By Aaron Collins

Ah, glorious spring! The beautiful flowers, balmy temperatures, blue skies … the bee stings and anaphylaxis, followed by death due to asphyxia.

Small wonder that poets leave anaphylactic shock out of their odes to springtime: The medical condition is not exactly a thing of beauty. Whether due to insect sting or the inadvertent consumption of a food allergen, anaphylaxis strikes quickly and can be deadly if not treated promptly.

The season’s rare medical downside is not usually high on people’s minds. But wary individuals might breathe a little easier with sufficient education and awareness about the condition and how to avoid it—and what to do if it happens.

As more people are lured outside by the mild climate of the Central California spring, health care professionals find themselves treating an uptick in outdoor-related cases of anaphylaxis. The San Joaquin Valley’s agricultural industry and the Sierra Nevada’s outdoor adventures are just two of many regional factors that pose particular hazards.

But while the warmer weather may see a spike in certain types of incidents, the allergic reaction known as anaphylaxis is hardly just a seasonal threat. Bad reactions to food and medicine are a serious year-round problem, according to Tulare District Hospital Medical Director Benny Benzeevi, M.D., FACEP.

Life Is On the Line

“I think that—unless one has experienced an anaphylactic reaction or has witnessed one—it is sometimes difficult to understand how serious it can be,” said Dr. Benzeevi.

So what should you know about recognizing anaphylaxis and its potential severity?

“Anaphylaxis is the most severe and life-threatening form of an allergic reaction,” said Dr. Benzeevi. The symptoms include hives, diffuse swelling, including swelling of the tongue and throat, and difficulty breathing. Those effects are perhaps most commonly known. But there are many others, including redness, wheezing, abdominal cramping, nausea, vomiting, diarrhea, and low blood pressure.

During the panic of the moment, said Dr. Benzeevi, “The important thing to remember is that anaphylaxis is serious and life-threatening, and should prompt an immediate response concurrently with a trip to the emergency department. The symptoms should be taken very seriously the minute they begin.”

Visalian Carole Firstman knows firsthand those moments of high anxiety. As with so many prior experiences, after a coworker’s visit to a Visalia bakery, Firstman discovered the hard way that the establishment had used peanut flour in its products. Within moments of eating the treat her friend had provided, she began swelling and having difficulty breathing.

Firstman is in the top 10^th percentile of allergic sensitivity to peanuts. Fortunately for her, most food service establishments long ago ceased using peanut products or follow disclosure regulations, because a certain small percentage of the population can die from exposure to even the smallest trace of peanuts. Her level of acuteness means that eating food that merely touched a cooking surface that was previously in contact with peanut oil can result in death.

More People in the Know

Firstman sees greater awareness about peanut allergies than was once the case. “Within the last ten years or so, it’s been in the media and news, so many folks have heard of it,” she said. “The biggest difference is that now, all processed foods must list peanut ingredients on food labels, including the possibility of cross-contamination during the manufacturing process. That regulation makes a huge difference for people like me.”

In the past, she would eat something that had no peanuts listed in the ingredients, but for some reason would get the “peanut sickness” anyway, often ending up in the emergency room. “In those days, eating anything was potentially dangerous for me! But now when I see even the remotely threatening words ‘May have been processed on equipment that also processes peanuts,’ I know to avoid that food.” she said.

In a culture that values social conformity and stoicism, societal expectations can result in subtle pressures to minimize special dietary constraints. But the cost of ignoring one’s severe allergies can be life itself. Firstman thinks old attitudes are beginning to change. “People today are much more aware than they used to be. Today when I tell someone ‘I’m deathly allergic to peanuts,’ they know what I’m talking about, I don’t need to give lengthy explanations.”

But she still must be constantly aware of the foods she eats. “I have to ask about ingredients all the time. If I don’t know what’s in the food, I have to pass. I can’t tell you how many gift trays of Christmas cookies I’ve had to give away or throw away simply because I didn’t know what was in them,” she said regretfully.

Any food that she has not prepared herself poses a risk. “Any derivative of peanuts—like peanut oil or peanut flour, no matter how minute—will cause a reaction for me. So eating at restaurants is always dicey. I rarely eat Asian food out, for example, unless I can either see the food cooked in front of me or I can have a conversation with the chef.”

Another pitfall: Servers may be unaware of what they are serving. “In any type restaurant, even if I specifically ask about peanut products in the food, I’m sometimes told the food is peanut-free, but it is not. There might be ‘hidden’ peanut products that the staff isn’t aware of, like an ingredient in a pre-made salad dressing, for instance, that is then used as a marinade for an entrée,” she noted, so staff may simply not be helpful despite her caution.

How is Anaphylaxis Treated?

Upon going into anaphylaxis following the bakery incident, Firstman’s friend—who had never before given a shot—administered epinephrine, the main go-to drug for emergency situations. Fortunately for the drafted Good Samaritan, epinephrine can be administered via an easy-to-use EpiPen, a pre-filled, auto-injecting syringe.

“It is very natural to be squeamish about giving a shot,” said Dr. Benzeevi. “However, I would remind the person that the shot of EpiPen may very well save someone’s life.  I think looking at it that way may be helpful to get over the initial discomfort.”

People with allergies to bee stings and certain foods who keep a supply of EpiPens on hand may go long periods without incident, and the medication can expire. That may leave an inexperienced bystander to play caregiver to an incoherent anaphylaxis sufferer, a novice who must decide quickly what to do.

“Ideally, you would want to use medication that is not expired. I think in deciding (whether) to use a very old EpiPen, you have to assess the situation at hand,” said Dr. Benzeevi. “If the patient’s throat is closing and they are unable to breathe, and no help is available, you have to do whatever it takes to save a life. By the way, injections into the thigh are more effective than injections into the deltoid (upper arm).”

Dr. Benzeevi said the important thing with all medical emergencies is rapid response and to remember the ABCs: Airway, Breathing, and Circulation. Don’t hesitate to call 911. “Anaphylaxis can deteriorate very rapidly,” he emphasized.

While the first-line therapy for anaphylaxis is epinephrine, IV fluids, and oxygen, if airway swelling is imminent the patient must be intubated rapidly, he said. “Otherwise, the airway will be lost, and an emergency surgical procedure called a cricothyroidotomy must be immediately performed. Additionally, after the first-line therapies have been given, steroids, antihistamines, and nebulizers are administered. In more severe cases, epinephrine has to be administered through an IV and even as a continuous infusion rather than as an intramuscular injection.”

Dr. Benzeevi pointed out that in patients already taking beta-blockers (a class of cardiac medications), epinephrine by itself may not be effective and may cause severe elevation in blood pressure. “In those cases, if the patient does not respond to the first-line therapy, sometimes an additional medication called glucagon is administered.”

Finally, epinephrine can cause other deleterious effects on the heart, and those have to be monitored closely. These are all issues that are considered in the Emergency Department, but are not critical for the first-responders, Dr. Benzeevi said.

“It’s important to remember the ABCs and treat the patient in that order,” the doctor said. “If issues arise after the administration of the first-line therapies, the first responders should be in close communication with the Emergency Department as they transport the patient.”

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