SimMan: Anaphylaxis

[Plabforum]

Where are you:
FY2 in a surgical department

Who the patient is:
Mr. David Green is a 56 year old man who had an operation done 3 hours ago. He was transfused 1 unit blood and currently he is receiving his 2nd unit of blood.

Other information you have about the patient:
He is currently having breathlessness. The nurse has called you to see the patient as she is worried about him.

What you must do:
Please assess the patient and discuss management with the patient.

Set up:

1. Talking manikin-patient breathing very heavy
2. Monitor with the following vitals:

BP (mmHg)	100/60	60/40
HR (bpm)	115	130
Sp02 (%)	88	92	84

• After giving oxygen, saturation rises to 92%
• Patient becomes unresponsive.

3. Oxygen face mask (non-rebreathing)
4. Stand with blood transfuser
5. Normal saline 0.9%
6. Nebulizer masks will be there

Patient information:

• Opening sentence: “I do not know doctor, but I am not feeling very well”
• I have shortness of breath, it started half an hour ago.
• You have redness on your right arm which is very itchy.

Patient Concerns:

• What is wrong with me?
• What are you going to do for me?
• Am I going to be ok?

Examination: wheeze bilateral +++

Emotions and attitude: Looks unwell and worried

Examiner prompt:

• If the candidate mentions antihistamine, please ask him/her which anti-histamine will you give to this patient?
• If the candidate says he will stop the blood transfusion, tell them assume the transfusion has been stopped.

Approach

1. GRIPS
2. Look at the monitor (ABC)
3. History of shortness of breath
4. DDs (pneumonia, Anaphylaxis, Acute asthma, MI)
5. PMHx, DHx, Allergies
6. Examination:
   – chest examination (palpation, percussion and auscultation- wheeze is audible)
   – rash
   – Observations
7. Diagnosis: severe reaction to blood transfusion.
8. Management
   – Stop blood transfusion
   – Oxygen and IV fluids (Normal saline 0.9%)
   – Nebulizers salbutamol 5mg
   – Adrenaline 0.5 mg IM (1:1000)
   – Hydrocortisone 200mg IV
   – Chlorphenamine 10mg IV
   – IV fluids (Normal Saline 0.9%)
   – We need senior help (call cardiac arrest)
   – Further management: Take the blood back to blood unit.

[Plabforum]

Where are you:
You are an FY2 doctor in the Emergency Department.

Who the patient is:
Mr. Alex fay, 60 years old, admitted in the hospital for an abdominal surgery. He was transfused 1 unit of blood. He is now complaining of shortness of breath.

What you must do:
Take focused history, do relevant examination and management.

What is Anaphylaxis?

• Anaphylaxis is a severe and potentially life-threatening reaction to a trigger such as an allergy.
• It is also known as anaphylactic shock.
• Anaphylaxis usually develops suddenly and gets worse very quickly.

Symptoms of anaphylaxis:

• feeling lightheaded or faint
• breathing difficulties – such as fast, shallow breathing
• wheezing
• a fast heartbeat
• clammy skin
• confusion and anxiety
• collapsing or losing consciousness
• There may also be other allergy symptoms,
• including an itchy, raised rash (hives);
• feeling or being sick; swelling
• (Angioedema)

Approach

D: (Start your station by the information given by the nurse) I can see that you’re struggling to breath, is this happened after taking this blood?
D: Any itchiness? any other symptoms?
P: My lip swollen up and my hand is itchy. I also feel dizzy.

Monitor:

• If monitor is not attached: Ideally I should attach the monitor
• If monitor is attached: I can See my patient is attached to the monitor.
• Vitals: SpO2 84%, BP 90/60 mmHg & HR = 120 bpm
• Note: Patient is hypotensive, tachycardia and tachypnoeic

Interfere ABCDE

Airway

• Check for any obstruction: Tongue or Lip Swelling?
• Explain the allergic reaction to the patient. I am suspecting a severe allergic reaction to the blood you are taking so we need to manage it urgently.
• Call for help
• Remove the source & trigger (detach everything blood, antibiotics, catheter, etc)
• Elevate the legs
• Intramuscular Adrenaline 0.5-1.0mg/ml (1:1000 conc.)- can repeat after 5 minutes until pt improves.
• Establish airway- Give high flow oxygen 100 % NRM
• You can continue history. Cough? Fever? Chest Pain? Calf Pain? Medications? Medical Conditions? Allergies? smoker’s cough? MMA

Breathing

• Examine the chest
• On Auscultation = Wheeze = Change mask to Nebuliser Mask (Repeat 2-3 times every 20mins via oxygen driven nebuliser mask 6L/min).
• Take ABG.

Circulation

• Check : Capillary Refill + Pulse + BP + Insert TWO large bore IV cannulas
• Take Blood (Relevant Investigations - Blood Group. Cross Matching. Inflammatory and infection markers + routine bloods) + ECG
  -BP
  – Give I.V. Fluids (HARTMAN SOL or NS) 500ml every 10-15mins up to 2L within 1st hr.
  – O2 Still Low = Repeat Salbutamol 5mg ( 2nd )
• BP Low = Raise Legs to elevate BP. Nebuliser mask

Disability

• Check : Blood Sugar + Temperature.
• As my patient is talking to me and is obeying commands, her GCS seems to be 15/15.
• Re-assess BP :
  – Low = Add another 500ml of Hartmaan/ NS.
  – Assuming 5mins have passed repeat Adrenaline dose.

Exposure.

• Check Abdomen : ( Check wound/ incision site , Bleeding. Discharge. Swelling).
• Check Private Area = Remove catheter if its latex and Insert silicone catheter (Monitor Urine output).
• Check Abdomen/Chest/Legs ( Rash ) = Give Chlorpheniramine 10-20mg I.V.
• Re-assess Bp :
  – Still Low = Add Another 500ml Fluids.
  – Improved = Start discussion with Patient

Discussion

• Either with Patient or Examiner (SBAR)

• How are you feeling now?
• Explain the situation: You seem to be having an Anaphylactic reaction which is an allergic reaction to the blood which you are receiving. I have stopped the blood and given you some O2 and IV Fluids.
• Involve Senior.
• Document in patient Notes.
• I would like to send the blood you are receiving to the lab to cross match and see if you are receiving the correct blood or not. If it is not the correct blood, then I will have to fill an incident form.
• Will check if taking any medication you allergic to.

CKS is only available in the UK