Anaphylaxis in the HOF office: recognize and act

Anaphylaxis is a severe allergic reaction, fast in onset and potentially fatal, that involves more than one body system: skin, airways, circulation and, sometimes, the digestive tract. In an orofacial harmonization (HOF) office it is rare, but it is not theoretical. Hyaluronidase, anesthetics, product excipients, latex and even medications the patient took before arriving can trigger it.

What determines the outcome is the time between the first sign and the first correct action. This guide is a review: it shows how to recognize it, what the team needs ready and where the official sources are. Doses and drug protocols are deliberately not given here: they follow current guidelines and the decision of the licensed practitioner, under the rules of their professional board.

What can trigger anaphylaxis in HOF?

An immediate-type hypersensitivity reaction is the basis of anaphylaxis. In HOF routine, possible triggers include:

The practical point: anaphylaxis does not need a "suspect" product to happen. A patient with no history of allergy can also have their first reaction in your office.

Which signs point to anaphylaxis?

The picture usually starts within minutes of contact with the trigger and can progress fast. The signs most cited in guidelines:

• Skin and mucous membranes: itching, hives (raised, reddish welts), diffuse erythema, sudden swelling of the lips, tongue, eyelids or uvula (angioedema).
• Respiratory: shortness of breath, wheezing, persistent cough, hoarseness, a feeling that the throat is "closing," difficulty swallowing.
• Circulatory: dizziness, fast and weak pulse, drop in blood pressure, fainting, pallor or bluish skin.
• Digestive: nausea, vomiting, abdominal cramps.
• Other: a sense of "impending doom," sudden anxiety, confusion.

Skin signs are not always present. A drop in blood pressure or breathing difficulty right after exposure to a likely trigger already deserves to be treated as anaphylaxis. The expected swelling from the procedure, localized and without other signs, is not the same as progressive angioedema.

Anaphylaxis or vasovagal reaction?

The most common mix-up in the office is with a vasovagal reaction, fainting provoked by fear, pain or the sight of a needle. The difference guides management but, when in doubt, treat it as anaphylaxis.

The page on vasovagal syncope in the office details the management of simple fainting.

What is the first-line treatment?

Allergy and immunology guidelines, such as those from the Brazilian Association of Allergy and Immunology (ASBAI), the Brazilian Society of Pediatrics and the World Allergy Organization, converge on one point: intramuscular epinephrine is the first-line treatment for anaphylaxis and should be given as early as possible. Antihistamines and corticosteroids are considered complementary; they do not reverse airway obstruction or the drop in blood pressure and do not replace epinephrine.

Other points that appear in the guidelines, at a review level:

• Position the patient lying down, with legs raised if blood pressure drops, or sitting if the main difficulty is breathing. Prevent them from standing up suddenly.
• Call for help and emergency services right at the start.
• Monitor breathing, pulse and consciousness until help arrives.
• Refer for observation at a health facility, even with improvement, because a delayed (biphasic) reaction can occur.

Dose, route, repetition and the use of oxygen, IV fluids and other resources are the protocol of the licensed practitioner, under current guidelines and the rules of their professional board. Always check the current version of the guidelines with the scientific societies and keep the office protocol up to date.

What does the office need to have ready?

The reaction takes minutes; the preparation takes weeks. A working plan covers:

1. A written protocol, approved by the technical lead, with the activation flow and who does what.
2. Emergency supplies defined by the technical lead, within their expiration date and in a place everyone knows. See the emergency kit for the HOF office.
3. Posted contacts: SAMU 192, the reference hospital, the clinic's address written out to give on the call.
4. A stretcher or chair that fully reclines, to lay the patient down.
5. Periodic team training, with timed simulation.
6. A blank incident form to record times and actions.

The office emergency checklist offers a ready-made template to adapt, with contacts, items and record keeping.

How does the medical history help prevent it?

There is no total prevention, but the medical history reduces avoidable risk. Ask and record:

• Known allergies to drugs, anesthetics, latex, antiseptics, foods and insect stings.
• Reactions in previous procedures, dental or aesthetic, even "mild" ones.
• A history of anaphylaxis, uncontrolled asthma and use of medications that make anaphylaxis harder to treat, such as beta-blockers, to be assessed by the practitioner.
• Aesthetic products already injected, including unknown ones.

Medical history in HOF and the general contraindications organize these questions. For the enzyme, there is a separate discussion of skin testing before elective use in hyaluronidase allergy and testing; in a vascular emergency, the decision weighs risk against benefit.

After the reaction: records and reporting

Once the patient is stable and referred, document everything in the patient record: time of the injection, product and lot, time of the first sign, signs observed, actions with times, who called emergency services and the patient's destination. This record helps the team receiving the patient, the investigation of the trigger and your own defense.

Serious adverse events with products subject to health surveillance can be reported to ANVISA. The route is in adverse event reporting in Notivisa. Tell the patient to see an allergist to investigate the trigger before any new procedure, and record that instruction.

How to talk to the patient about this risk?

The risk needs to be in the informed consent, in plain language and without alarmism. In conversation, what reassures is showing preparation, not denying the risk.

When discharging the patient, explain which signs call for going straight to an emergency room and calling you.

Anaphylaxis checklist for the office

1. Written protocol, reviewed by the technical lead.
2. Emergency supplies defined, within their expiration date, in a known location.
3. Trained team, with periodic simulation and defined roles.
4. Medical history covering allergies, previous reactions and medications in use.
5. Product, lot and time of each injection recorded.
6. Patient observed after the procedure before discharge.
7. Incident form and reporting flow known.
8. Risk described in the consent form.

For an overview of the risks of the practice, see safety and complications in HOF and the biosafety in HOF routine.