# Handling Allergic Reactions When the Doctor is You



## Themedicalprepper (Feb 17, 2016)

Allergic reactions are a common medical emergency. They can present as mild, moderate, severe, or anaphylactic (the worst). Allergic reactions (AR's for short), are the immune system's way of responding to a specific "something" that it has decided shouldn't be in the body. The immune system's response can vary wildly from person to person, and also based on how strongly it feels the "something" shouldn't be in the body and how quickly it wants to get rid of it. The most basic immune response to AR's is a release of histamine. Histamine is a really cool chemical in the body that serves a lot of purposes. There are two kinds of histamine - H1 (histamine type 1) and H2 (histamine type 2). Both types increase in an allergic response, however it is primarily type 1 that is related to a "histamine response" (swelling, itching, redness of skin), whereas type 2 is really involved in regulating stomach acid (among other things in the body). But, again, both are involved in an AR immune response. There are other chemicals (think of them a soldiers the immune system sends out to wage war and attack an invader), but their names and roles aren't really important. What is important is recognizing an allergic reaction (the causes, signs, and symptoms), and knowing what to do about it.
There are some very common causes of AR's in children and adults. These include:


Milk and dairy products
Peanuts
Tree nuts
Eggs
Soy
Fish
Wheat / Gluten
Shellfish
Insect venom
Medications (like penicillin)


As I mentioned earlier, there are varying degrees of reaction and immune response. I will explain what mild, moderate, and severe reactions look like in the next section, but I first want to explain what the worst kind of reaction - anaphylaxis - looks like. I learned in school that an anaphylactoid reaction is anaphylaxis that has never happened before with a specific trigger. So, an anaphalctoid reaction has occurred in the child or adult stung by a wasp when there has never been a bad reaction in the past. Anaphylaxis is just simply the word to describe the very severe immune response to a given allergic trigger, and this reaction has a very distinct appearance.

Anaphylaxis is the worst of the worst types of reactions. These AR's must be treated immediately and, usually, the treatment requires an initial dose of epinephrine (aka, the Epi-Pen). In these posts, my mindset is that you don't have a hospital to go to, that you're the end-all for medical care. I will do my best to give you all of the information. This is one of those medical emergencies, though, that will make you wish you had an emergency department to go to. The throat and facial swelling of extreme anaphylaxis sometimes results in rapid intubation (a tube that slides down the trachea to help air get past the swollen throat tissues) or an emergency tracheotomy (a hole is cut in the throat through the outer wall of the trachea and a tube is inserted for the same reason as in intubation). What are you going to do? The rapid decline of blood pressure in extreme anaphylaxis often results in the need for both IV fluid and medicines to increase the blood pressure which must be tightly controlled. What are you going to do? This is a hairy emergency to think about treating in a situation where you're calling the shots.

I will describe the signs and symptoms of allergic reactions based on the degree of immune response (again, how bad does the immune system want the trigger [allergen] out of the body and how quickly is it going to try to make this happen).

MILD

Watery eyes
Itchy eyes
Runny nose
Itchy skin
Some sneezing

MODERATE - includes any of the above with any of the following:

Skin rash
Hives
Swelling around the lips
Swelling around the eyes
Swelling of an area of skin that has been stung

SEVERE - includes any of the above with any of the following:

A degree of skin swelling that is greater than twice the normal size
A degree of swelling around the eyes that covers the eyes
A degree of tongue swelling so that swallowing is difficult

ANAPHYLAXIS - These symptoms usually occur within minutes of exposure to a trigger (allergen) but can occur hours after being exposed. Symptoms can include any of the above with any of the following:

Wheezing with breathing
Difficulty breathing
Increased heart rate
Decreased blood pressure
Dizziness
Nausea, vomiting, or both
Diarrhea
Abdominal cramping
Faintness
Sweating

A note on traditional versus complementary / natural treatments. In mild to moderate allergic reactions, it may be acceptable for you to whip out your natural, complementary, or other non-traditional med-kit. However, in severe reactions, and absolutely always in anaphylactic reactions, go straight for the traditional treatment approach. We have engineered some exceptional medications for treating allergic reactions. Don't spare them in the worst cases because they aren't natural. They may not be natural, but they are surely life-saving with little to no degree of adverse side effects. The primary objective in a severe or anaphylactic reaction is to stabilize and treat quickly.

*TREATMENT*
MILD to MODERATE (choose 1, wait 1 hour, then choose 1 more if symptoms indicate)

Oral diphenhydramine (benadryl) 25mg to 75mg
Oral cetirizine (zyrtec) 10mg

SEVERE / ANAPHYLACTIC - This is where it gets hairy. Pay attention to the dosing because I differentiate based on age.

Adult (greater than 60 pounds)

Initial treatment should be with an Epi-Pen auto-injector, or with 0.3-0.5 mL of epinephrine 1:1,000 using a 22 gauge 1.5″ needle with syringe, injected into the outer middle of the thigh. This can be repeated every 5 to 15 minutes depending on the response, up to 4 times.
Give 50mg oral diphenhydramine (benadryl, an H1 blocker) AND 40mg oral famotidine (pepcid, an H2 blocker), as long as there is no swallowing difficulty.
Lay the person flat and elevate their feet.

Child (60 pounds or less) - CAUTION: treating kids is much more complex than adults

Initial treatment should be with an Epi-Pen Jr. auto-injector, or with 0.01 mg/kg of epinephrine 1:1,000 using a 22 gauge 1″ needle with syringe, injected into the outer middle of the thigh. This can be repeated every 5 to 15 minutes depending on the response, up to 4 times. The math on this is more simple than you might think. If a child weighs 40 pounds, then you divide 40 (or their weight in pounds) by 2.2 to figure out how many kilograms whey weight which, in this case, is 19kg (rounded). Then you multiply 19 by 0.01 (our dose above) which equals 0.19 (rounded) milligrams as the total dose. If you don't have an Epi-Pen Jr. (in which case this math is unnecessary), then you should have epinephrine 1:1,000 in a vial. This is a 1mL vial containing 1mg. Simple math here because you need 0.19mg (also 0.19mL because it is a 1mL vial containing 1mg of epi). You'll also need a 1mL or TB syringe. You'll draw up 0.19mL to 0.20mL and inject as described above. Kids are complicated, but you have to get it right.
For oral diphenhydramine (benadryl), use a weight based dosage guide, and as long as there is no swallowing difficulty.
Oral famotidine (pepcid) 10mg can be given if there is no swallowing difficulty

ADVANCED (if available and if you have the training):

Give 100% oxygen at 10 liters per minute
Start a large bore IV (16 to 20 gauge for adults, 20 to 22 gauge for children) and give:
Adults:1 liter of 0.9% normal saline (regular IV fluid)
Children: 10 to 20mL/kg of 0.9% normal saline (regular IV fluid)
Assess for breathing difficulty and make a decision about an airway. If the person is unconscious and breathing is mildly labored because of a closed mouth, use an oropharyngeal or nasopharyngeal airway (with lubrication). If the airway is in imminent closure because of swelling, and you have the training, intubate and use a bag valve connected to 100% oxygen. Manually breathe for them using the bag valve at a rate of 6 to 8 breaths per minute.
For swelling, especially around the lips, eyes, and throat, consider 125mg of methylprednisolone (solumedrol) or 10mg dexamethasone (decadron) IV slow push.
At this point, hopefully, you've either got the reaction under control or you can ride out the rest of it using some of the advanced techniques from above. If a person does not respond to epinephrine after 4 injections it may be time to mix a "dirty bag". A "dirty bag" is 250mL of dextrose 5% in water mixed with 1mL of epinephrine 1:1,000 and infused at about 4 drops per minute if you don't have an IV pump. But preload your line with the "dirty" solution so you're not waiting an hour before any medicine actually reaches the blood.

*FOLLOW-UP*
Your primary objective after stabilizing a patient following an allergic reaction is making sure their ABC's (airway, breathing, circulation) remain stabilized. For skin reactions, follow-up includes making sure a rash (like the one pictured above) doesn't turn into a skin infection (cellulitis). A good way to remember the signs of a skin infection are to memorize the Latin mantra "rubor, tumor, calor, dolor", or redness, swelling, heat, pain. These indicate inflammation and, usually, infection if persistent. Waiting a day to watch for the rash to spread after you have treated the allergic reaction is a rule of thumb. If the rash has the four signs after treatment with anti-histamines, and if the affected person gets a fever greater than 102 F, start treatment with clindamycin (cleocin) 300mg oral 3 times daily for 10 days.

*FOUNDATIONS FOR TREATMENT*
Start aggressively based on the type of reaction. As mentioned above, in mild to moderate reactions it may be appropriate to use complementary / natural methods for treatment. But monitor symptoms and watch for signs of a worsening reaction. Following allergic reactions, the though should always be to prevent more reactions. The best prevention is avoidance of the trigger (if known).

*ASSESSMENT PEARLS*
Look at the tongue. In any allergic reaction, especially a new one, always look at a person's tongue. Ask them if it feels bigger and whether they're having difficulty swallowing. This is a great indicator for impending anaphylaxis as it let's you know they're immune system is really upset and that the reaction is more than just moderate.


----------



## Coastie dad (Jan 2, 2016)

Thanks. I, for one, appreciate this post.


----------



## Maine-Marine (Mar 7, 2014)

benadryl.....


----------



## Arklatex (May 24, 2014)

I didn't know Zyrtec worked like benedryl. Is one better than the other?


----------



## Mad Trapper (Feb 12, 2014)

I have benadryl, should be in you BOB med kit, and an epi-pen (several) if you have a script

P.S. benadryl gives a false positive for cocaine in urine screens.


----------



## Medic33 (Mar 29, 2015)

epi pen and transport to a med center asap
do not f-around seek and ER


----------



## Camel923 (Aug 13, 2014)

epi pens and epinephrine in a vial have short expiration dates. The question is how long are they actually good? Some antibiotics can be good for a decade. Nice post medicalprepper


----------



## Medic33 (Mar 29, 2015)

if you have that issue you got a pen and when you need a new one you get one 
you want to try and use ditch medicine on your kid go for it 
you know the difference between God and doctor? God never claims to be a doctor.


----------



## ffparamedic (Dec 14, 2015)

Very good detailed post, thanks for posting it.

Epi stays potent for quite some time.


----------



## turbo6 (Jun 27, 2014)

Benadryl is a first gen antihistamine, works the best but has most sedative effect. Zyrtec, despite being a newer antihistamine can have some sedative effect as well so you can try others in the class and see which works best and/or makes you less drowsy.

For instance, Zyrtec makes me mildly tired, not as bad as Benadryl. Taken a night, either one is fine and Zyrtec tends to last longer for me. 

For day time use I go with Allegra or Claritin, much less drowsy but slightly less effective, more so with Claritin as that is a last resort for me as it is the least effective I've used.


----------



## Kauboy (May 12, 2014)

This is an exceedingly informative post, and eye-opening.
I'm wholly unprepared and unqualified to do most of this.
I have benedryl in adult and child dosages, but that's where it stops.
Even in a short-term grid down scenario, the likelihood that I would be able to do anything to remedy anaphylaxis is very low.

Epinephrine vials? IV kits? Saline bags? The various medications?
I know "about" all of these things, but real-world application and availability is severely lacking.
I was only just introduced to IV insertion last week when I got lost wandering the pages of Youtube.

Thank the Lord I don't have any family members with severe allergies.
My wife's throat itches when she eats bananas, and that's about it.


----------



## tirednurse (Oct 2, 2013)

Kauboy said:


> This is an exceedingly informative post, and eye-opening.
> I'm wholly unprepared and unqualified to do most of this.
> I have benedryl in adult and child dosages, but that's where it stops.
> Even in a short-term grid down scenario, the likelihood that I would be able to do anything to remedy anaphylaxis is very low.
> ...


Kauboy, as informative as this post is, in reality "if you are the Doctor" in a real life SHTF situation most of this will not apply to you. 
over the counter antihistamines are about the only thing we would have access to, unless you were able to secure a pharmacy in your looting. There are lots of times when we could have a mild reaction to something that we can quickly take care of with our stocks of benadryl, the more serious reactions we will not be able to do anything about. Just like we won't be able to cure cancer, provide insulin to a diabetic, medications for heart disease, chronic obstructive pulmonary disease, and a bunch of other conditions and emergencies we may encounter. Unfortunately this will be out of our control.
hopefully those with the chance of such a bad reaction will already have epi pens available and the knowledge to use them. people like you wife should be very careful. Even a tickle in the throat can develop into a full blown attack


----------



## cdell (Feb 27, 2014)

Very informative, thanks. We have young kids and haven't found any allergies yet but we got two epi pens to keep at home in case we come across something and one of them react badly. We live out in the country and we are half an hour to the hospital when the roads are good so I figured it's cheap insurance if we find out the hard way someone is allergic to bees.


----------



## Denton (Sep 18, 2012)

Arklatex said:


> I didn't know Zyrtec worked like benedryl. Is one better than the other?


Depends. No matter how similar, antihistamines are different. Even the effective difference between brand name and store equivalent varies between persons.

Know your allergies and the meds needed.

I'm allergic to wheat. It makes me itch madly. I'll wake up bleeding because I was clawing at my arms or legs. It's one thing when things are normal, but it will cause infection when the world has gone unsanitarily nasty.

Benedryl is worthless for allergies involving the skin, but Zyrtec is great; the gel caps in particular.

The catch is that the body gets used to allergy meds, and that can suck. Good news for those with allergies that cause itching, though! Xyzal! Yes, it is prescription, so, you get a prescription but use it only a few months and switch to OTC Zyrtec while still picking up the Xyzal.

I hope we have time to stock up on the meds we will need.


----------



## SittingElf (Feb 9, 2016)

Denton said:


> *Know your allergies and the meds needed.
> *
> 
> I hope we have time to stock up on the meds we will need.


Absolutely the most important piece of the puzzle. Find out what your allergies are NOW...not after SHTF!

I'm fortunate in having a pharmacist as a next door neighbor, and who is part of our SHTF contingency prep group. Instant access to a hoard of pharma supplies he will grab when the grid goes down (he has already planned a list), and secure in what will become a compound instead of our "neighborhood".

The most difficult challenge we have not yet figured out is how to keep and store drugs that need some sort of refrigeration, or temperature control (like insulin and some antibiotics). Been looking at small battery powered refrigeration units (like you find for car travel), that might be able to utilize solar powered batteries, but still working on the ultimate solution. (Fortunately, our Florida location favors the use of solar power for whatever we can utilize it for.)


----------



## Themedicalprepper (Feb 17, 2016)

Xyzal is great. Xyzal is levocetirizine - the left isomer of cetrizine (zyrtec). Chemists isolated the left branch isomer to weed out a lot of the adverse effects and increase the potency. Xyzal is usually 5mg, versus the OTC cetirizine 10mg. It does work great.


----------



## Denton (Sep 18, 2012)

Themedicalprepper said:


> Xyzal is great. Xyzal is levocetirizine - the left isomer of cetrizine (zyrtec). Chemists isolated the left branch isomer to weed out a lot of the adverse effects and increase the potency. Xyzal is usually 5mg, versus the OTC cetirizine 10mg. It does work great.


Pain in the butt to get as it means a doctor's visit. That costs me vacation hours. I wish they'd make it OTC.


----------



## azrancher (Dec 14, 2014)

Denton said:


> Pain in the butt to get as it means a doctor's visit. That costs me vacation hours. I wish they'd make it OTC.


Everybody should see their PCP yearly. I asked him for a prescription to epipen and he had no qualms about doing it, said I had asthma, and didn't want to take a chance.

Later that year, I was cleaning the garden out, taking the dry hops vines down, apparently they grow a quality form of penicillin, or similar. Later that night I broke out in hives went into shock, forgot about the epipen used benedryl took a ride with the medics to the hospital where they proceeded to pump me full of epinephrine, they didn't have a 24 hr bed available so helio to Tucson ($38,000) and 2 days in the critical care unit, BS University hospital care...

*Rancher *


----------



## Denton (Sep 18, 2012)

azrancher said:


> Everybody should see their PCP yearly. I asked him for a prescription to epipen and he had no qualms about doing it, said I had asthma, and didn't want to take a chance.
> 
> Later that year, I was cleaning the garden out, taking the dry hops vines down, apparently they grow a quality form of penicillin, or similar. Later that night I broke out in hives went into shock, forgot about the epipen used benedryl took a ride with the medics to the hospital where they proceeded to pump me full of epinephrine, they didn't have a 24 hr bed available so helio to Tucson ($38,000) and 2 days in the critical care unit, BS University hospital care...
> 
> *Rancher *


Point taken. Inconvenience and money spent now is better than a whole lot of money and inconvenience, later.

Will make an appointment very soon.


----------



## Mad Trapper (Feb 12, 2014)

So how about poison ivy/oak?

my remedy is learn what it looks like and avoid, if exposed cold water and detergent ASAP


----------



## azrancher (Dec 14, 2014)

Mad Trapper said:


> So how about poison ivy/oak?
> 
> my remedy is learn what it looks like and avoid, if exposed cold water and detergent ASAP


There are special remedies for poison ivy/oak, that not really an allergic reaction, you need to get the oils off your skin asap, I killed off every bit we had here. An epipen is also not good for rattlesnake bite.

*Rancher*


----------



## Mad Trapper (Feb 12, 2014)

azrancher said:


> There are special remedies for poison ivy/oak, that not really an allergic reaction, you need to get the oils off your skin asap, I killed off every bit we had here. An epipen is also not good for rattlesnake bite.
> 
> *Rancher*


I concur with eliminating the plants, I do a cleanup every 2-3 years of crap that has taken hold like poison ivy, bayberry, bittersweet etc....

Don't burn it, the smoke is poison too, I use roundup/glyphosphate. Damm birds eat then crap out the seeds so you have to look over things regularly. I sprayed a bunch last fall I found scouting deer.

Poison ivy/oak is an allergy. Some people need several exposures to build up a reaction.


----------

