Anaphylactic shock, absolute emergency of allergy

Anaphylactic shock

it is also called anaphylaxis.

The most serious, most worrying, most feared allergy reaction. It is the accumulation of several organ damage, the generalization of the allergic problem, the moment of the fight for life, against death. Allergic.org, recently did an article to show who is at risk for severe allergies.

My son told me that during one of his most violent anaphylactic shocks, he felt like he was disappearing, peaceful, without strength and that he had to fight against himself to come back, not to let himself die. He appealed to his deep desire: to live.

I admit that I would not at all like to be an allergist whose son died of an allergy. I became an allergist to prevent this from happening; not being able to do so would be terrible.

Anaphylaxis is the generalization of the allergy. It occurs a few minutes to a few hours after the onset of the allergy attack.

Respiratory damage is common, also cardiovascular, mucocutaneous or sometimes digestive.

It is therefore mainly the asthma attack associated with the instability of the heart rate and blood pressure which dominates but the plaques on the skin, the swelling of the eyes, the face, the abdominal pain accompany the most complete forms. .

3 out of 1000 Europeans will experience anaphylaxis in their lifetime.

Between 2 and 8 people in 100,000 will experience anaphylactic shock during the year. This score increases from year to year.

Cardiac arrest generally occurs within 30 minutes for food, 15 minutes for hymenoptera stings, and 5 minutes for injected medications.

There is a real urgency.

Food kills mainly between the ages of 10 and 30, venoms and medications around the age of 60.

The causes of anaphylaxis vary depending on the country but are always in these three groups: foods, venoms, drugs.

For foods (65% of children, 25% of adults) it is milk, eggs, various nuts, peanuts and shellfish which are most often the cause but with the increase in the number of allergies and with so many cross-reactions, there is significant diversification to be expected with, I think, an increase in cases linked to spices and legumes.

From 2002 to 2015, the allergy vigilance network recorded 53 cases of anaphylaxis occurring during school hours and there were unfortunately two deaths.
Both were allergic to milk proteins: goat and cow.

In Habib Chabanne’s excellent book on food allergies, a Spanish study showed that in 22% of cases anaphylaxis occurred due to a masked allergen.
That is to say that it was not indicated in the ingredients.

The implementation of individualized reception projects has greatly helped in the proper care of allergic children at school.

However, I fear that the latest versions proposed, by their complexity and their number of pages to be completed and signed by so many participants, will harm the proper management of this vital emergency.
I hope I’m wrong.

For venoms, 20% of children and 48% of adults, bees and wasps are the culprits. But be careful, the venom itself is deadly: not all reactions are allergic. If there is no allergy, adrenaline is of no use: it is an envenomation.

Finally, regarding medications, 5% of children and 22% of adults, antibiotics come in first position followed by non-steroidal anti-inflammatories.

How does anaphylaxis work?

It was our 1913 Nobel Prize winner Charles Richet who in 1901 studied this phenomenon at the Monaco Oceanographic Institute.

He gave the following definition: “We call anaphylactic, as opposed to phylaxis, the property with which a venom is endowed of reducing and not strengthening immunity, when it is injected in non-lethal doses”

In short, he had noticed that by wanting to vaccinate dogs against jellyfish venom, some of them died even though they only received small quantities which were in principle non-lethal.

He highlighted a product in the serum that he called reagin, it was the future type E antibody which would earn another Nobel Prize for a Japanese woman: Teruko Ishizaka in 1966.

This type E antibody recognizes a precise pattern, we speak of an epitope, on a molecule, we speak of an allergen.

If this antibody is present in quantity on the receptors of mast cells, defense cells present in our mucous membranes, it can activate them on contact with the allergen.
The cascade activation of mast cells induces a generalization of the reaction with damage to different organs.

Schematically, the blood leaves the blood circulation to swell the affected organs, the blood pressure drops, the heart accelerates to compensate and defuses: bam, it’s shock.

Obviously it’s not exactly like that, eh, I gave you in three lines a summary of what takes up pages of physiology studies. But that will be enough for today.

Sometimes anaphylaxis is not anaphylaxis: it is a panic attack, an isolated asthma attack, envenomation, food poisoning, bradykinin edema. The diagnosis must be corrected.

A blood tryptase test to be carried out between half an hour after the start of the episode and two hours allows us to argue in favor of anaphylaxis.

This enzyme is stored in mast cells and its release into the blood is a good indicator of their activity.

We will do a 2nd dosage 24 hours later to have a baseline level to compare.

Factors promoting anaphylaxis

we talk about it almost every episode, below the presence of a certain quantity of allergen nothing happens.
For each individual there is a threshold dose that will trigger the anaphylactic reaction.

So easy, for me it’s 5 peanuts and you 2 ok. Easy.

Too easy yes.

There is a vague area in the threshold dose which will trigger because there are so-called “promoting” factors. they reduce the necessary threshold dose, the one that will trigger the crisis.

It is for example physical effort with exertional anaphylaxis which is usually wheat for the French and tomatoes for the Italians but it is also the consumption of alcohol which increases digestive permeability such as taking aspirin or anti-inflammatories is the presence of a gastric ulcer, gastroenteritis not yet cured or taking medications such as beta-blockers or enzyme-converting enzyme inhibitors.

The dose that is usually well tolerated no longer passes, and it’s a shock.

Okay, here we are: I shock, so what do I do?

The only treatment for anaphylactic shock is adrenaline. The quicker you react, the more you inject your adre into your thigh without qualms, the greater your chance of survival.

You feel that you are having a severe allergy attack, whether it affects more than two organs: the breath, the skin, the digestive tract or just one with a feeling of discomfort.

You draw your adrenaline pen and prick yourself in the thigh on the outside and then, only then, do you call the emergency services: 15 or 112 on your phone.

• What about my antihistamine? he will not save you.
• And my cortisone? It will make you deflate in half an hour, you will already be dead
• And my ventolin? Take it after taking the bite, you’ve already taken it anyway, I know it.
• And after? Afterwards you wait for help, your 2nd pen in hand. You should be fine after ten minutes, otherwise you’ll transplant.

In the emergency room they will monitor you and if you have no signs of seriousness they will send you home within a few hours, or in a few days if you have persistent signs of seriousness.

It will be time to make an appointment with the allergist to debrief: what is it? For what? Did I manage it well? Can I be better?

there is no urgency to see him: after an anaphylactic episode there is no assessment before six weeks otherwise there is a risk of a false negative.
You have been shaken, your cells too: give yourself time.

In summary,

• Anaphylactic shock is an absolute emergency.
• If this happens to you or those around you, there is an urgent need to inject adrenaline. You only call emergency services afterwards: 112 or 15.
• Other medicines are just magic bullets: forget them.
• Adrenaline pens are widely prescribed to at-risk allergy sufferers, they should always have them on hand.
• After the attack you will need to debrief with an allergist but this time it is not urgent: let your body recover.

In the next episode we will talk about dust mites.

Thank you friends, take care of yourselves.