Anaphylaxis (Allergic Reactions)

For people with severe allergies, exposure to certain allergens can result in a life-threatening reaction called anaphylaxis. Anaphylaxis is a severe allergic reaction to venom, food, or medication. Learn about managing severe allergies and the life-saving benefits of emergency epinephrine.

Step-by-Step Guide to Dealing with Anaphylaxis

Learn what to do in the event of an extreme allergy attack.
By Erica Manfred

Anaphylaxis can be a terrifying event, mostly because it happens so quickly and is so unexpected. One minute you’re fine, the next minute you’re gasping for breath. If you or a loved one has a history of any type of allergic reaction, they are at higher risk, but it can still happen to anyone, anytime.

What Are the Signs?
If you suspect someone is suffering from an extreme allergy attack, check for these signs:

  • abnormal heart rhythm
  • hives
  • low blood pressure
  • mental confusion
  • rapid pulse
  • skin that is blue from lack of oxygen or pale from shock
  • swelling in the throat that may be severe enough to block the airway
  • swelling of the eyes or face
  • weakness
  • wheezing

The National Institutes of Health recommends following these steps:

  • Call 911 immediately. Don’t assume that any allergy shots the person has received will provide protection.
  • After calling 911, calm and reassure the person. Panic will make the anaphylaxis worse.
  • Check the person’s airway, breathing, and circulation (the ABCs of basic life support). A warning sign of dangerous throat swelling is a very hoarse or whispered voice, or raspy sounds when the person breathes in. If necessary, begin rescue breathing and CPR.
  • If the allergic reaction is from a bee sting, scrape the stinger off the skin with something stiff such as a fingernail or credit card. Do not use tweezers—squeezing the stinger will release more venom.
  • If the person has an emergency epinephrine injector, help him or her find it and assist in administering the shot. Avoid giving oral medication if the person is having trouble breathing.
  • Try to prevent shock. Have the person lie flat, raise his or her feet about a foot (unless he or she is injured), and cover the person up with a coat or blanket .

Dot not place a pillow under the person’s head if he or she is having trouble breathing, or give him or her anything by mouth.

Interim Measures
An injection of epinephrine is the only sure-fire way to reverse anaphylaxis, and it can be administered only with an emergency epinephrine injector or in the hospital There is some disagreement about whether to give a person in anaphylaxis Benadryl or other non-emergency allergy drugs.

Dallas anesthesiologist David Draghinas, MD, reports what happened when he was bitten by fire ants. “I took some Benadryl and ibuprofen and quickly made my way to the local ER. In the emergency room an IV was started, I was closely monitored by the staff there, and I was given epinephrine, more Benadryl, an H2 blocker, and steroids. The reaction improved significantly within minutes of treatment.”

Other medicines that may help alleviate some of the symptoms before the EMTs arrive include H2 receptor blockers like Zantac or Rantidine, according to nurse anesthetist Nick Angelis. Whatever measures you take, do not delay in getting the person to the emergency room.

Be S.A.F.E.
Be S.A.F.E. in case of an extreme allergic reaction. “Summer is peak time for allergic exposures, because children are at camp and are exposed to food allergies and stinging insects. People let down their guard. Be on your guard and have a game plan in place. People with a history of risk need to be most on guard,” says allergist Clifford Bassett, M.D., fellow of the ACAII (American College of Allergy, Asthma and Immunology) in New York City.

S: Seek emergency care. Call 911 and get to the nearest emergency facility at the first sign of anaphylaxis, even if you have already administered epinephrine, the drug used to treat severe allergic reactions. If you have had an anaphylactic reaction in the past, you are at risk of future reactions. Be aware that up to 50 percent of anaphylactic reactions are to food. The big four are peanuts, tree nuts, fish, milk, and eggs.

A: Identify the Allergen. Prevention is key. Think about what you might have eaten or come in contact with—food, insect sting, medication, latex—to trigger an allergic reaction. It is particularly important to identify the cause because the best way to prevent anaphylaxis is to avoid its trigger. Make sure you get diagnostic testing. Communicate with family and friends about food allergies, particularly when it comes to your child. Carry a chef card that lists all the foods you or your child is allergic to. A written list is much more powerful than reciting the list orally to the waiter.

F: Follow up with a specialist. Only 11 percent of people get referred to an allergist after an allergy attack. We are the ultimate fixer. It is important that you consult an allergist for testing, diagnosis, and ongoing management of your allergic disease.

E: Epinephrine. Carry an auto injector. Always have two doses. Twenty percent of people need the second dose. There is sometimes a bi-phasic reaction, which is where you have an extreme allergy attack and then you get it again—up to 10 hours later.

What Happens During an Extreme Allergy Attack

Anaphylaxis stems from a cascade of physiological events as your body attempts to purge itself of an allergen. Learn about the process, the complications, and the dangers this can pose.
By Erica Manfred

Anaphylaxis, or a whole-body allergic reaction, is a life-threatening overreaction by the body to a stimulus that it perceives as threatening. The body’s immune system, which is supposed to protect against outside invaders such as viruses and bacteria, mistakenly identifies an innocent substance such as a food, medication, or insect sting as a dangerous invader, and a massive immune response is triggered, causing swelling of the airway, a dangerous drop in blood pressure, and shock.

The reaction can, to a certain degree, be associated with the route of entry to the body, explains Rauno Joks, MD, chief of the Division of Allergy and Immunology at SUNY Downstate Medical Center. “For example, with a food allergy or an oral drug allergy, the first symptoms may include nausea and vomiting. A sting may trigger a circulatory response including lightheadedness and low blood pressure. Both may be attempts on the part of the body to limit exposure, either by expelling by mouth or limiting circulation of the allergic trigger with a low blood pressure response. Frequently, there is an element of itching, as mast cells, central cellular responders in the majority of allergic responses, release histamine, which causes an itch.”

Many organ systems can be affected by anaphylaxis including respiratory, both upper (increased nasal secretions and sneezing) and lower tracts (asthma, wheezing); GI (nausea, vomiting, abdominal cramping, diarrhea); skin (hives and angioedema (deeper swelling that can include the lips, tongue, throat, eyes, palms, and soles of the feet); and the cardiovascular system (low blood pressure and shock). Death can result from low blood pressure and shock, as well as from a compromised airway.

The Role of IgE
Anaphylaxis starts when the allergic person comes in contact with one of his or her allergy triggers, which the body perceives as a foreign invader. The immune system then releases immunoglobulin E (IgE), an antibody that binds to the allergen and tries to neutralize it. The bound IgE activates receptors, which in turn release inflammatory mediators, including histamine. These mediators cause the symptoms of allergy, including congestion and swelling. In anaphylactic reactions, this inflammation is more severe and occurs in the throat, which can cut off the flow of air. Additionally, an anaphylactic reaction may cause the body’s blood vessels to widen, which can reduce blood pressure to life-threatening levels.

“The IgE binds to mast cells, which are found throughout the body as part of the immune system, but are most concentrated in mucus membranes, gut, and skin,” explains Dr. Martha V. White, director of research at the Institute for Asthma and Allergy. “The body makes IgE to recognize things that we’re allergic to. You might have IgE against peanuts, for instance.”

Genes and Allergies
There is a strong genetic component to allergies. If you are genetically predisposed toward allergies, you are atopic. This means your immune cells, T and B cells specifically, are quick to be stimulated by allergens. Once stimulated by T cells, the B cells develop into plasma cells, which produce the IgE antibodies targeted to that allergen. Then the IgE binds to receptors on the mast (immune) cells. At this point you become sensitized. Without knowing it, your mast cells are little time bombs waiting to go off when hit by whatever you’re allergic to.

When a critical mass of IgEs becomes linked, you get a cascade of life-threatening symptoms such as your throat closing, etc. “The chemicals in combination cause swelling and sequestration of fluids in the skin and bowel,” explains Dr. Harlan A. Steuven, an emergency room doctor. “If that swelling occurs in the airway, the patient can’t breathe, can’t get oxygen in, and carbon dioxide out, and they go into respiratory arrest. If the sequestration of fluids is severe it can cause shock, with increased heart rate and decreased blood pressure. Severe anaphylaxis happens when both events occur.”

Testing for Food Allergies
Fortunately, most allergies are not severe enough to cause such a dangerous reaction. “Food allergies, one of the most common causes of anaphylaxis, vary widely in severity, and the danger can depend on the exact protein in the food the allergic person is sensitized to,” says Dr. Rob Reinhardt, a researcher and developer of allergy tests for Thermo Fisher Scientific and an assistant professor of family medicine at Michigan State University.

“Take peanuts, for example: There are several individual proteins within the peanut that can cause an allergic reaction, and each one has an associated level of severity, from a mild to life-threatening systemic reaction. The ideal place to begin any allergy diagnosis is with a detailed and accurate history of the patient’s exposure and reaction to the allergen(s) in question. Once that data is available, tests can be done to find out the exact allergen molecules to which the patient is sensitized, how severe their reaction is likely to be, and how their allergies can best be managed.”

Dr. Reinhardt recommends the ImmunoCAP test, a new FDA-approved specific IgE test that measures reactions to allergens at the molecular level, providing further information on patients’ allergy triggers that can help them understand exactly how dangerous their food allergies are, including their risk of anaphylaxis.

First Responder: Anaphylaxis

Hear from an emergency room physician about how first responders and emergency rooms assess and treat anaphylaxis.
By Kimberly Holland

How Anaphylaxis Appears to First Responders
Anaphylaxis is a severe, potentially life-threatening allergic response to an allergen. Allergens enter your body all the time. In some cases, allergens cause a reaction. These reactions can range from itchy skin (mild) to shock (severe). The most common food allergens include peanuts, shellfish, milk, and eggs.

People react differently to allergens. For example, people rarely have an anaphylactic response to pollen or dust, but a tiny amount of peanut can cause a severe anaphylaxis reaction in highly allergic people.

“When your body reacts to an allergen, your heart rate goes up, and your blood pressure goes down,” says Brian Walsh, MD, MBA, an attending physician at Morristown (N.J.) Medical Center and a partner of Emergency Medical Associates. “In severe cases, you can even go into shock.”

Unless you know you ingested an allergen and can report that to a first responder or physician, they have to evaluate all your symptoms to reach a diagnosis.

“It’s not always clear if a patient is in anaphylactic shock. Some things can mimic that, especially in a young child,” Walsh says. “Often, people will come in with a story of exactly what happened: Symptoms come on very quickly. The quicker the onset of symptoms, the more severe it’s going to get.”

Anaphylaxis Treatments
“The good news is the treatment is kind of the same for anaphylaxis and conditions that mimic it. The main treatment for anaphylaxis is epinephrine, or adrenaline. An EpiPen is what most people have heard of,” Walsh says. If you are unable to administer your injectable epinephrine to yourself, first responders can administer it for you in most cases. However, Walsh is quick to point out that not every state allows EMTs or emergency personnel to do that. “I believe in most states, they are able to assist you with your own device, but in some states, they actually carry an EpiPen with them. If they come across someone they believe is having a reaction, they can actually administer an injection.”

Epinephrine is the first-line treatment for anaphylaxis. It immediately eases most symptoms of anaphylaxis and returns your breathing and heart rate back to normal. Other first lines of treatment include antihistamines, such as Benadryl, steroids, and in some cases, Pepcid, the heartburn medicine, according to Walsh.

Don’t Dally
Walsh stresses that anaphylaxis is a medical emergency, a life-threatening situation that needs to be treated by medical professionals at a hospital.

“If you think of allergy responses on a continuum, a mild reaction can be a runny nose or one or two hives. In the middle is sneezing and runny eyes. But wheezing, swelling of the mouth, and anaphylaxis with low blood pressure and high heart rate, this is a real emergency,” Walsh says. “Certainly when you get to that stage, even if you don’t call that anaphylaxis shock, it should be treated with epinephrine.”

If you begin having a reaction and are able to inject yourself with epinephrine, that doesn’t necessarily mean you’re out of danger. People who have an anaphylaxis response can have a rebound anaphylaxis reaction within 24 hours of the first reaction. “It’s rare, but it’s very important you are monitored,” Walsh says.

“The take-home point is that there’s a big difference between allergic reaction and severe anaphylaxis,” Walsh says. “Anaphylaxis is almost by definition a medical emergency and should be treated that way.”

A Parent’s Guide to Food Allergies

Having a child with extreme food allergies can be a challenge. Get tips for managing your child’s condition and how to educate others in case of an emergency.
By Kimberly Holland

Food allergies are becoming more and more common among America’s school-aged children. In fact, the prevalence of food allergy among American children (infant to 18 years old) increased 18 percent from 1997 to 2007. Today, eight percent of children have a food allergy.

The most common food allergens are peanut, milk, and shellfish. Other common food allergens include tree nuts, eggs, wheat, and soy.

Reactions to these allergens can range from mild to severe. Most mild reactions include itchy mouth, hives, and upset stomach. More severe reactions can be dangerous, even deadly. Anaphylaxis is the most severe food allergy reaction. Anaphylaxis can cause symptoms such as a weak pulse; difficulty breathing; nausea, vomiting, or diarrhea; and dizziness or fainting. More than 38 percent of children with a food allergy have a history of these types of severe reactions.

For parents, this is a frightening prospect. Food is both necessary to maintain life and a part of everyday social interactions. Many parents live in fear their child will eat something that could trigger a severe allergic response. The good news is you can manage the condition and learn ways to make eating and living life easier on your child—and on you, too. Here, what parents of kids with food allergies should know and where they can turn for more advice.

Get Educated
Make an appointment to see an allergist. Your child’s doctor can be a wealth of knowledge when you’re learning to cope with your child’s allergies. He or she can help you understand possible allergy triggers and learn to recognize ingredients that could be a problem. The allergist can also help direct you and your child to local and national food allergy support organizations. - Learn how to use epinephrine. The first and best treatment for anaphylaxis is epinephrine. If your child’s doctor decides the allergy is severe enough that your child needs to carry anaphylaxis with him or her at all times, it’s important you, your child (when age-appropriate), and any other adults that will care for him or her regularly learn how to use injectable epinephrine. Local health departments and hospitals sometimes sponsor classes for people with food allergies. Your child’s doctor may also be able to teach you how to use the medicine. - Seek out support. Food Allergy Research and Education (FARE) maintains up-to-date information on research and treatments for food allergies. They can also keep you informed of potential allergen contaminations: If a company announces one of their products has been accidentally contaminated with an allergen, FARE will e-mail you an alert so you can prevent an exposure. - Print resources. FARE also maintains materials that can help you prepare your child’s school or daycare for the allergy. You can print a card to take to restaurants so chefs and cooks will understand how to prepare food for your child.

Be Prepared
Make an allergy kit. You cannot anticipate when your child will have a reaction. Being prepared can help treat a reaction if one occurs. Be sure to include your child’s prescription injectable epinephrine; a liquid or chewable antihistamine, such as Benadryl; your child’s inhaler, if he or she has one; and a paper documenting your child’s important medical information, including allergies, doctor contact information, and current prescriptions. In the event of an emergency, you can use the kit to ease your child’s anaphylaxis symptoms while on your way to a hospital. Make extra kits and share them with other adults when your child is not with you.

Educate Others
Once you’ve educated yourself, it’s time to educate other adults in your child’s life. This includes babysitters, teachers, daycare instructors, and other family members. You are your best resource for this step. Draw on what you learned, and direct people to the same resources you used to educate yourself. Here, a few things to keep in mind: - Explain how dangerous the situation can be. Until a person has had experience with anaphylaxis and severe food allergies, it may be difficult to comprehend how dangerous and even deadly exposure to an allergen can be. Familiarize yourself and the other adults with typical symptoms so a reaction can be spotted quickly. - Provide a list of foods to be avoided. Some allergens can be in foods you wouldn’t suspect. Keep a list of foods and ingredients your child cannot have in order to avoid an allergic reaction. “Safe” lists aren’t always safe—it’s important to know what to avoid and to read labels to be sure. - Learn how to use epinephrine. Offer information about classes where adults can learn to inject your child with epinephrine in the event of a reaction. This is especially important if your child is too young to administer the medication.

How to Recognize the Signs of Anaphylaxis

Learn about the key signs and symptoms that you or someone else may be experiencing an extreme allergic reaction.
By Erica Manfred

Extreme allergy attacks cause an estimated 1,500 deaths in the U.S. each year. People may be severely allergic to almost anything, including food, insect stings, medications, latex, and even exercise and seminal fluid. Even though anaphylaxis is a growing health problem that may affect you or a loved one someday (anywhere between three million and 43 million Americans have experienced it), many people do not know what signs and symptoms to watch out for. The incidence of food allergy in particular is increasing. The most frightening statistic is the increase in peanut allergy in American children under 5 years of age, which doubled between 1999 and 2004.

Despite these statistics, most of us don’t worry about suffering a severe allergy attack. “We just tend to just wait until something bad happens,” says actress Julie Bowen, who founded Raise Your Hand for Anaphylaxis Awareness after her son got an extreme allergy attack from eating peanut butter. “We rushed him immediately to the hospital and they treated him and he was OK, but it made me realize how many people probably don’t have the information they need about anaphylaxis.”

The early symptoms may be mild, such as a runny nose, a skin rash, or a “strange feeling,” but these symptoms can rapidly lead to more serious problems that directly affect breathing and blood circulation. Here are the body systems affected and what to look out for:

  • Skin. Up to 90 percent of episodes involve hives, itching, flushing, and swelling of lips, tongue, and palate.
  • Central nervous system. Up to 15 percent of episodes involve symptoms that include uneasiness, throbbing headache, dizziness, confusion, and tunnel vision.
  • Airway. Up to 70 percent of episodes involve shortness of breath, chest tightness, wheezing, itchy throat, or hoarseness.
  • Cardiovascular system: Up to 45 percent of episodes involve lowered blood pressure, chest pain, fast heart rate, weak pulse, dizziness, and fainting.
  • Gastrointestinal system. Up to 45 of episodes involve nausea, cramping, abdominal pain, vomiting, and diarrhea.

Types of Allergic Reactions
There are generally three different types of allergic reactions—mild, moderate, and severe—according to Chief Paramedic Larry Smythe, Mercy Fitzgerald Hospital EMS, who describes the level of reactions and what to do about them.

An allergic reaction is considered mild when it is isolated to minor hives without shortness of breath, extensive hives and itching, and swelling of the tongue and lips. For minor reactions, keep an eye on the patient for any changes in his or her level of distress.

A patient with moderate allergic reaction may have:

  • mild shortness of breath with wheezing
  • extensive hives and itching
  • mild tongue/lip swelling without difficulty swallowing or shortness of breath

For moderate reactions, watch the patient for worsening condition. Contact your family physician or take the patient to the local emergency room for evaluation. You may want to call 911, as moderate reactions can quickly turn severe.

The most severe form of an allergic reaction is called anaphylaxis, when the patient experiences these symptoms:

  • difficulty breathing; wheezing
  • swollen tongue and lips or difficulty swallowing
  • hypotension (low blood pressure)

In cases of severe allergic reactions, call 911 immediately. Don’t wait to see if it gets better. Use an emergency epinephrine injector if you have one. Try to determine what caused the reaction.

Don’t assume that if you don’t have a reaction to an allergen immediately, you’re out of the woods. The signs and symptoms of an allergic reaction usually start within minutes of exposure to the offending allergen (food, drugs, latex, insect venom, etc.), but less commonly the reaction can start hours after the exposure.

Typical Anaphylactic Reaction
Betsy Lampe, a retired paramedic who is now an EMT instructor in Highland City, Florida, describes what happened to her husband: “The first time my husband had an anaphylactic reaction was when he was bitten by a fire ant. I happened to be along, fortunately, and I even saw the ant.”

“Of course, first you note the bite or sting,” she continues. “Then immediately a huge flushing sensation along with profuse redness around the area and a very quick development of swelling. Within seconds the redness covered his face and body. He experienced dizziness, extremely swollen lips and tongue, and increasing shortness of breath soon followed as his airway began to close. He experienced hallucinations while in the hospital ER. Rapid pulse, sweaty skin were also part of the picture. Interestingly, my husband says he was bitten all the time growing up, and it was a mystery that it should suddenly become a life-threatening emergency. The immunologist said it happens that way many times with insect stings.”

Why Anaphylaxis and Allergies Are More Common Today
Anaphylaxis is more common today than ever before, possibly due to our germ phobia as a culture. “There is a suspicion that our obsession with germ-free living is actually causing allergies,” says Dr. Martha V. White, director of research for the Institute for Asthma & Allergy, Washington, DC. Dr. White explains, “If the immune system is busy making antibodies to attack parasites and other dangerous pathogens, it won’t attack innocent targets. If you grow up on a farm, for example, where you got exposed to a lot of bacteria as a child, you’re less likely to have allergies. Children who grow up with pets are less likely to be allergic to dogs and cats as adults.”

True Stories: How I Survived a Life-Threatening Allergy Attack

By Kimberly Holland

“I crawled on my hands and knees to the hospital.”

In May 2008, Aaron Gast was celebrating a big day in his sister’s life. She had just graduated from Wesleyan University, and the family was enjoying appetizers before dinner—fried brie, hummus, chicken wings. “I ate a bit of everything. Then I could tell something was off,” Gast says. “You can almost immediately tell.”

Gast is allergic to peanuts, and that day something he ate contained peanuts. “I turned to my wife, Angela, and I said, ‘I think I don’t feel good. We might need to go,’” he says. When this event occurred, Gast didn’t carry self-injectable epinephrine with him. (He now does.) He just knew he needed to get medicine quickly, so he and his wife took off to the nearest pharmacy.

“We got there, and it was closed. I could barely walk by the time we arrived, so I told my wife she was going to have to call 911 because we were in a strange place and didn’t know where to find anything,” he says. “They told her we were really close to the hospital, and we could probably get there faster if we walked.” The couple took off for the hospital, Gast’s anaphylaxis growing worse by the minute. “I crawled on my hands and knees to the hospital.”

Emergency workers immediately saw Gast and wheeled him into the emergency room. “I could barely talk, but I tried to tell them I needed epinephrine,” he says. They administered the life-saving medicine quickly. “The craziest thing about [the shot], when you get it, it’s almost like immediate improvement. It happens so fast you almost feel like you could get up and do whatever it was you were doing.”
Unfortunately for Gast, this anaphylaxis ended up being his worst allergic reaction ever, and he eventually required a second epinephrine injection. He also had to stay the night with IV steroids and medicines.

Growing up allergic
Gast, now 30, and his parents realized when he was about 2 years old that he had an allergy to peanuts. When he was diagnosed, peanut allergy wasn’t as common, and people weren’t as aware of the potential hazards the legume could pose.

“I remember my mom giving me regular plain M&Ms when I was growing up, and they would make my tongue feel funny. Now I know it’s because they may be contaminated with peanuts,” Gast says. It was when he ate a rice treat at a church function that his parents—and a member of his church who happened to be a pediatrician—diagnosed the problem.

“I didn’t like to make a big deal, but I ate the treat and soon threw up behind the swing sets. Then my eyes were swelling shut,” Gast recalls. “The pediatrician took me to her office, where she happened to have a vial of epinephrine.”

Today, most every packaged food will include a warning that it may contain or be contaminated by peanuts. But when Gast was a kid, it wasn’t as black and white. “There was a time when I’d eat some new cereal, and I couldn’t go to school that day because I was throwing up. My mom would call the cereal company, and they would say, ‘Yes, our cereal might contain peanuts,’” Gast says.

Living with the Threat of Anaphylaxis
Unfortunately for Gast, his allergies have become worse as he has gotten older. He now has allergic reactions to raw peas, raw sugar snap peas, and other raw legumes. But he’s quick to point out the positive in the situation: “It made me learn to cook my own food. When my wife and I moved in together, we began cooking meals rather than going out to eat. Cooking together led to some fun times,” Gast says. Today, the two maintain a food blog together.

“I also carry emergency shot now wherever I go. I keep them in the cases and carry it in a book bag,” Gast says. He also has practice pens, and he’s showed his wife how to use them in the event of another serious reaction like the one he had after his sister’s graduation. “You can be cautious, but it can really hinder your life if you take it too far. Don’t be ashamed of it. It is what it is,” Gast says.