Michelle Dawn Mooney: Hello, and welcome to the HealthFirst Talks podcast. I’m your host, Michelle Dawn Mooney, and today we are talking about anaphylaxis. So first off, thank you so much for being here today. Appreciate your time.
Dr. Jason Brady: No problem. Thank you.
Michelle Dawn Mooney: If we can, just having you give us a brief bio before we get into the question and answers. Dr. Brady, starting with you.
Dr. Jason Brady: Absolutely. I’m Dr. Jason Brady. I’m from Gilbert, Arizona. I’m a dentist anesthesiologist. I’m in private practice, and I’m also associate program director for NYU Langone. We’re all into education, so we’re very happy to be here today.
Dr. Amanda Okundaye: Hello, I’m Dr. Amanda Okundaye. I’m a dentist anesthesiologist based in Las Vegas, Nevada. I have a mobile practice, as well as being the associate program director at UNLV Dental Anesthesiology Residency. I’m very happy to be here with you today.
Michelle Dawn Mooney: Happy to have you both here. So let’s start off here with defining anaphylaxis. What is it, and how does it present itself?
Dr. Jason Brady: Well, anaphylaxis can be defined as — some people would say — something as simple as a bad allergy. So you have mild, which would be an allergic response, and then you have something major, which is anaphylaxis. Anaphylaxis truly is a whole-body immune response, where, as we say in anesthesia, everything’s circling the drain.
So you see airway issues, you see a release of histamine, leukotrienes — all of these things if we’re getting into the physiology of this. And patients can have many different triggers to anaphylaxis. In dentistry or in medicine, it can be antibiotics, it can be latex, it can be insect venom, it could be peanuts. So there are many different triggers for anaphylaxis, but it is truly just considered a major allergy.
And sometimes it’s not even the first exposure that causes anaphylaxis. So you may not even know that it’s coming because you’ve had exposures to this before and you may not have had that type of reaction.
Michelle Dawn Mooney: So with all of that in mind, what would you say is the biggest mistake that clinicians make with anaphylaxis?
Dr. Jason Brady: I think it’s hesitation. When you have to do something and act on a crisis event, the first step is always the most important. And when you hesitate with anaphylaxis, your airway is starting to be compromised because all that swelling and that edema is closing up, literally, that patient’s airway.
Dr. Amanda Okundaye: Yes. As Jason said, it really is one of the most time-sensitive medical emergencies that we see, and you really don’t have time. You have to predict what’s happening and not hesitate, and move forward fairly quickly with whatever medical emergency intervention there is.
Michelle Dawn Mooney: What is, then, the first line of intervention?
Dr. Amanda Okundaye: The first line of intervention for anaphylaxis is epinephrine. We want to stabilize those mast cells because that is what’s causing a lot of the histamine release, the prostaglandins, and the leukotrienes. So epinephrine is going to be your first line of offense when you have an anaphylactic reaction.
Dr. Jason Brady: And to piggyback off that, epinephrine is your first-line drug. It’s given intramuscularly with an auto-injector or another source of epinephrine. But that drug is your only first-line drug. It’s not antihistamines. It’s not steroids. It’s epinephrine, intramuscularly given in the upper thigh or the vastus lateralis.
Michelle Dawn Mooney: I want to ask you about biphasic anaphylaxis. What do people need to know about that? And how often can that happen?
Dr. Jason Brady: So biphasic anaphylaxis is where you think that the issue is resolved, and that resolution is not there — because afterwards you could have another reaction, and sometimes these are very delayed. Usually eight to 11 hours afterwards, you can have another issue with anaphylaxis where you have a lot of symptoms, such as swelling, itching, and also hypotension. So there are a lot of things that could happen afterwards that are very critical to manage.
Dr. Amanda Okundaye: I also would say that I think it surprises a lot of clinicians that people can assume they treated it, it’s done, and they’ve moved on — but physiologically, things are still happening, and that could be without more exposure to whatever the trigger was. And I think that’s something really important to point out: even without having more of that trigger that caused the anaphylaxis in the first place, you can still have symptoms later on, as Jason said, eight to 12 hours after that exposure.
Michelle Dawn Mooney: And as a follow-up to that, is there a way to predict who is going to bounce back from anaphylaxis or have that experience?
Dr. Jason Brady: I would say not reliably. There are many risk factors that we can’t predict. We have no idea. All we can do is observe the patient and give that first dose of epinephrine. And that’s why we say anaphylaxis is truly not a single event — it is a process physiologically.
And a lot of people get themselves in trouble with that because if you don’t have that understanding, you think all is well and you can send your patient home, and then they’re in a home environment with no healthcare provider, and then they run into a crisis event.
Dr. Amanda Okundaye: Absolutely. And we know with anaphylaxis, time is crucial. It is not your friend.
Michelle Dawn Mooney: So you mentioned timing, and I want to talk about that. What are we looking at? Just how crucial is that timing? Can you maybe break it down for us?
Dr. Jason Brady: I think that initially, your presentation can look very mild. If it’s just hives or a rash, you assume mild allergy, not major anaphylaxis. And when you’re going down an algorithm of how to treat this, I think that clinicians would be first to reach for antihistamines thinking it’s just an allergic reaction — with more fear around giving epinephrine too soon or too early. But really, that’s not what they should be doing. So I would say the early presentation can look mild, and so it does delay people from giving epinephrine.
Dr. Amanda Okundaye: Yeah, for sure. When you’re called to action, it’s easier to give a little bit of medicine intravenously than to use a large auto-injector into someone’s thigh. A lot of times, as dentists, we can do injections intraorally, and we’re very comfortable with that. But we’re very uncomfortable with giving injections around the body. And I know a lot of our physicians are exactly the opposite of that.
And so we know what we know, and we do what we do, and I think that’s the hesitation that plays into that human factor.
Dr. Amanda Okundaye: I would also, since we’re still on epinephrine, like to say that I think the biggest risk when it comes to anaphylaxis and treating anaphylaxis would be the word under-treatment. Not reaching for that epinephrine early enough would be under-treatment. And so that hesitation, as Jason said earlier, really is where that comes into play. Epinephrine is the only early intervention we can do to reduce morbidity and mortality.
Michelle Dawn Mooney: And why are two doses needed in some cases?
Dr. Amanda Okundaye: Because, as Jason said earlier, progression is unpredictable. We have no idea, honestly, what’s happening physiologically other than by symptoms — looking at blood pressure, looking at the airway. We don’t really know if these persistent symptoms or a poor initial response to epinephrine really did the trick. So because recurrence is an issue, you must be prepared to treat those sequelae of more symptoms.
You’re way better off being prepared and not needing it, than needing it and not having it. And really, at least 20% of the population is going to have some anaphylactic type of situation, and there’s a large time window during which we don’t know when that is actually going to occur.
Dr. Jason Brady: And it brings up another point: people have to understand that if it is truly anaphylaxis — and that’s what you think your differential diagnosis is — the patient needs to be observed. Most state boards say you need to have multiple doses of epinephrine on hand. They’re not saying that so that you have to spend an exponential amount of money on epinephrine auto-injectors.
They’re saying that because it’s very clear in national data that patients may need a second dose of epinephrine. And so in a real-world setting, a second dose may be needed before EMS shows up to your dental practice or before EMS transports them to the ER.
Dr. Amanda Okundaye: And it makes me think of another human factor that we have, too. We’re very hesitant to transport to higher levels of care, to go to the hospital. We have to have that observation window, and in a dental office, you don’t want to manage this there. It needs to be where someone has the resources to take care of it quickly.
That human factor of hesitation is also because many states require you to report if you transport a patient, and providers are then in fear of their license or their permit. So it is one of these barriers that we need to get over within our community as well.
Michelle Dawn Mooney: And of course, observation is where practice can vary significantly. So who is at highest risk of needing that second dose?
Dr. Jason Brady: Well, just like we’ve talked about, it’s a huge range of when that biphasic event could happen. And so the highest-risk patients are the ones that have a more severe initial presentation. If something happens very quickly and you’re deteriorating very rapidly — that is a rapid-onset type of situation. They are the ones more predictably going to have a biphasic event.
Versus someone with a little bit of itching and a rash, which is a slow progression — usually those are a little tamer type of situations.
But if you see the vitals swirling down the tank, so to speak, those are the ones at the highest risk — especially if there has been a delay in the first dose of epinephrine, because that is the only thing that’s going to prevent the airway from closing up and the patient from losing a patent airway.
Dr. Amanda Okundaye: And as Jason said, prediction is imperfect. So if a patient is unstable from a physiologic standpoint — they have hypotension, cardiovascular instability, they’re now having wheezing and other symptoms — we know that our prediction is imperfect, so they really do need to be observed within that 24-hour window in case they do have biphasic anaphylaxis.
Dr. Jason Brady: Yes, absolutely. And I will share a story with you. I had an anaphylactic event that happened in the hospital. A person was allergic to shellfish and had eaten at a seafood restaurant where something got cross-contaminated. He knew about it, and he had a very severe reaction. He had an EpiPen that he used to treat himself.
And he didn’t want to go to the hospital — he felt like everything was working just fine and actually went home. By the time he had that biphasic event — going back into anaphylactic shock at the house — once he got to the hospital, his airway was closing down very rapidly. In fact, they were almost about to perform a cricothyrotomy on this patient. That’s how severe and how quickly this happened.
Michelle Dawn Mooney: And when he got to the hospital, what happened?
Dr. Jason Brady: So once he got to the hospital, we had to perform a blind nasal intubation. We couldn’t even use a scope because the tissues were touching each other — we couldn’t even get to that point. Thankfully, we were able to perform a blind nasal intubation, and once he was intubated, people kind of let their guard down. Even the physicians that were there — they all left.
And what we noticed afterwards was severe hypotension and bradycardia and other cardiovascular events that go along with it. So we had to start an epinephrine infusion, and we had to place what’s called an A-line. The pressures were so sensitive that we had to catheterize the artery to get real-time blood pressures on this patient to manage him appropriately. So you’re not going to be able to manage this in a dental office.
It really needs to be in a hospital setting.
Dr. Amanda Okundaye: I think that’s the point: with biphasic anaphylaxis, you can assume that something’s okay, and later it can turn into a major hospitalization emergency — and that can happen in many different settings.
Michelle Dawn Mooney: And of course, it’s a situation that can escalate very quickly. I carry two EpiPens myself because of a tree nut allergy, so I know how fast things can move. Fortunately, I’ve never had that experience, and I’m so glad we’re having this conversation so that this information can be put out there and people can understand how quickly and seriously this can turn.
You’re literally talking about the difference between life and death. So as we wrap up here, any final thoughts you would like to leave the audience with before we close it out?
Dr. Jason Brady: Sure, I have a few thoughts. One of the things that we talk about is being quick to react and actually knowing what to do. Under stress, even if we practice these things, our minds can go blank. There are really good doctors who can just have a bad day because it’s something they’re not practicing or very familiar with all the time — it’s just human nature.
And when we get scared to do something, it’s hard to take that very first step. But taking that very first step is the most critical part.
And that’s why I’m really glad that we have auto-injectors like the Auvi-Q that will actually talk to you and walk you through exactly what those first steps are — because even though we may know it and we may have practiced it, until we’re challenged with it in the moment, we don’t fully realize the implications of the stress that’s there.
Having something to simply guide us through the steps is a big help in making that first move.
Dr. Amanda Okundaye: Absolutely. And that’s the same thing with HealthFirst. In your kits, you get an Auvi-Q. One of the nicest things about that Auvi-Q is that it provides a simulated emergency response — it tells you what to do. And we’re moving toward that as a standard. The AED tells you what to do. The same applies to epinephrine for anaphylaxis. It says, “Remove this. Hold to the patient’s thigh.
Count one one thousand, two one thousand.” It takes the human error out of it, because under stress, we freeze. We overthink. But the same thing happens in an emergency. And when we fumble, it’s life or death, as you said. So we don’t want to fumble when it’s something that we can be prepared for — with multiple doses on hand and good recognition of the signs.
Dr. Amanda Okundaye: And I think that’s part of what this podcast is about — building familiarity before an emergency happens and understanding why you need to have two doses of epinephrine. Keeping in the back of your mind that a second dose may be absolutely necessary in about 20% of the population — and that this could be one of those patients in your chair right now — I think will really lend itself to better outcomes and fewer hospitalizations. So carrying two doses and being prepared is absolutely very important.
Dr. Jason Brady: Actually, there’s a great video that we’re going to share within the link that shows what anaphylaxis looks like and how quickly epinephrine takes effect. When you watch this video, what I want you to appreciate is that she takes the auto-injector, administers it herself, and you can see how severe the anaphylaxis is — with the wheezing — and how quickly it’s resolved.
Michelle Dawn Mooney: So if people had any questions or wanted to reach out to either of you, where can they find you?
Dr. Jason Brady: Personally, they can email me at ddsanesthesia@gmail.com. They can also reach out by sending an email to info@sedationacademy.org to ask any questions of our professionals.
Michelle Dawn Mooney: Thank you so much for joining me. Appreciate your time, and this is obviously a very important topic, so thank you both for being here.
Dr. Jason Brady / Dr. Amanda Okundaye: Thank you.
Michelle Dawn Mooney: And I want to thank all of you for tuning in and listening to the HealthFirst Talks podcast. If you’d like to catch more conversations like the one you heard today, we would encourage you to subscribe to the podcast. I’m your host, Michelle Dawn Mooney. Thanks again for joining us. We hope to connect with you on another podcast soon.
