Project #84668 - Responses

Response # 1 to Deana for DQ#2


Anaphylactic Shock

Anaphylactic shock, or anaphylaxis, is a severe, acute, multisystem reaction that results in an insufficient flow of blood and oxygen to the body’s tissues (Caple & Schub, 2015). Anaphylaxis is caused by the exposure of common allergens to sensitized individuals.  The allergens that cause these reactions are peanuts, latex, medications, shellfish and insect venoms. Initially, these allergens produce an immune response leading to a rapid release of inflammatory mediators resulting in vasodilation, bronchoconstriction, and increased capillary permeability. Symptoms of anaphylactic shock include hypotension, tachycardia, difficulty breathing and swallowing due to airway inflammation or spasm, hives, skin flushing, dizziness, diarrhea, and weakness (2015).

Emergency Care vs. Outpatient

The onset of anaphylactic shock is usually rapid within 30 mins, and progression to death can occur within minutes unless emergency treatment is given. Circulatory collapse can result in death within 10-15 mins (Caple & Schub, 2015). Therefore, an individual presenting with shortness of breath, hives, or facial swelling should be taken to the Emergency Department for treatment. According to Jacobsen & Gratton (2011) treatment consists of prompt removal of the causative agent, administration of medications to restore vascular tone, and provision of emergency supportive care, including maintenance of a patent airway. A decreased, mixed venous oxygen saturation indicates poor tissue oxygenation and an alteration in cellular oxygen extraction and can be used to monitor response to therapy (Huether & McCance, 2012). Because subjective complaints in shock are usually nonspecific, I recommend that any individual who presents with symptoms of anaphylactic shock be sent to the ED for treatment right away.

Patient Factors

Gender is a factor in anaphylactic shock due to women being slightly more likely than men to suffer anaphylaxis (Caple & Schub, 2015).  Also, the age of individuals is an important factor. According to the study by Caple & Schub (2015) anaphylaxis in middle-aged and older adults is most commonly caused by medications, insect stings, or substances (e.g., I.V. radiocontrast, fluorescent dyes). Likewise, children suffer more from food allergies like peanuts. The first line of treatment for patients suffering from anaphylactic shock is epinephrine. Based on a patient’s age, the dose of the epinephrine will be adjusted and can be repeated every 5-20 minutes depending on patient responses. Bronchodilators may be ordered for bronchospasms, along with antihistamines for skin irritation and improving respiratory function.


In conclusion, patient and families need to be education on identifying and avoiding allergy triggers. This includes reading food labels and asking about ingredients and informing healthcare professionals about all drug allergies.


Caple, C., & Schub, T. (2015). Shock, Anaphylactic.

Huether, S. E., & McCance, K. L. (2012). Understanding pathophysiology (Laureate custom ed.). St. Louis, MO: Mosby.

Jacobsen, R. C., & Gratton, M. C. (2011). A case of unrecognized prehospital anaphylactic shock. Prehospital Emergency Care15(1), 61–66.


Response # 2 to  Chelsea  for DQ#2


Pathophysiology of Anaphylactic Shock

            Anaphylactic shock begins when an individual is exposed to an allergen. These allergens could include various foods, medications, insects, or other environmental factors such as latex (Heuther & McCance, 2012). In response to the allergen, the body’s mast cells and basophils release mediators (Cheng, 2011). Large amounts of released histamine produce vasodilation causing decreased blood pressure (McPhee & Hammer, 2012). Hypovolemia also occurs contributing to decreased tissue perfusion and an inadequate amount of cellular metabolism (Heuther & McCance, 2012). In some individuals, allergens initiate an immune process that releases immunoglobulin E (IgE) which damages the previously discussed mast cells (Heuther & McCance, 2012). These mast cells then release cytokines that begin the inflammatory response (Heuther & McCance, 2012). Smooth muscle contraction can cause laryngospasm, bronchospasm, and abdominal upset (Heuther & McCance, 2012).

Emergency or Outpatient Treatment

             Jacobsen and Gratton (2011) describe anaphylactic shock as a “life-threatening allergic reaction that requires prompt recognition and treatment” (p. 61).  Anaphylactic shock is usually sudden, and death can occur within minutes (Heuther and McCance, 2012). Anaphylaxis can often have respiratory complications. For these reasons, anyone suspected of anaphylactic shock should receive emergency care. Additional clinical findings include rashes, gastrointestinal disturbances and occasionally, cardiac issues (Cheng, 2011). A quick assessment of respiratory status should ideally be immediately followed by an intramuscular injection of epinephrine, oxygen supplementation, and cardiorespiratory monitoring (Cheng, 2011). It is becoming more common for schools and other facilities that cater to children to keep EpiPens available for use in case of anaphylaxis (Orlando, 2013). Cheng (2011) stated that even if an EpiPen is utilized, children should still be taken to the local emergency room if there are any concerns about anaphylaxis.

            There are few instances where anaphylaxis could be cared for in an outpatient setting. One circumstance, where a primary care clinic may be needed, would be for a family living in a rural area where there was no emergency care within a safe distance (Arnold & Williams, 2011). The Arnold and Williams (2011) journal article gives a step by step approach to anaphylaxis care in an outpatient setting. Another instance that may be appropriate for the outpatient setting would be a situation where the individual was deemed stable but still needed to be monitored for any recurring episodes. According to Arnold and Williams (2011) the post-monitoring time frame may be a difficult decision due to the “unpredictable nature of biphasic reactions” (p. 1114). This second instance may be more suitable for those with established allergies that have some idea of how their body responds. On discharge from either an emergency or outpatient setting, anaphylaxis patients should be given a prescription for an EpiPen and instruction on how to administer the injectable. Oral antihistamines and corticosteroids may also be given at discharge (Cheng, 2011). Education is extremely important and should be directed toward the parent and the child if they are age appropriate.

Age and Gender

             Rudders, Banerji, Clark, and Camargo (2011) performed a records review of 605 children who presented to an emergency room with food-related allergies. Rudders et al. (2011) stated that about half of these cases were diagnosed with anaphylaxis, and the majority of these patients were less than two years old.  Rudders et al. (2011) contributed a lack of diagnosis in this age group to an absence of anaphylactic diagnostic criteria and the practice of not taking blood pressures on patients this young. Younger children also may have more exposure to new foods and increased sensitivity to certain allergens. Rudders et al. (2011) also found that in younger ages, male cases were predominant and at adolescence, females took over the majority. This gender gap is thought to be due to an increase in female hormones related to age (Rudders at al., 2011).  

            Jacobsen and Gratton (2011) stated that without any evidenced of a known antigen, clinicians may be hesitant to treat anaphylaxis aggressively. As advanced practice nurses we must be informed and vigilant when it comes to this life threatening reaction. It is important to understand the pathophysiology of anaphylactic shock as well as age and gender related variables to appropriately diagnosis and treat anaphylaxis.



Arnold, J. & Williams, P. (2011). Anaphylaxis: Recognition and management. American Family Physician, 84(10), 1111-1118. Retrieved from

Cheng, A. (2011). Emergency treatment of anaphylaxis in children. Pediatric Child Health, 16(1), 35-40. Retrieved from

Huether, S. E., & McCance, K. L. (2012). Understanding pathophysiology (Laureate custom ed.). St. Louis, MO: Mosby.

Jacobsen, R. C., & Gratton, M. C. (2011). A case of unrecognized prehospital anaphylactic shock.Prehospital Emergency Care, 15(1), 61–66. Retrieved from

McPhee, S. J., & Hammer, G. D. (2012). Pathophysiology of disease: An introduction to clinical medicine (Laureate Education, Inc., custom ed.). New York, NY: McGraw-Hill Medical.

Orlando, J. (2013). Federal legislation of Epipens in schools. OLR Research Report. Retrieved from

Rudders, S.A., Banerji, A., Clark, S., & Camargo, C.A. (2011). Age-related differences int eh clinical presentation of food-induced anaphylaxis. Journal of Pediatrics, 158(2), 326-328. Retrieved from

Response #2 to Jennifer  for DQ#1 

My assessment and treatment

As an advanced practice nurse (APN) assessing this patient I would need to remember a few anatomical and physiological aspects of the heart after auscultating the murmur.  This specific murmur occurs during systole, when blood is propelled out of the ventricles and into circulation (Huether & McCance, 2012).   The American Heart Association ([AHA], 2015) states a heart murmur, a noise, is caused by valve defect.  This murmur grade is II/VI, which audible, but soft.  The murmur is heard best over the apex of the heart which is located at the bottom near the left ventricle.   The location and time of this murmur leads me to believe there may be a problem with the mitral valve, such as mitral regurgitation and possible cardiomyopathy.  Although there is no other history or problems, I would refer to a cardiologist for further testing such as an echocardiogram, EKG, and possibly a stress test.  While most murmurs are common in children, this finding during a sports physical exam indicates a need for further and more advanced care.  If indeed the problem is with the mitral valve a few options exist.   The patient can be referred to a cardiothoracic surgeon who may suggest a mitral valve repair or replacement.  Replacement can be done with a mechanical valve or tissue valve.  The use of a mechanical valve requires anticoagulant medication which typically limits sports options.  These procedures can be done through sternotomy, robotic-assisted laparoscopically, or thoracotomy (Northwestern Medicine, 2015).  Another option is percutaneous transcatheter valve repair/replacement.


In a young patient, it is often difficult to determine the cause of heart condition such as valvular dysfunction.  For young children, cardiac issues are often linked to genetics.  For a patient like this one with no other medical history or family history suggestive of cardiac death, determination is harder.  The heart of an athlete exerts a lot of pressure and capacity when exercising, and for some, sudden cardiac death is the first sign of a genetic link (Sarquella-Brugada, et al., 2013).   The most common cause of sudden cardiac death is congenital electrical or structural diseases (Sarquella-Brugada, et al., 2013).   Some genetic diseases contributing to sudden cardiac death are Brugada syndrome, long and short QT syndrome, catecholaminergic polymorphic ventricular tachycardia, marfan syndrome, and cardiomyopathies (Sarquella-Brugada, et al., 2013).  DNA testing can be done on the patient and should also be done on the family in case other members are at risk, treatment can be provided before a fatal event. 


American Heart Association. (2015). When A Heart Murmur Signals Valve Disease. Retrieved from

Huether, S., & McCance, K. (2012). Understanding pathophysiology (Laureate Custom ed.). St. Louis, MO: Mosby.

Northwestern Medicine. (2015). Mitral Valve Surgery Options. Retrieved from

Sarquella-Brugada, G., Campuzano, O., Iglesias, A., Sánchez-Malagón, J., Guerra-Balic, M., Brugada, J., & Brugada, R. (2013). Genetics of sudden cardiac death in children and young athletes.Cardiology In The Young, 23(2), 159-173. doi:10.1017/S1047951112001138





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