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8/8/2019 Emergency - Allergic Reactions
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ALLERGIC REACTIONSALLERGIC REACTIONS
in thein theDENTAL OFFICEDENTAL OFFICE
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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
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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
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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
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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
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Type IType I
Immediate HypersensitivityImmediate Hypersensitivity
Generalized (Systemic) AnaphylaxisGeneralized (Systemic) Anaphylaxis
Localized AnaphylaxisLocalized Anaphylaxis
UrticariaUrticaria
Bronchial AsthmaBronchial Asthma
Food AllergyFood Allergy
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AntigenAntigen
A substance that elicits an allergicA substance that elicits an allergic
reactionreaction
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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)
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AtopyAtopy
Clinical hypersensitivity state, subjectClinical hypersensitivity state, subject toto
heredity (asthma, hay fever, etc.)heredity (asthma, hay fever, etc.)
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UrticariaUrticaria
Wheals (hives)Wheals (hives)
Smooth elevated patches surrounded bySmooth elevated patches surrounded by
erythematous areaserythematous areas
Pruritus (itching)Pruritus (itching)
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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
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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
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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
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Other Substances CausingOther Substances Causing
ReactionsReactions
IodinesIodines VaccinesVaccines
InsulinInsulin HeparinHeparin
SalicylatesSalicylates SulfonamidesSulfonamides
OpiatesOpiates Local AnestheticsLocal Anesthetics
Venom from stinging insectsVenom from stinging insects
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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
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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
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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
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Local AnestheticsLocal Anesthetics
Reactions occur most frequently with EstersReactions occur most frequently with Esters
Preservatives also cause reactionsPreservatives also cause reactions
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Ester DrugsEster Drugs
ProcaineProcaine PropoxycainePropoxycaine
BenzocaineBenzocaine TetracaineTetracaine
Related compoundsRelated compounds
Procaine Penicillin GProcaine Penicillin G
ProcainamideProcainamide
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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Drugs Used in Allergic ReactionsDrugs Used in Allergic Reactions
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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
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EpinephrineEpinephrine
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
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EpinephrineEpinephrine
Risks of repeated use:Risks of repeated use:
Excessive elevation of blood pressureExcessive elevation of blood pressure
CVACVA
Cardiac rhythm abnormalitiesCardiac rhythm abnormalities
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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
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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
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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
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Treatment of Treatment of
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
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Treatment of Treatment of
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)
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Treatment of Treatment of
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)
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Treatment of Treatment of
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
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Treatment of Treatment of
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
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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
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Generalized AnaphylaxisGeneralized Anaphylaxis
withwith Signs of AllergySigns of AllergyMonitor vital signsMonitor vital signs
Additional drug therapyAdditional drug therapy
AntihistaminesAntihistamines
CorticosteroidsCorticosteroids
Repeat epinephrine Q5min prnRepeat epinephrine Q5min prn
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Generalized AnaphylaxisGeneralized Anaphylaxis
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
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Generalized AnaphylaxisGeneralized Anaphylaxis
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
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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
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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)
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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!