconomic
obesity
allergens

Question 7

Allergy

Type 1: ____ mediated -This is when the penicillin goes from B cells to plasma cells, releasing IgG anybody, that go to mast cells, causing mast cells to degranulate and release ____ and prostaglandins
This is called type 1 immune reaction
◦ Type 2: this is more ____ conditions like good-pasture condition
Type 3: this is complexes of ____. More immune base conditions

reaction.
Type 4: ____ based ones will be lie ____. When something touch one’s ski or lips and skin and it causes it to break out

What we see in practice is
anaphylactic reactions, which are ____ base type 1 mediated reactions
◦ And type 4 which is ____ based like contact dermatitis, topical contact

Answer 7

IgE
histamine

immunologic
ABs and allergen complexes

T cell
contact dermatitis

IgE
T cell

Question 8

Allergy

This shows that breakdown. Type 1 ____ and type 4 contact mediated ones are shown below (far left and far right).

Type 1 is anaphylactic reactions and things like ____. Immune complex ones are like ____, lupus.

____ reactions is like type 2

Answer 8

IgE
seasonal allergies
rheumatoid arthritis
blood transfusions

Question 9

Allergy

1. ____
2. ____ phase reaction
3. ____ phase reaction

1: this is first exposure of allergen: called sensitization, It primes the immune system. Most common reaction we see is to ____. If people complain feeling itchy, say don’t take anymore and if see symptom call 911.
2: When person complains braking out in a hive. If stomach hurts NOT necessarily due to allergy, its a drug reaction. Can take a probiotic to help this.
3: This is what we want to ____! This is where people’s airway close up and people. Go into cardiopulmonary arrest. He tells a story 37 min in about person peanut allergy. Person starts to feel sick but restaurant said restaurant said they did not use peanut oil. Therefore, they hesitated to inject him with epi pen, but it ended up being too late.

Answer 9

sensitization
early
late

penicillin
prevent

Question 10

Allergy

1. Sensitization

This is allegen, mediation, overproduction of ____. The mast cells are ready, roaming body looking for more penicillin. Every time person takes penicillin person is making more ____ cells

Answer 10

IgE

sensitized

Question 11

Allergy

2. Early phase reaction
3. Late phase reaction

In early phase and late phase reactions, when ____ occurs. In sensitization did not granulate they jus made ____ mast cells ready to react, so symptoms are not there yet. Person could have taken ____ awhile ago and been sensitized. They may be unaware of their allergy until take is a ____ time and symptoms occur.

Answer 11

degranulation
sensitized
medicine
second

Question 12

Allergy

Early phase
Subsides in ____ minutes

Late phase
Within ____ hours after a decline in immediate reaction

The Hardest part of identifying a true penicillin allergy is when someone is young and has ____ infection. Parents may say they want the child to have antibiotics. However viral infections can cause hives. Therefore, no one knows whether the antibiotics or viral infection may be causing the hives. Keep this in mind for many patients who say they had a ____ allergic reaction when they were young. They could have just had a ____ infection at the time they took antibiotics. Tell them to be tested because they may not be allergic. Clindamycin does not work as well so want to use penicillin if we can.

Answer 12

30-90
3-4

viral
penicillin
cold/viral

Question 13

Drug Allergy

Immediate reaction
Evolve within the ____ hour of drug exposure (e.g., anaphylaxis, pruritis, urticaria, angioedema)

Accelerate reaction
\_\_\_\_ hours (e.g., pruritis, urticaria, angioedema

Delayed reaction
> ____ hours (e.g., benign skin eruptions, fever, serum sickness like reaction, systemic disorders)

Answer 13

1st
1-72
72

Question 14

Anaphylaxis

90% of patients will have ____ and ____

This is how most present. Most patients will have urticaria: itchiness or angioedema: swelling puffiness. Hives can occur anywhere on body. We Immediately stop ____ if see these signs!!

Answer 14

urticaria
angioedema
meds

Question 15

Anaphylaxis

Why do eyelids and lips get puffy and not the feet or hands?
has to do with the thinnest of their skin: which is the ____ and its, not hands
or feet
If retaining water eyes will show the fluid its retaining

Other sings:
Eyes puffy runny nose - BVs get ____, leaky, and can fill with fluid, like with seasonal allergies
Can get tired, confused anxious, which we think this has to do with ____
of the brain
BP drops cause heart rate to go ____ in compensation
Histamines can cause spams of bronchioles, causing ____ or asthma
attack
GI: can get ____ from histamines
skin: can break out in ____ become itchy

Answer 15

eyes
dilated
edema
up
wheezing
hives

Question 16

Anaphylaxis

When look at skin level: 85-90% patients can get urticaria and angioedema.
Common things occur commonly!!
If you notice this its sign of allergic deciton

◦ ____ symptoms in about 1/2 of its but want to avoid these! ____ don’t want to see these either 1/3 patients
Nausea and vomiting hard to know what this is from. Not ____ line symptoms Because can be due to dehydration or other reasons
◦ Don’t use ____ reaction to guide allergic reactions.
____ are rarely due to allergies

Answer 16

respiratory
CV
first
GI
seizures

Question 17

Anaphylaxis
• Call for help (911)
• Epinephrine pen!!!!
• ____ flow oxygen, cardiac monitoring, ____ access

Never be hesitant to call 911 if person seems to be having an allergic reaction. A person can get worse in minutes and your out of luck if airway closes up. He talks about offices doing simulations for emergencies a few times a year. Want to have a game plan how to deal with an emergency.

O2 is always good, NO scenario when don’t want to give O2. Can give it when person faints, lightheaded, looks like having an Allergic Reaction, or they are weak. Want to monitor heart and BP. If in place with IV access, make sure can give meds with IV, especially if sedating in your office.

Answer 17

high

IV

Question 18

Anaphylaxis

Repeat every ____ minutes if necessary

IM epinephrine (to lateral aspect of ____) from 1:1,000 dilution (1 mg/mL) injected as 0.2 to 0.5 mL (0.01 mg/kg in children, maximum dose ____ mg)

Would you give it through his clothes or on direct skin?
Through his ____
Yes, that perfectly fine!
Why? Due to time, you want to give it as fast as possible
if you can access thigh can you I’ve it in ____

Answer 18

5-10
thigh
0.3
clothes
deltoid

Question 19

REVIEW

A person comes into the office, they will require to have have wisdom teeth removed. We give them 2g of amoxicillin which is a high dose. Some dentists prefer to give PO than IV because more likely to have anaphylactic reaction with PO. People are nervous to be first ones to give ampicillin.
Lets say the person has an allergic reaction. The ampicillin get absorbed into gut

What is first cell that beta lactic molecule is going to contact to initiate action?
____

B cell will see the beta lactic molecules and what is the cell that follow it?
____

• plasma cell senses that it is a foreign substance and causes an immune based reaction with IgE antibody
  GAME!! - ____, ____, ____, ____
  What are the 4 types of Antibody?

◦
Then you release IgE, which then circulates in the body. You do procedure and patient goes home with prescription for another antibiotics post opt.
Px for 500mg 3 a day.

Answer 19

B cell
plasma cell
IgG
IgA
IgM
IgE

Question 20

REVIEW

What is the process called when the IgE plasma cells have been made and bound to the mast cells?
____
◦ .Their system is NOW sensitized to amoxicillin and they take their med once again post opt. The beta lactic molecule now contact the sensitized mast cells with the IgE and their receptor. This causes them to ____ and release ____.

Answer 20

sensitized
degranulate
histamines

Question 21

REVIEW

What are the sings and symptoms you see from early on that show degranulation?

____, which is itchiness with hives, and ____, which is puffiness of the lips and eyelids
Remember those are the thinnest skin in the body

What type of reaction is this?
____ reaction

Answer 21

urticaria
angioedema
early phase

Question 22

The parents call the office, and tells you their child is having these symptoms. What is a very important question to ask?

Is their child having ____ of breath! That is how someone can die of this
◦ They will have a massive asthma attack and constrict their bronchioles and can’t move air,

Ask if have ____ pain, dizziness, gasping for air, lightheadedness, shortness of breath
If say they are what do you do? ◦ CALL ____
‣ If they say no but they are itchy and lips are puffy
CALL ____

Why tell them to call 911 versus drive them to the hospital?
You can’t afford to have parent to make the decision when their child is having
bad enough symptoms and when they should drive their child to hospital. You
don’t know when they can tip over so make sure to call 911 right away.
Side note: He says that shellfish allergies can develop much alter in life. He knew a doctor who has a shellfish sample in Whole Foods and felt sick. He went to get Benadryl to ease
his seasonal allergies like symptoms. He symptoms kept getting worse and he drove
himself to urgent care center. He needed 3 injections of epi when he got there.

Answer 22

shortness
chest
911
911

Question 23

Another scenario
Person in your office says they are allergic to certain material. The staff mixes it up and give them that material, like topical for example.
The person is exposed.
◦ This is usually a minor allergy, however in this case it escalates. The patient has puffy lips and is short of breath. What is the first thing you do? ◦
Call ____
‣ What do you do while you wait for ambulance?
Give them ____
There is no order of this, you several people in the staff helping to give ____ pen, ____ check them with monitors, call ____.

Where you give epi pen?
Lateral ____ through their clothes
You wait 30 seconds an they are getting worse. What do you do?
Give them ____, prednisone or Benadryl if you have it in your office.
The person is still looking worse. What do you do?
____! Epi has a half-life of ____ minutes and probably hasn’t gotten into effect yet.
You can t keep giving them epic every 20 seconds. Can give them ____
if give them too much too quickly.
REPEAT every ____ minutes - NEED TO GIVE TIME TO CIRCULATE!

Answer 23

911
oxygen
epi
oxygen
911

thigh
steroids
wait
2
5-10