Adrenaline Junkie

punch1Although we repeatedly hear about the negative health effects of stress, today we’re here to tell you that stress isn’t necessarily all bad. Like food, sex, and shoes, it’s quality, not quantity, that determines whether stress helps or hurts!

Beneficial stress comes in the form of an acute, stimulating surge, like when your raft starts to overturn in some seriously churning rapids. The resulting single adrenaline (epinephrine) burst that comes and goes very quickly is a good thing because it gives you energy and gets you ready to mobilize for immediate action.

Physiologically, the adrenaline created by an abrupt blast of stress sends a flood of oxygen-rich red blood cells through your body, boosts your immune system, and signals your brain to start releasing painkilling endorphins.

stressed-womanBad stress, on the other hand, is intense and drags on and on. This constant grind causes your adrenal glands to leak a slow, steady stream of another stress hormone: cortisol. And unlike adrenaline, which tends to hit your system in a flash and then dissipate, cortisol often wears out its welcome by hanging around in your bloodstream, driving up blood pressure, suppressing your immune system, and making you more susceptible to a slew of stress-related ailments, including colds, irritable bowel syndrome, migraines, and even heart disease and stroke.

So how do good stressors battle the bad ones? It all comes back to the positive power of adrenaline. In addition to all of its performance-enhancing effects, it triggers the release of dopamine and endorphins, two neurotransmitters that make you feel good – really, really good.

It also makes me feel good – really, really good, given the activities I have planned this weekend. But more of that later…

skydivingFor now, let’s return to our favorite stress hormone – epinephrine. If you’ve ever tried skydiving, bungee jumping or heli-skiing, you’ll probably remember literally flipping out during your first attempt. But once you landed safely you probably experienced a euphoric, fist-pumping high thanks to dopamine flooding your brain’s pleasure center, giving you. During the next jump, you may still have felt all the same physiological stress responses such as a pounding heart and sweaty palms but instead of being terrifying, it’s exhilarating, because your mind’s already anticipating the thrill of that dopamine reward.

And the more times you do it, the less anxiety you’re likely to feel and the more fun you’ll have. That’s because your brain’s tagging the experience as a positive one.

And the benefits persist.  Before long, your body can start to develop an almost Pavlovian response to stressful situations. If your nerves are tingling, your stomach is clenching, and you can barely breathe, then it’s tricked into thinking something really awesome is about to happen!

white-water-canoeing-18990699That’s what researchers at Texas A&M University found when they put a small sample of men and women through a series of purposely stressful outdoor adventure tasks. Some subjects – the fittest ones who were already comfortable with physical challenges fared better than others. The researchers discovered that those participants had a reduced stress response (including lower blood levels of cortisol) when facing demanding activities like whitewater canoeing or rock climbing. Essentially, they were more confident and less stressed out, even though the tasks were potentially hazardous. This may be because their past experience blazing through strenuous situations made them less likely to perceive new challenges as stressful or difficult. And according to the researchers, it’s possible to transfer that oh-so-cool-and-collected response to life’s other nerve-racking events.

Better still, you don’t have to scuba dive with great whites or BASE jump off the Empire State Building to reap the stress-busting perks of adrenaline. Whether you hit the bunny slope or the double-black-diamond mogul fields, as long as you’re taking a giant step outside your comfort zone, you’ll give your body that adrenaline kick and when you do it regularly and keep testing your edge, you’ll change your relationship with stress for the better.

So next time that little voice inside your head starts clamoring, no freaking way, just go for it and be prepared to reap the rewards.

dropcoaster

bull runWhich brings me back to my weekend. Keen to test the above theory for myself and readers of SRxA’s Word on Health, I will be spending tomorrow riding some of the longest, highest, fastest most insane rollercoasters in the country…and the following day I will be running with the bulls. If being pursued by twenty-four 1,000-pound bulls doesn’t set my adrenaline firing on all cylinders, then I guess nothing will.

I”ll let you know (hopefully) on Monday!

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Emergency! Epinephrine in Anaphylaxis: under-use and inappropriate use by EMS

anaphylaxis 3Despite a decline in anaphylaxis deaths over the past 25 years, lack of epinephrine and incorrect administration of epinephrine still play a significant role in mortality.

According to a retrospective case study by researchers from McMaster University in Hamilton, Ontario only a quarter of patients received epinephrine prior to cardiac arrest, including those treated by emergency medicine personnel.

anaphylaxis deathsOf the 80 deaths recorded in Ontario from 1986 – 2011, 47 had a known or suspected allergy to the fatal allergen, but only 18 had been prescribed an epinephrine auto-injector and only 9 had their auto-injector at the time of the reaction. And at least 8 of these people received epinephrine that was either expired or administered incorrectly.

The low proportion of patients who received epinephrine correctly may indicate that more information is needed by both patients and first responders regarding indications and techniques for administering epinephrine and auto-injectors,” said lead investigator, Ya Sophia Xu, MD

Most of the fatalities were caused by food allergy (n = 37), insect sting (n = 27), or medication (n = 11).  But in 5 patients, death occurred with no known allergen.

More than half (59%) of the food-related fatalities involved food eaten away from home – at public places including school, camp, or another person’s home.

Patients with food allergies should be especially vigilant when eating outside of the home,” added Dr. Xu “restaurants need to improve the labeling and disclosure of potential allergens to the public.”

The study also revealed that Coroners’ reports are sometimes lacking information about the severity of previous allergic reactions, level of asthma control, time of administration of the first epinephrine dose, body mass index of patients, and anatomical location of the epinephrine injection.

Ambulance at Emergency EntranceRyan Jacobsen, MD, EMT who is associate emergency medical services director for the Kansas City Fire Department in Missouri commented “there seems a perception among pre-hospital personnel that the administration of epinephrine is dangerous.”  He and his colleagues recently published a study with very similar results.

Dr. Jacobsen’s team surveyed 3,500 nationally registered paramedics in the United States and found that 36.2% of responders felt there were contraindications to the administration of epinephrine for a patient in anaphylactic shock. And 40% of paramedics (incorrectly) believed that diphenhydramine was the first-line medication for a patient suffering from anaphylactic shock.

They also had challenges in the recognition of atypical presentations of anaphylaxis and determining the correct location and route of epinephrine administration,” he said.

Only 2.9% correctly identified atypical presentation of anaphylaxis, while less than half (46.2%) identified epinephrine as the initial drug of choice. Equally concerning, only 38.9% correctly chose the intramuscular route of administration, while 60.6% incorrectly identified the deltoid, rather than the anterolateral thigh as the preferred injection site location.

As an EMS educator I spend much of my time, discussing the 5 Rights of Administration: right patient, right time, right drug, right route, right dose.

Yet, according to this study, it seems as if emergency medical personnel are routinely failing on all 5 when it comes to anaphylaxis.

Basically, we have the same issues in the United States that were found in the Canadian study,” says Jacobsen. “There needs to be an aggressive educational campaign geared toward emergency personnel in both the safety of epinephrine and its importance as the first-line therapy for anaphylaxisThe benefits of epinephrine almost always outweigh the risks, but there’s a reluctance to use it. Patients get palpitations, they might get a headache, their heart rate goes up, but it’s a potentially life-saving treatment.

Amen to that.

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Doctors Deficient in Anaphylaxis Care

Having just returned from the American College of Allergy, Asthma and Immunology (ACAAI) annual meeting, we’re spoiled for choice of news. But among all the science there was one stand out shocker.  In a session on Sunday, physicians presented the results of a survey, sponsored by the Asthma and Allergy Foundation of America (AAFA). During this, they revealed that a disturbingly high proportion of primary care and emergency physicians don’t know how to treat anaphylaxis.

Interviews with 318 physicians indicated that:

  • substantial numbers do not always provide epinephrine to patients – even those  they believe are having anaphylactic reactions
  • they often fail to refer anaphylaxis patients for follow-up care
  • they believe incorrectly that some patients should not receive epinephrine auto-injectors

Myron Zitt, MD, says the results reveal “likely deficiencies in physician knowledge,” and corroborate results from earlier chart review studies.

In the telephone-based survey, researchers conducted interviews lasting an average of 19 minutes with approximately 100 emergency room physicians, 100 allergists, 50 adult primary care physicians, and 50 pediatricians.

82% to 99% of respondents in each group said they had treated at least one anaphylaxis case.

Although epinephrine is supposed to be given to all patients having such reactions, about 10% of emergency room physicians and 20% of primary care and pediatric physicians said they had done something else.  These “something else’s” included prescribed another drug, sending the patient to a hospital, or an “other” action.

Prescribing of auto-injectors for patients to take home also was far from universal. Barely 60% of emergency room physicians said they did. In fact, emergency physicians were generally bad at all phases of follow-up care. They rarely referred patients for diagnostic tests, they almost never demonstrated use of an auto-injector, and seldom explained that auto-injectors have an expiration date.

Another disturbing finding from the survey, Zitt said, was that many physicians of all types – even the allergists – mistakenly believed that some patients should never receive epinephrine.

In the same session, Akhil Chouksey, MD, reported that anaphylaxis care in a major teaching hospital usually failed to meet guidelines established by a consortium of allergy societies including the ACAAI.  In a 10-year review of anaphylaxis cases only 15% met the standards of care recommendations i.e. that epinephrine be administered within 30 minutes of triage, that auto-injectors be prescribed at discharge, and that patients be referred to an allergist or immunologist for follow-up investigations and treatment.

The review also found that in 26% of cases in which anaphylaxis was definitively confirmed, the patients never received epinephrine.  Antihistamines, such as benadryl (diphenhydramine), were given in nearly all cases but epinephrine was omitted in one-quarter. In fact, epinephrine was only the third most commonly administered medication, with corticosteroids such as methylprednisolone, taking the second spot after antihistamines.

During the question-and-answer period, an audience member suggested that, when patients present with relatively mild symptoms, the treating physicians may decide that epinephrine isn’t needed at that point.  Zitt countered, that this was a very dangerous approach.

The national guidelines state explicitly that there are no absolute contraindications to epinephrine. Nevertheless, 16% of the pediatric allergists and 32% of the other allergists said there were such contraindications, as did 38% of adult primary care and emergency physicians.

Also common were beliefs that schools, restaurants, and ambulances always stock epinephrine. In fact, Zitt said, there are no general requirements for schools or restaurants to do so, and approximately half of all ambulances do not have epinephrine on hand.

Clearly there is much work still to be done in terms of education.  SRxA’s Word on Health suggests a first step would be to instill a healthy fear of anaphylaxis into doctors and the general public while simultaneously removing the fear of epinephrine.

Or as Dr Zitt says, “Give epinephrine first, ask questions later.”

Modern Family’s Emmy winning actress takes on the most important role of her life

Actress Julie Bowen, recently awarded her second Emmy for her role in the hit TV comedy “Modern Family,” started a more serious role last week: raising awareness about life-threatening childhood allergies and anaphylaxis.

The two-time best supporting actress in a comedy series and mother of three knows firsthand about potentially fatal allergic reactions. Her oldest son, Oliver, was 2 years old when he developed anaphylaxis as a result of a double-whammy exposure to a bee sting coupled with a bit of peanut butter.

“We had no reason to suspect we might have a problem. He had had peanuts before. And he had always been fine,” explained Bowen. “But then one day we found out that, no, he’s not.”

Almost immediately, Oliver’s face swelled dramatically. Other symptoms of anaphylaxis include chest pain; hives; breathing difficulties; tightening of the throat; lip and tongue swelling; nausea; dizziness and fainting.

Bowen’s husband, who was at home with the toddler, was terrified. “He knew it was bad.” Oliver was rushed to the hospital and immediately given an injection of epinephrine – the drug used for the emergency treatment of anaphylactic reactions that can follow exposure to allergens such as peanuts, walnuts, shellfish, bee stings, medications and/or latex.

Although any child can develop an allergy, or abnormal immune response, they are more likely to occur in people whose family members also have allergies.

Bowen now is spearheading the nationwide awareness campaign with the help of Mylan Specialty L.P., the pharmaceutical company that makes EpiPen®.

The goal is education,” said Bowen. “We, as parents, can’t always be with our children all day, every day. So we want the people around them to be educated.”

Thankfully, Oliver made a full and quick recovery. “Once he had the proper medicine, it was a very quick process,” she noted. “But today we always carry epinephrine with us wherever we go.”

Food allergies are the leading cause of anaphylaxis. The U.S. Centers for Disease Control and Prevention (CDC) estimates that food allergies in children have increased 18% since 1997. More than 9,000 children are hospitalized because of severe food allergies each year.

Many allergic reactions occur when children accidentally consume foods they’re allergic to at school. According to the CDC as many as one-quarter of anaphylaxis happens in students with no history of food allergies.

Parents and school employees shouldn’t dismiss a child’s complaints, Bowen says, “We want parents and teachers to know the signs, so that if you see them coughing, scratching at their throat some, or that they’ve got some rash, that you go ahead and look into it further.”

If you suspect your child may have an allergic reaction to anything, get it checked out. Call 911 and get medical attention immediately because there’s no way to guarantee that your child is never going to have an anaphylactic reaction.

The odds are not insignificant. “One to two children in each classroom could potentially be at risk for a serious food allergy,” says Dr. Carla Davis, an assistant professor of pediatrics in the section of immunology, allergy and rheumatology at Texas Children’s Hospital in Houston.  Of those, 30-40% would be at risk for life-threatening anaphylaxis.

Epinephrine is the first-line treatment, and caregivers must act quickly in order to treat effectively.  How quickly? Ideally, within minutes of the child developing a reaction.

For more information on anaphylaxis, visit the Food Allergy & Anaphylaxis Network.

Be S.A.F.E.

SRxA’s Word on Health was deeply saddened to hear of the seven-year-old girl from Chesterfield County, Virginia who died this week after suffering an allergic reaction at school.  According to news reports she was given a peanut from another child who was unaware of her allergy.

Our heartfelt condolences go out to her family and friends. We dedicate this blog as a tribute to her and all the other children who have lost their lives to anaphylaxis.

Although there’s no cure for food allergies, as we’ve reported in the past, such deaths are almost entirely preventable with proper education and immediate treatment with epinephrine.   And even though we don’t know all the details of this case, what we do know is that food allergies are on the rise. 8% of children under age 18 in the United States have at least one food allergy.

Now, we’d like your help to prevent a similar tragedy from happening in the future.

The American Academy of Allergy, Asthma and Immunology’s  Be S.A.F.E. campaign is dedicated to educating patients and healthcare professionals on the steps needed to save lives. We urge you to read the campain’s action guide and share it with your colleagues, friends, and relatives. If you have kids in school, make sure the teachers are aware of it. If you use a gym, make sure the trainers know. Tell your favorite restaurant, share with your employer…the list goes on and on.

BE SAFE

Seek immediate medical help. Call 911 and get to the nearest emergency facility at the first sign of anaphylaxis, even if you have already administered epinephrine.

Identify the Allergen. 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.

Follow up with a Specialist. Ask your doctor for a referral to an allergist/immunologist, a physician who specializes in treating asthma and allergies. It is important that you consult an allergist for testing, diagnosis and ongoing management of your allergic disease.

Carry Epinephrine for emergencies. If you are at risk for anaphylaxis, make sure that you carry an epinephrine kit with you at all times, and that family and friends know of your condition, your triggers and how to use epinephrine. Consider wearing an emergency medical bracelet or necklace identifying yourself as a person at risk of anaphylaxis. Teachers and other caregivers should be informed of children who are at risk for anaphylaxis and know what to do in an allergic emergency.

So there you have it. 4 simple steps that could save lives. Go share them!

Emergency Epinephrine Act

SRxA’s Word on Health is pleased to start the week with some good news.  Last Friday a new federal bill known as the School Access to Emergency Epinephrine Act was introduced in the Senate.  The Bill encourages schools to prevent allergy-related deaths by allowing trained, qualified staff to give an injection of epinephrine to a student suffering from a severe allergic reaction.

The tragic deaths of teenagers in Georgia and Illinois, who did not have immediate access to epinephrine, underscores the importance of immediate treatment and the passage of this legislation. One, a 13-year-old student from Albany Park, IL who had previously suffered from only minor allergies died at her school because of a severe allergic reaction.

Following this, Illinois passed a law that allowed school nurses to administer epinephrine shots to any student suffering from a severe allergic reaction. The new legislation proposed by Illinois Senators Mark Kirk and Dick Durbin would expand the law by allowing all trained and authorized school personnel — not just school nurses — to administer the shot.

U.S. Senator Mark Kirk (R-IL) said, “For the millions of children suffering from serious, potentially fatal allergies, the safe and expedient administration of epinephrine can mean the difference between life and death. Something as seemingly harmless as a bee sting during recess or a peanut butter and jelly sandwich during lunch can quickly become a tragedy.”

For about 1 in every 13 children, school lunchtime or a classmate’s school birthday party can risk exposure to foods that can cause a severe and life-threatening reaction. For these children, the consequences of exposure to the wrong food can be fatal.  However, if epinephrine is available such consequences are preventable.

The legislation would reward states that require schools to maintain a supply of epinephrine auto-injectors, such as EpiPen, and train authorized school personnel to administer an epinephrine injection if a student experiences an anaphylactic reaction. The bill also contains a provision that requires those states to have Good Samaritan laws in place to protect school employees who administer an epinephrine injector to any student believed to be experiencing anaphylaxis.

Although students with severe allergies are allowed to self-administer epinephrine if they have a serious allergic reaction, a quarter of anaphylaxis cases at schools involve young people with no previous allergy who are unlikely to carry a personal epinephrine injector.

Attorney General Lisa Madigan applauded Durbin and Kirk on their push for federal legislation. “Growing numbers of children suffer from life-threatening food allergies,” Madigan said. “In Illinois, we were able to eliminate bureaucratic barriers that previously prevented schools from acting when a child could be suffering from a severe allergic reaction but whose medical records didn’t reflect an allergy diagnosis.”

Word on Health also applauds the introduction of a law that could save children’s lives and raise awareness that in anaphylaxis every second counts. We also hope it will stimulate a wider dialog that could eventually lead to epinephrine autoinjectors becoming available in airports and on airplanes, in restaurants, sports stadiums and other public places…much as automated external defibrillators (AED’s) are today.