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session. It was probably. People are very tired and exhausted. So, um, we will try to do it, um, as interactive as possible. My name is Sarah, a pediatric consultant are participating with this program because I believe we have to all stand together in solidarity without borders, because injustice anywhere is injustice everywhere. So, um, I'm going to continue from the previous, uh, discussion when we were talking about identifying the sick child and then about the A B c D approach for resuscitation. And we had one lecture about allergy, and this is a combination between allergy and emergency. So, uh, I mean the Notting Hill carnival. Um, Charles, who's 14 year old boy, decided that he would like to go and attend. And Charles has not allergy. He as well has got asthma. And he has in his treatment inhalers antihistamine. And he has adrenaline auto injector to carry on with him. The Notting Hill carnival is a musical carnival. There's a lot of street food. Um, there should be, you know, different cultures, and not only Caribbean food, but the main females from the Caribbean. But there can be multi culture event with different people. Um cooking and offering drinks. So he thought with his friends that they would like to go and attend as, um, before we go further, do you think there is any risk for Charles or do you think there is any preparation that he needs to do? And I can't see the chat books, so kind of kindly workout. There's nothing in the chat. But if people want to respond on mute themselves So, um, do you think there are any sort of preparation that Charles needs to do or there's any risk? If you don't want to write in the chart, you can. You know there is a There is a huge risk because there is straight food. His young boy with friends already in our theology, asthmatic as well. So he should be prepared to carry everything with him or avoid well done a wide food, you know, essentially avoid. We may come to avoid, or maybe something else. Um what about asthma? Is asthma increases his risk? Do you think so? Uh, when you are asthmatic. Yes. Yeah, but if you have got asthma, your asthma is not under control. Then there is an increased risk. If you have an allergic reaction to food that the allergic reaction will be worse. So it's important for us to understand about Charles about his type of nut allergy about his asthma control. Okay, so see if it to go. Um, So Charles is saying I don't want to be different, okay? I don't want to be different. Um, and so he was trying to downplay his symptoms. He doesn't want people, you know, to treat him differently or to be seen different from his peers. So they got hungry, and they there was some soul. There was some chicken. Um, and there was some sauce near the chicken, so it was very loud. There was a lot of music. People were dancing and he laying down to the person who's cooking and said to him, I have not allergy. I can't eat any food with nuts. Does this food contain nuts? And the response came No, no, no, no. Peanut. Um, but the music was very loud, but Charles has tree nuts, which is casual. Pistachio will not become So Do you think the answer from the, uh you know, the chef who was cooking? Um, is it e quit or not, it's not adequate. Yes, it's not a liquid because the food may contain the other types of nuts, all not related derivatives, you know, know how to prevent, uh, or pre the event how to arrange and prevent any problems. So on the right side, you can see this is a patient of mine who has prepared a a poster or a card traveling in three or different countries. And he has written, I have not allergies. And then in, um, French and in Dutch and then in Arabic. Uh, and this is after, um, you know, you know, you have to prepare for the event, Understand? Um, what it is expected there have an allergy card, an allergy plan, and not only carry the adrenaline auto injector, but you know when to use it and how to use it. And Charles has to make his friends aware about his allergies. And where is his that training? Or to inject their kept? Because, um, what? We tend to see that girls would like to have a sometimes back at all, but they would have a bag and they would keep the pens. Well, boys don't like to have a bag and also depends will be carried in their pockets. Some of them they carry them. Um, you know, inside the like socks. Um And so if you don't tell your friend, they wouldn't be aware. Usually this age group, whether it's boys or girls, there is a risk taking behavior. They may as well have some other like alcohol, and then they forget and he eats and he doesn't remember exactly. Where is his pen? Um, Eliza mentioned If there is a poor asthma control, then then that's a problem. So the energy, uh, emergency kit is very important. So pre event preparation is important. Uh, do you have any question here or should we go to the next slide? So we're going to talk about severe allergic reaction or anaphylaxis as one of the example of the analysis that can affect the circulation. We are here talking about life threatening allergic reaction. Overall, the progress is good. If the patient could reach the hospital or the treatment tree hospital was adequate. But the risk of poor prognosis increases if Children have got poor control, asthma as well. If the use of adrenaline is delayed, that will increase the risk of death when we look at the fatal outcome from anaphylaxis. If it's related to food, severe food allergy, it will happen within 30 minutes. And so there are 30 minutes windows to help and support and reverse the allergic reaction. But it gets worse if you if it's bee or wasp allergy, like venom allergies and if it's related to intravenous medication. And this is a worry if you are working in a hospital setting, because the first thing you have to do is stop the intravenous infusion or blood transfusion. If it's ongoing the physiology of here, um, and a phylaxis, it's important to understand it, so then we can manage the patient. There is significant tissue edema, and that may lead to hypovolemia as well. But that is true. Edema in the upper airway may lead to airway obstruction. There is smooth muscle contraction, and that may lead to Bronchospasm and Louise. And, uh, there is a direct, you know, effect on the myocardial function on the heart, which may lead to shock. The fluid redistribution into the third space will, uh, lead as well to the hypervolemia and to the shock. So it's a combination of hypervolemia dysfunctional, my cardiac function, the redistribution of fluid and smooth muscle contraction. So it's important to recognize anaphylaxis. There's a sudden onset, but that's following exposure. So whether something you ate, whether it's a medication you had or whether it's an insect or is it like a bee or wasp bite? Usually, but not always. You know the allergy in Not always, sometimes maybe not. The A B C D approach is the most important approach, and when you look at the skin, you can have hives that arctic area. But not always. You can have hives and Arctic areas, so if you only depend on having hives as the clue, you may miss a lot of patient. Sometimes you can have vomiting and diarrhea, and you say, Oh, possibly this person have ended, you know he eating something, or he drags something that may have led to the allergy. But that's not always the case. If you have venom allergy after an ethic bite, they can be vomiting and diarrhea. So if you look at the A B approach first because we're going to, um, look at them, you know separately. So we have spoken about the mucosal edema about the deep body, no edema following the allergic reaction that may need to swelling, and that may lead to stridor. The throat may be hurting. The patient may be unable to swallow, and they may be changing voice. And there may be, you know, swelling of the tongue swelling of the lips on its own is not an indication of a severe allergic reaction. But it is the edema of the tongue and the mucosa in the or four in jail her way. There is a smooth muscle contraction and that we need to bronco spasm. We have shortness of breath, cough of sudden onset. And this is an important symptom. Someone was in, uh, an event was eating and then started to have this, you know, cough ongoing, ongoing. And we know this person has got allergy, and there may be an exposure to an allergen, and the cough is not cannot go away. We have to start worrying because it indicates that the airway is involved and the severe deterioration will lead to hypoxia cyanosis an arrest. And if you remember, in the last discussion about two weeks ago, we talked that in Children the primary cause of an arrest is usually respiratory and hypoxia. But is it an insect bite? Sometimes it may be the first, and the patient does not know whether they have been exposed to an allergic or not. And you may find you know, some evidence when you are examining them. Or sometimes you may not. This is as it can be clear. It can be a patient on the ward who has, uh, penicillin allergy. Nobody asked him. The patient, you know, was given the penicillin, and then this happens. Or it can be sometimes for the patient the first time, and they didn't know. But if you recognize the pattern of the involvement of the airway, the breathing and we come to the, uh, circulation the pathophysiology for it that there is a direct effect on the heart, it's not only the hypovolemia, it's not only the vision irritation, it's not only the capillary league. During an allergic reaction, there is depression of the micro O'Dea function, so the patient may look pale, feels dizzy, have cool hands and feet, have prolonged capillary refill time, have sticky cardia hypertensive, and if the patient is not saved, will collapse have loss of consciousness and arrest. Now, if we reach the level or the degree of the direct my cardio depression and that is not reversed, the outcome is poor. So the management, if you the patient is receiving a blood transfusion or antibiotics infusion or medication infusion or contrast in, um, you know, you have to stop that. Your approach is a B C D. E. We talked about a have to maintain patent airway. Otherwise, you can't move to be. We are giving the oxygen, and I'd really auto injector I am is important, even in A and B because you want to reverse the edema and the bronchospasm so we wouldn't wait until see, and we have to give it every five minutes. The patient's must lie flat. We may have to raise or lift the legs, and we need an access that can be a cannula or an eye O. M. To give fluid bonuses and that which should be as a heart mint or nor muscle I isotonic crystalloid that can be repeated. If you're a junior doctor, obviously you should have called for help by now from your senior colleague to come and assess the child and, you know, lead on the management. But as I said, if you are called to the world and the patient or in the radiology department, you have to stop the infusion or the transfusion. Maintain the airway. Give the oxygen, give the adrenaline while you're awaiting the help from your senior patient will need an access IV cannula. And if there is a cannula and you're not happy with that perfusion, you need to give them fluids. In about 10% of Children or anaphylaxis, they develop what we call refractory anaphylaxis so they don't respond initially to your treatment, and they may need infusion of adrenaline. The infusion of a draining is something that has to be delivered in a specialized unit or, if it's going to be delivered in any there, has to be the expert who can prepare it. Now there is a confusion about when to use, and the histamine want to use hydrocortisone. The most important treatment is I am adrenaline, an IV fluid and the oxygen you can use the antihistamine later, after stabilization, the antihistamine that you you should not be sedative because you don't want the patient to become sedated, and then you don't know. Is this patient sedated because of the allergic reaction or insidated because of a side effect from the medication? And sometimes there is. There is a window to use hydrocortisone, refractory anaphylaxis. But that's after the patient has received IV infusion of a draining. So you should not delay the use of adrenaline or IV fluids to give anti histamine or corticosteroid ones. I don't know whether you can see this or not, but this is the, uh, phylaxis pathway. The first, um, sort of level it talks about the A B C D approach about the diagnosis about the call for help about the position of the patient should not be standing to be lying down, raising the legs about giving intramuscular adrenaline and repeating that every five minutes and giving IV fluids. And at the bottom there are the the doses. For I Am, uh, training. It is directly anaphylaxis. Obviously, you we need to go to an infusion of, um, IV adrenaline, and that has to be done by an expert. It's a different concentration, and there is a different dose, and at this level it's important for you to concentrate on the treatment of anaphylaxis, the factory anaphylaxis. It's something you have to be led, obviously by your senior. But if you are at that position and you have identified that the patient is not responding, it means that this patient will need, um, more fluids and more adrenal Mm. And really, when we come and talk about how to give it and and how much? If we're talking about, I am adrenaline. The concentration is one in 1000. You cannot take this concentration and give it as an IV bonus. This is dangerous when we talk about I m. It is one in 1000 but when we talk about IV infusion, it's a different strength. It's a different delusion. You can give it their peripheral access or a central access. So if you want to remember, one thing today is the concentration of I am. Adrenaline is different from the concentration of IV adrenaline. So when you are a junior and you graduate, remember that if you are facing someone with Anaphylaxic that if you're going to give it, I am, you have to check that you're giving the right concentration. Sometimes you know when it's refractory, and the patient is realistic. There may be a need for tracking intubation and intraocular intubation that they may sometimes use. You realize the drilling to reduce the, uh, edema. However, there is no at all recommendation that new realized adrenaline should be used instead of I am as well as can be used, but that after we give the I am adrenaline and the IV fluids and we have to remember that magnesium sulfate is not recommended for bronchospasm because it will cause further basic palpitation. As I mentioned earlier, if the child has got refractory, uh, anaphylaxis, there is a window to give IV IV hydrocortisone, but we should not stop the ADDr alien infusion. It means that you will need another access to give IV hydrocortisone IV fluid while the ADDr alien infusion is ongoing. And if you have a child who is really that bad or really sick, possibly they need more than one access, and they will need possibly a central line, and that will be done by senior expert in this A. So there is we don't usually have a lot of tests for allergy in this situation. It's about the history. It's about the examination. It's about the clinical judgment. But when you put the cannula, you can take muscle trip days. We are expecting if there is an anaphylaxis, especially if you're not sure about what is the trigger. And the patient, you know, does not have a background of non allergy, and you're not quite sure of what's going on. You should take them or sell tryptase because this will be, um, produced, inaccessible amount during an NFL axis. And that should be taken in three samples on presentation at two hours and at 24 hours. Because we would like to see the baseline and how will that will go back to normal? Um, and that may indicate that there was a must cell activation and NFL axis. But if it's normal, then then we have to think about what has been going on. And if it doesn't go back to normal, we have to think about more complicated things. So if you have a child who had a severe allergic reaction and you have to give them one injection to injection, I am, do you have to admit them? Because there is what is known as the rebound rebound reaction in 35% of Children. They may have another episode of severe allergic reaction after you treat them in about, you know, eight or 12 hours when you discharge these patient's, you have to remember that they should have an allergy plan. They have an adrenaline auto injector. They have been trained, and if they have not met the allergy team, you have to refer them. In the UK there is an anaphylaxis anaphylaxis registry, which is recent. You have to, um, you know, uh, include that, but that may be that not the case in other countries. But it's important to have a registry because you need to know the presentation and outcome and the care, especially if it's an adverse event to drugs or blood products. There is a responsibility to report and investigate that to make sure that it is not missed. And the patient has got the labels if they have, uh, drug allergy or if there has been any, um uh, mistake in regard to, uh, blood sampling and blood collection and blood administration. Um, because that's important. So coming back to Charles, his friends stopped him from eating the grilled chicken with a spicy sauce. They encourage him to eat in a cafe where there is food preparation standard and appropriate labels. So he was saved because he had a good understanding from his fears, good understanding about his illness and support. He was not bullied, and he did not feel, you know, that he needs to hide his illness and put his self at risk. However, that's not always the case. So do you have any question at this stage or this? Anything you would like me to clarify? I'm not sure how that there is anything that, no, there's nothing in the chair. Does anybody would like to talk or share an experience? Do you see it confident with approaching a child with a anaphylaxis of severe allergy, I'm going to hear from you if you have any question, or do you feel like you have the initial sort of tools to approach a patient with with with severe allergic reaction? Well, if the child is already have an established allergic, um, reaction documented, it might be easy. But if that is the first time child's having an attack, so so it is right. Sometimes you may have the history. Um, and you may suspect that, but sometimes you may not. But if you are suspecting that a child is coming with undue edema and hypertension and as you said, the hives will just help you with that, um, then you will have to suspect and ask about the history and start the treatment, especially if the child is hypertensive. You need to give the IV fluids. And if you don't have an explanation So you're not dealing with a sub sepsis, for example, because, you know, you may think okay, if there are no hives, Um, am I dealing with substance here or or something else? Um, but there have been a case when we had a baby arriving and well and um was breastfeeding, and the first he had the first bottle of a standard formula and the child did not have hives. Um, but the history we kept going back to the history and the child was really unwell. Uh, people thought that he may have had a seizure or going through the pathway of the seizure. And then we started talking to Mom going back to the history and gave him I am adrenaline and gave him IV fluids. And as we are treating him, then his ears started to swallow. Uh oh. And you know, swollen, um, ears. And, um then we noticed that, you know, the swelling lips and swelling tongue. But they this appeared after he arrived and after we started assessing him, and so that was a challenging case. But what was the hint? The history? Well, child happy. No fever, no foreign body inhalation. Nothing had a the bottle of milk and then collapsed. It would be like a left dose of the G. Uh, so the allergies in the cosmetic is to the approach. The lactose, the sugar that's in dollars. It wouldn't cause a very important point because we need to differentiate between them. So for anaphylaxis, the food anaphylaxis in Children babies is usually the milk. Sometimes the peanut in teenagers is usually the nuts and the shellfish for the fish. And then we have allergies to the drug medication, um, and contrast and some anesthetic medication. And then we have the venom, which is the B and the wasp. And there are some allergies to some insects and other parts of the world. So if I am expelling. If you are a clinician, suspecting energy is important and to to to reassess because you don't want to delay that until there is my cardia depression. When you reach that point of my cardio depression Last week, we spoke about secondary cardio respiratory arrest. Then the progresses is poor. Uh, doctor, there is There is a question in the chat. Um, the question is, is there a specific question you would ask the patient to give you a clue that you're dealing with an allergic reaction? Yes. You for any patient you would see in, you know, in your assessment, whether it's anaphylaxis or not Anaphylaxis, you have to ask them, Do you have any allergies that that should be standard of any assessment? Even if you are seeing them in an outpatient, that's number one, because that may give you a clue. Okay, immediate clue. But if you're suspecting that this is anaphylaxis and the the person tells you I don't have, you have to go to the history. Where have you been? What have you had? What have you been exposed to? What did you eat? Um, do you think you were stung by a bee or by a wasp. Um, okay. Where you given a medication that you then have before. So it is about the history and the pattern, and it is rarely that you wouldn't identify that. It is not any that case of the baby, uh was, you know, in I would say, 20 years. That was, like not from the beginning, straightforward. But the history was was good. And the experience I just felt this is going to be cosmic protein allergy, giving the child the adrenal. At the second one, the child was saved. So giving the first one when I have a suspicion is justifiable. Because if I delayed and the child already has lost its consciousness, it means it's a very severe allergic reaction. Now it's important to recognize it's anaphylaxis. It's important to use the right treatment. I am adrenaline IV fluids. So don't waste the time about giving the Sanpete, um, a nebulizer. Where is the, uh, Easter mean? Where is the hydrocortisone? You give this, uh, afterwards oxygen airway. I am adrenal IV fluids. Then you can give the Salam to manipulate eyes the hydrocortisone and Easter million dollars. These are websites that will help you with the understanding about energy. These are for patient and for the, you know, professionals. The World Allergy Organization, the European Association for Energy, Um, and Clinical Immunology and the British Society for Allergy and Clinical Immunology. Um, what you need to know as a medical student is, uh, the presentation of NFL access. The A, B C D E. Approach, the approach for management and the plan on discharge. I think this is the last one. And, uh, and my set of, uh, teaching. This is the last week, isn't it? Um, I think you have one more if I'm not mistaken. Do her. Yeah, not so I'll check the timetable, but no, I was going to say that if there is any question or anything, I'm a happy go. Answer it if you want to post it or send it to the organizers. Uh, doctor, I think you have on the 15th of December, you've got a lecture. Uh huh. So we can see whether there's any of these for that. Anyone? Anyone wants me to repeat any of the presentation or there's something not clear it's about five or six child or whether it's about allergies, You let me know. And, uh, about which one they would like me to, you know, go back to if they have any questions. Um, for the 15. Now, is there anything else? Because I'm sure it's the end of the day, and you have a long day. I'm happy to take any questions to answer them until the end of the session. But if you don't have any questions, you may have an early evening. Does anyone have any questions If they want to mute themselves, So go and read these sort of, uh, phase. If yourself familiar with them, they will give you a lot of information. Is that okay? I doubt you should be. What, in the day, or do you want us to wait for? Anybody may join later. Um I mean, if if no one has any questions, then we can end it here. Um, just if I could ask everyone to do the feedback before you leave the meeting, and then I'll post this the difficult If you once you confirm you've done the feedback. Um, Thank you very much, Doctor. As always. Thank you very much. Some sherry. Okay. Thank you. And Yeah, I wish you a good evening and Yeah, See you on the 15th. Um, it could be useful, Hannah, because if there is one specific one that they would like to repeat or they want me to answer specific things in relation to identifying the sick child or allergies Yeah, I don't know if anyone does have a specific topic they'd like to have covered again. You can put a message on the WhatsApp group, maybe, Um what email? Yeah, So I will wait to hear from you. Thank you very much for your help today. And, um um Good evening, everybody. Thank you, Doctor. Thank you very much. Um, so if everyone could just fill in the feedback form quickly and let me know that you've done it and then I'll put in this to forget in the chat. And then we have, uh we have Tuesday. We have lectures. So if you could please, um, sign up for lectures on eventbrite, it's easier. Easier for us to manage to keep track of numbers. And it's a better way for you to get links for everything. So if you could please sign up for lectures on eventbrite, I'll put the link on again? Um, yeah. Other than that, please let me know if you've done the feedback and then I'll post certificate. And like I said before and like, the doctor said, if you have any requests for a topic you'd have you'd like to have covered again. Um, by this lecturer, you can send us a message on WhatsApp or on the email. Um, but yeah, let us know if you have any specific topic you'd like to have covered again. The certificate is in the chat. Um, so if you can't download it, contact the email address that I put in the chat. Um, I'll give everyone a chance to download. I'll give you an extra minute, then I'll end this meeting. Thank you for today, everyone.