Allergy/Anaphylaxis treatment and Shivering

[1fastRN]

A while back a young woman came into the ED with angioedema/oral swelling. She was treated with the usual cocktail IV: benadryl/pepcid/solumedrol. I believe she was given epi as well, but I can't remember.

Anywho, after the meds were administered she started shivering pretty bad and got goosebumps all over her body. Another nurse grabbed her some warm blankets and said something to her saying not to worry, this was a normal side effect of the medications and she mentioned something about histamine release.

Does anyone know the pathophysiology behind this? Does this have something to do with the response of the sympathetic nervous system or what?

I thought the shivering could just be a result of anaphylactic shock but she made it seem like it was the med administration that caused it. Maybe I misheard her.

Thanks for any clarification

[Altra, BSN, RN]

It was the epi.

[nurse2033, MSN, RN]

I agree...

[Anna Flaxis, BSN, RN]

Me too. Epi.

[zmansc, ASN, RN]

I would concur with the resposnes that it was the epinephrine that most likely caused the shaking.

As for the pathophysiology of this, I understand it better than I can explain it, so don't be offended :) lol

Epinephrine aka adrenaline is a hormone released as part of the sympathetic nervous system, when the body detects a stressor. This is commonly referred to as the fight-or-flight response. It's has many specific actions on the body, one of them being heightened awareness cause by increasing the action potential of many neurons. In this case these neurons are reaching action potential so rapidly that they are causing the muscles to twitch, aka, the shaking.

I don't mean to dumb it down too much for you, if your looking for more detail I'm sure you can google things now and find an infinite level of detail.

The question I would have for your co-worker is why the warm blankets? The patient wasn't shivering because she was cold, and I don't think I've ever heard of evidence indicating that warmth would reduce the shakes in this situation? Maybe it was just to try to appease the patient and keep her calm while the reaction was occurring.

[Anna Flaxis, BSN, RN]

Goosebumps are also caused by adrenaline (epinephrine). Adrenaline causes the little muscles in your skin to make your hairs stand up, causing goosebumps.

[Sassy5d]

I've had this experience and I remember feeling cold with the shaking. I wish I had a blanket ha!

[meanmaryjean, DNP, RN]

It was the epi- and it is a miserable feeling, let me tell you!

[turnforthenurse, MSN, NP]

Yup, epi. It IS a miserable feeling, I know from experience!

[itsmejuli]

I'll never forget that feeling even though it happened to me 40 years ago. The blankets would be comforting

[1fastRN]

The question I would have for your co-worker is why the warm blankets? The patient wasn't shivering because she was cold, and I don't think I've ever heard of evidence indicating that warmth would reduce the shakes in this situation? Maybe it was just to try to appease the patient and keep her calm while the reaction was occurring.

Cool, I was thinking it was the epi, but I couldn't remember if she was given it which is why I was wondering why she had that reaction. So I guess we did give her epi!

And yeah I think the blankets were just to calm her down so she could relax.

Thanks guys! Silly question but I wasn't sure if she had actually gotten epi so I didn't know if it could be from another med.

[Esme12, ASN, BSN, RN]

Well every one is right and wrong. It is the epinepherine but not necessarily the administered one.

It is the body's response to fight or flight reaction and the stimulation of the sympathetic and parasympathetic nervous system.

The stress response begins in the brain (see illustration). When someone confronts an oncoming car or other danger, the eyes or ears (or both) send the information to the amygdala, an area of the brain that contributes to emotional processing. The amygdala interprets the images and sounds. When it perceives danger, it instantly sends a distress signal to the hypothalamus.

The hypothalamus is a bit like a command center. This area of the brain communicates with the rest of the body through the autonomic nervous system, which controls such involuntary body functions as breathing, blood pressure, heartbeat, and the dilation or constriction of key blood vessels and small airways in the lungs called bronchioles. The autonomic nervous system has two components, the sympathetic nervous system and the parasympathetic nervous system. The sympathetic nervous system functions like a gas pedal in a car. It triggers the fight-or-flight response, providing the body with a burst of energy so that it can respond to perceived dangers. The parasympathetic nervous system acts like a brake. It promotes the "rest and digest" response that calms the body down after the danger has passed.

After the amygdala sends a distress signal, the hypothalamus activates the sympathetic nervous system by sending signals through the autonomic nerves to the adrenal glands. These glands respond by pumping the hormone epinephrine (also known as adrenaline) into the bloodstream. As epinephrine circulates through the body, it brings on a number of physiological changes. The heart beats faster than normal, pushing blood to the muscles, heart, and other vital organs. Pulse rate and blood pressure go up. The person undergoing these changes also starts to breathe more rapidly. Small airways in the lungs open wide. This way, the lungs can take in as much oxygen as possible with each breath. Extra oxygen is sent to the brain, increasing alertness. Sight, hearing, and other senses become sharper. Meanwhile, epinephrine triggers the release of blood sugar (glucose) and fats from temporary storage sites in the body. These nutrients flood into the bloodstream, supplying energy to all parts of the body.

All of these changes happen so quickly that people aren't aware of them. In fact, the wiring is so efficient that the amygdala and hypothalamus start this cascade even before the brain's visual centers have had a chance to fully process what is happening. That's why people are able to jump out of the path of an oncoming car even before they think about what they are doing.

As the initial surge of epinephrine subsides, the hypothalamus activates the second component of the stress response system — known as the HPA axis. This network consists of the hypothalamus, the pituitary gland, and the adrenal glands.

The HPA axis relies on a series of hormonal signals to keep the sympathetic nervous system — the "gas pedal" — pressed down. If the brain continues to perceive something as dangerous, the hypothalamus releases corticotropin-releasing hormone (CRH), which travels to the pituitary gland, triggering the release of adrenocorticotropic hormone (ACTH). This hormone travels to the adrenal glands, prompting them to release cortisol. The body thus stays revved up and on high alert. When the threat passes, cortisol levels fall. The parasympathetic nervous system — the "brake" — then dampens the stress response.

Understanding the Stress Response - Harvard Health Publications

The resulting shaking and chills/teeth chattering is in response of this activation and fear.

Give them warm blankets they are not only comforting (which helps stabilize/deactivate the fight flight/fear) but assist with the calming reversal of hormones and vasoconstriction that accompanies this response.