To have adrenaline and not hesitate to use it

Proven content

In the case of an allergy sufferer, the effects of a sting may take place a few minutes after it and are then extremely dangerous. A person diagnosed with hypersensitivity should carry an adrenaline auto-injector. But still, calling an ambulance is a necessity in such a situation – says Dr. Marcin Stobiecki *, an allergist, in an interview for TvoiLokony

1. Bites and Stings – Facts You Need to Know

With dr. Mateusz Zimmerman talks with Marcin Stobiecki:

– I’ve never been stung by an insect. If I’m allergic, will I find out after the fact?

– That’s how it works. Insect venom hypersensitivity tests can be done, but the result is only relevant in conjunction with the symptoms. They suggest hypersensitivity to us, i.e. allergy to the venom. But they only occur after a sting. And not all of them are allergic.

– Which reaction is then allergic?

– If a non-allergic person is stung repeatedly, for example by a swarm of insects, it is undoubtedly a serious case and requires medical attention. But this is still the result of the toxic influence of the venom and its large amount, not of the human hypersensitivity to the venom as such. On the other hand, for a hypersensitive person, an allergic reaction may be the result of just one sting.

– Does the number of such post-sting allergic reactions increase or decrease from year to year?

– No, it’s more or less the same constant percentage of patients. For obvious reasons, there are more and more such cases in the summer.

– What percentage of people are affected by these stings?

– Estimated between 0.5 and 3 percent. population.

– All these reactions are dangerous to health and life?

– Of course not. The lighter ones – local ones, are more common and are also of concern to patients. A reaction such as a swollen limb requires mainly symptomatic treatment. It is more dangerous when we are dealing with a generalized, systemic reaction.

Several systems are heard at the same time – for example, swelling on the skin, shortness of breath, nausea, vomiting appear almost simultaneously … It is the systemic reactions that make us suspect an allergy in the first place. And it is the patients who have experienced them who require diagnosis and treatment. Simply put: desensitization. For them, another such reaction will be life threatening.

– You mean that this situation must happen first for someone to think about desensitization? Not the other way around?

– A patient who is only suspected will not be eligible for desensitization. The statistics say: if you’ve had a severe, generalized post-sting reaction, there’s more than a 50 percent chance that the next sting will end the same. The severity of these symptoms is therefore an indicator – not every patient has to be desensitized, just as not all patients with certain ailments qualify for surgery.

“So let’s assume I get stung for the first time and find out about my allergy. When and how will it happen?

“You know every sting is painful, and you know roughly what its effects are. Pain or redness at the site of a sting for several hours is only a normal reaction of a healthy organism to the venom. In an allergy sufferer, the effects may be immediate. They play out a few minutes after a sting and are extremely dangerous. Of course, we are talking about these systemic responses.

– We have already mentioned some of their symptoms. What else could happen?

– The anaphylactic shock that may occur in this situation is gradual. But at any stage it should not be taken lightly, you just have to call an ambulance.

The first degree is a mainly skin reaction: itching, burning, hives all over the body, swelling. The farther down this scale, the more severe the symptoms become: breathing problems, diarrhea and vomiting. There is severe anxiety, tightness in the chest, pressure drop, loss of consciousness. Deaths for this reason are extreme cases, literally a few cases for a few million people, but this is because, in general, proper medical care is provided.

– It may take up to 20 minutes for the ambulance to show up. What to do during this time?

– You have to follow the simplest rules. When an insect stings – you need to gently remove the sting as quickly as possible. We can put a tourniquet above the sting site – if we’re talking about a limb, of course. I mentioned that an allergic reaction is also revealed by a state of increased anxiety – the less sudden movements the victim will make in this situation, the better.

“And those who already know about their venom allergy?”

– Anyone who has experienced such a situation and referred to a doctor in relation to it can get a prescription for adrenaline. It can be purchased under the trade name EpiPen® in the form of an auto-syringe or Adrenalina WZF® in the form of a pre-filled syringe.

The family of such a person should be informed in the same way. Suppose the stung’s tongue or larynx is swollen and unable to utter a word. Someone close to you must then help, and every minute counts.

– Why is the drug sold in this form?

– This gives the greatest guarantee of proper use in an extreme situation. You need to administer adrenaline intramuscularly, so let’s imagine that something sudden happens, and here you have to unpack an ordinary syringe, stretch the adrenaline from the ampoule and inject yourself … Many people have resistance to injecting themselves, you can bend the needle in your nerves – you can predict what few potential dangers that such an injection will not be done properly.

This is not the case with the auto-injector or the pre-filled syringe. You can train its use in the office, it’s nothing complicated. [Dr. Stobiecki demonstrates the operation of the tester – MZ]. It looks like a pen. We take the hood off, hit the thigh, even through the pants. The quadriceps are the best because it is the largest. We hold it for about 10 seconds, the rest is done by the machine.

There is also a version for children – here the dose of adrenaline is halved.

– Can’t you just buy adrenaline? Prophylactically?

– It must be sold on prescription – remember that adrenaline is a double-edged weapon, it can cause a lot of side effects and life-threatening ones. The physician must have an unequivocal indication to prescribe such a drug; know that someone’s immune system is not able to defend itself against an anaphylactic reaction. After all, the human body produces adrenaline on its own, but in this particular situation – too little and hence the need to administer it from the outside.

The other problem with adrenaline is that it’s just expensive. The auto-syringe is an expense of min. PLN 250, and the pre-filled syringe about PLN 60. And – like all medicines – it has an expiry date, so an unused auto-syringe or pre-filled syringe has to be replaced periodically with a new one. And it is worth mentioning that with strong reactions, one dose may not be enough.

– How do we know that one dose is not enough?

– When, after giving it, the symptoms of shock do not subside within a few minutes. Then you need to give another dose. But let’s point out that these are really rare cases.

– Suppose I don’t have an auto-injector – I’m experiencing a severe allergic reaction. How to react to further symptoms?

– Let us repeat: calling an ambulance is a necessity. You can also lie down with your legs elevated. What is it for? In this way, blood from the venous circulation in the legs can return to the central system.

Compare the human body to a vessel in which several liters of blood circulate. The capacity of the vessel is adjusted to the amount of liquid. The essence of anaphylactic shock is that this vessel suddenly enlarges while the amount of blood remains. And the problem with its circulation begins. By lifting the legs higher, we ensure that the blood from the muscles and veins in the legs returns to the center.

– And possible swelling of the larynx, trouble breathing? Tracheotomy, cricothyroidism – are these solutions desperate or justified?

– The larynx is a tube with a certain cross section. And when it starts to swell, it does so inside. Airways close, you just can’t breathe, you hear a whistle when you try to inhale. We will not perform a tracheotomy, it is a tracheal incision procedure and is performed in a rather hospital setting.

However, you can try cricothyrotomy – in the field. Between the cartilages of the larynx there are ligaments that we feel under our fingers when we touch the neck in front: hard-soft-hard. You can try to clear the airways in these soft places. This can even be done with a pocket knife. But we are talking about situations where breathing stops precisely because the larynx is closed.

– How to behave when the injured person loses consciousness?

– Here we start standard CPR. Opening the airway, two breaths, 30 chest compressions. Of course, we check all the time whether the breathing and circulation are returning.

– We said that patients in such an extreme condition can be saved. What makes it a failure? A few years ago, it was loud about the case of actress Ewa S Pałacka. A sting, shock, ambulance service was able to help, but the actress had already died in the ambulance. How to translate it?

– I do not know the case exactly, but it is most likely one of the few situations where nothing could be done. When we are dealing with exceptional hypersensitivity to venom – which depends on individual predisposition – or the insect stings a sensitive place, mouth or tongue, help, even if provided as a textbook, will turn out to be ineffective.

There is also another risk: several hours pass after the aid is given, the administered medications stop working. Meanwhile, the venom continues to work, i.e. the inflammation enters the next stages – the anaphylactic reaction will return. This is called late phase of an allergic reaction. Quick improvement is not always a guarantee that nothing worrying will happen again.

So when can a victim of anaphylactic shock be considered safe?

– Any sensible ambulance doctor will drive such a patient to the emergency department. Another sensible physician will keep the casualty under 24-hour observation. And then you have to think about desensitization.

– What does desensitization look like?

– It consists in administering increasing doses of the vaccine. Reaching the prescribed dose may take a day, several days, or several weeks depending on the method. And the question remains, how will the patient react to the increasing doses. After reaching the dose of the so-called maintenance therapy is treated for 5 years at monthly intervals.

It is assumed that the desensitized person must consume a total portion of venom corresponding to approximately two bee stings – 100 micrograms. This should protect him from an extreme reaction, i.e. a shock, in the future.

As a result, more than 90 percent of patients after desensitisation treatment no longer experience the drastic effects of stings. There are only a few percent in whom these symptoms may recur despite the treatment. It is especially them who should remember to have adrenaline with them in such an event and know how to use it.

* Marcin Stobiecki, MD, PhD – specialist in allergy, specialist in internal diseases, physician of the Clinical Department of the Clinics of Internal Diseases of the University Hospital in Krakow, researcher at the Department of Clinical and Environmental Allergology at Collegium Medicum of the Jagiellonian University.

Read also: When a wasp can kill