In addition to today’s resource, please review “Just A Routine Operation” With A Tragic Outcome – YouTube Video By Martin Brimley With Two Additional Resources
Posted on January 4, 2021 by Tom Wade MD.
Today I link to and embed the YouTube video “AMAX4 Lecture – COMPLETE” For The Treatment Of Life-Threatening Anaphylaxis. [And Asthma]
All that follows from the above outstanding resource.
Jun 5, 2023
The rationale behind this algorithm and related concepts are presented below by Dr Ben McKenzie in an hour-long lecture presentation. Ben has been a Director of Emergency Medicine Training for 10 years, a retrieval specialist for 15 years and cares about the standard of Emergency Medicine. The concepts are presented in a lecture that Ben has presented to two thirds of Victoria’s Emergency Departments and over 500 consultants and registrars. This is the complete, all-in-one, lecture video.
Previous slides.
Transcript:
[2:33] if you die from anaphylaxis uh and you’re allergic to food um it’s almost always young people and [2:39]it’s uh almost always with someone with asthma and it’s usually from bronchospasm that they die.
2:33
Transcript:
[3:09] in Sydney at Prince of Wales Hospital there was a Corona’s report delivered a [3:15] few months ago that outlines how a 20 year old with appendicitis died from [3:20] anaphylaxis in recovery to the sugammadex which he received intravenously. He had a [3:25] history of asthma not bad asthma but he died from bronchospasm so that was medication related. [3:31] Again, asthma was the the important history as a young person dying from anaphylaxis
3:40
Transcript:
[3:42] So part one is about recognizing anaphylaxis and just the importance of that it’s just as important to diagnose
[3:49] mild acute allergies as it is to recognize anaphylaxis when we talk about anaphylaxis we talk about we talk we
[3:56] call it anaphylaxis when there’s uh wheezing or blood pressure problems or Airway problems then we call it [4:02]
anaphylaxis but actually it’s a spectrum from type one. So type 1 hypersensitivity might be mild and I’m [4:08] going to give you an example of Max and as you know Max is my 15 year old boy
[4:14] and as as many of you know he died from anaphylaxis and we’re going to get to [4:20] Max’s story in a little while but Max’s first reaction was mild he was a toddler [4:25]
sitting in his high chair adding some peanut butter and he wanted to scratch his face off so there was a trigger
[4:31] there was an acute reaction but it was a mild reaction it was skin symptoms but that [4:37] so just because he had a number of mild reactions didn’t mean that that the next reaction and the way that Max actually [4:42] died when he was 15 years old was from anaphylaxis it’s really important to diagnose those
[4:48] mild reactions because then they get linked into Alergy Services; they get their EpiPen; they get education and [4:54] hopefully avoid avoid tragedy. Sometimes those mild reactions are only
[4:59] on history so you have to you have to be able to talk to the parents acknowledge [5:05] the story because that it may be just as important. [5:11] So something that we can do better on historical features of allergy uh on [5:16] patient history are really important as seeing it in front of you.
5:34
Transcript:
[6:47] It’s important [toknow that]intramuscular adrenaline does not need [6:53] cardiac monitoring it should be a triage medication and I encourage you all to look at what happens in your own shops [6:59] in your own emergency department and say right well how are we going to get immediate adrenaline at the front door. [7:06] If they’re going straight through to Resource that’s great. But what if they’re not and it’s full and you want to give some adrenaline like you need to [7:12]
have a mechanism for that. And the nurses need to be engaged and be empowered to to facilitate that* because they should
[7:18] be able to fit that’s that’s number one all right uh just in terms of time frame
*The nurses need to be empowered to give IM epinephrine at triage if indicated.
8:36
9:14 Severity grading system for acute allergic reactions: A multidisciplinary Delphi study. J Allergy Clin Immunol. 2021 Jul;148(1):173-181. doi: 10.1016/j.jaci.2021.01.003. Epub 2021 Jan 19. [PubMed Abstract] [Full-Text HTML]
Fig 2 The grading system does not dictate management decisions; reactions of any severity grade may require treatment with epinephrine.
Severity grading system for acute allergic reactions (pocket guide). *The severity grading system is designed for use across the spectrum of acute allergic reactions regardless of whether they fulfill the NIAID/FAAN criteria for anaphylaxis. **For patients with multiple symptoms, reaction severity is based on the most severe symptom; symptoms that constitute more severe grades always supersede symptoms from less severe grades. The grading system can be used to assign reaction severity at any time during the course of reactions; reactions may progress rapidly (within minutes) from one severity grade to another. The grading system does not dictate management decisions; reactions of any severity grade may require treatment with epinephrine.
[10:45] …we use these action plans (below). I’m not going to go through them but for we [10:52] expect everyone to go home with an action plan. They’re freely available on the on the ascia website (https://www.allergy.org.au/)
10:53
Transcript
[10:59] I’m just showing you this slide again really to to to hammer home the point that that it’s a spectrum of disease so
[11:06] from mild to moderate. So I’ve I’ve just cropped it down from one of their other slides in this paper and just drawing [11:13] your attention to the purple box on the left with an arrow that show that there’s acute allergy that’s mild and [11:19] acute allergy that’s life-threatening.
10:59
Transcript:
[11:25] So we’re skipping part two to go to part three.
Part three has only got one slide.
[11:31] it here it is it’s organizing follow-up.
Okay so the patient has recovered from [11:36] their acute allergy. That you’ve treated their anaphylaxis. You’ve done a great job. Fantastic, the majority get [11:43] one dose of adrenaline, maybe two. `They go to Short Stay or for some observation [11:50] for four hours. That’s what we do at our place and and then they go [11:55] home but when they go home it’s very important they need you need to discuss the allergen and identify it you need to [12:01] tell them how to avoid it sometimes that’s easy like drugs. Sometimes it’s hard like food [and/or] they need an EpiPen, [12:08] script and training. They need an action plan and they need a referral to a [12:14] allergist in Victoria in Australia we have a mandatory notification system which [is for] [12:20] all anaphylaxis not just food and that that’s related to making sure uh to it
[12:27] really helps get some data about what further changes need to be made from public health point of view. [12:33] So that’s follow-up it’s all straightforward but it’s really important because if you don’t do it then that mild reaction who doesn’t
[12:41] get appropriate follow-up then is left exposed and gets mixed messages. So [12:48] it’s just it’s it’s really important.
Transcript
[12:54] So now we’re going to get to the main part which is part two and that’s actually trading anaphylaxis. [13:00] Treating anaphylaxis is a core specialist emergency medicine skill. This
[13:05] is just like we expect surgeons to be good at operations and not cut the wrong thing while [13:13] they’re doing the operation. We expect Emergency Specialists to be experts at resuscitating someone with anaphylaxis.
12:54
42:09:
42:36
43:50
44:18 The Hard Stop is underlined in red:
45:05:
47:30 In asthma and in bronchospasm in anaphylaxis only an endotracheal tube will provide adequate oxygenation:
48:36
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51:43
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56:28
This is the summary slide for the AMAX 4 Algorithm.
The indication for this algorithm is “If unconscious needing assisted ventilation frm asthma or anaphylaxis.”
57:45 What Happened To Max
58:18 The slide below gives the start of Max’s fatal anaphylaxis.
59:04
1:00:20
1:01:13
1:04:13
1:06:56: How Dr. McKenzie wants us to remember his son Max.
