The condition known as laryngeal edema is usually part of the multiple involvement of anaphylaxis; occasionally, it may be the sole reaction to a food, drug, or sting. The best remedy is to inject epi­nephrine, as described above; the next best thing to do is inhale two doses from an epinephrine aerosol, supplemented by oral antihista­mine tablets. Normally, the condition improves within minutes; if it does not, suffocation, cyanosis (bluish skin caused by lack of air), and loss of consciousness will occur. If the throat or the lower windpipe remains closed despite self-medication, medical attention should be sought immediately. During the approximately five minutes available before permanent damage results from lack of oxygen, a surgical procedure known as a tracheotomy must be performed. The procedure consists of making an opening in the windpipe below the obstructed area, to allow oxygen to enter the lungs. Another medical procedure, called cardiopulmonary resuscitation, is sometimes used, but the procedure is not effective if air cannot be forced through the ob­structed windpipe. Asthma The injection of epinephrine is, with only a few exceptions, the treatment of choice. Alternatives should be sought if an epinephrine or epinephrine-type aerosol has been inhaled four or more times within the preceding hour, or if the heartbeat is extremely fast and irregular. (A fast but regular heartbeat, or a moderate increase in high blood pressure, should not deter one from injecting epinephrine if an asthma attack is becoming more severe.) If prescribed drugs have not been taken up to the dosage level allowed, they should be taken to that level before resorting to injections. Two tablets of Tedral, Marax, or a similar combination drug can be tolerated without serious side effects in an otherwise healthy adult with a severe asthma attack. Similarly, the following drugs may be taken safely: up to two tablets of metaproterenol (Alupent and Metaprel), 10 milligrams each; terbutaline (Bricanyl and Brethine), 5 milligrams each; or one of the standard (not long-acting) theophylline preparations, up to 250 milligrams. Depending on someone’s prior experience, he or she may be able to tolerate single doses of both the adrenergic and the theophylline drugs taken together. If nausea or vomiting precludes oral therapy, an inhaled or injected bronchodilator is the next treatment. An acute asthma attack is not the time for treatment with inhaled cromolyn (Intal) or beclomethasone (Vanceril and Beclovent); these are designed for prevention. A person regularly taking prescribed steroid drugs such as prednisone, who has omitted one or more doses, should take the amount missed immediately. Many physicians prescribe extra doses of steroids in treating attacks of asthma that are increasing in severity. Consult your physician ahead of time about what you should do in case of worsening asthma or for a sudden, severe attack in cases where medical attention is not readily available. It is most important that you become familiar with all asthma medication. Know the name, amount (usually given in milligrams, abbreviated "mg" if in tablet or capsule form, and "mg per ml" if liquid), and frequency of dosage. It is equally important that you regularly monitor medication to ensure an adequate supply, and that the expiration date printed on the label has not passed. Keep medi- f cations only in clearly labeled containers —with names, directions for use, and expiration dates. Because one occasionally forgets, the location and business hours of the nearest pharmacy should be kept » handy. Prevention is still the most effective treatment for asthma. Try to anticipate when and where asthma will be aggravated, so you can take measures to avoid these times and places and increase medica­tion. Because asthma can get out of control fairly rapidly, you should not ignore attacks that are worsening; neither should you test the limit of your tolerance. You should, of course, avoid anything that can aggravate asthma. The careful asthma victim will fully and quickly treat an attack with prescribed medication, thus avoiding in most cases, discomfort, emergency room treatment, and hospital­ization. Skin Reactions Eczema and contact dermatitis are lesions that have become in­flamed. In the early stages of inflammation, the lesions should be cleaned carefully with cool water, baking soda or cornstarch soaks, or with a nonperfumed lotion. Avoid excessive exposure to water, heavy ointments, and heat, since these tend to smother the skin and cause it to dry out, thus adding to the inflammation. A solution or lotion containing steroids for the skin usually speeds the healing process. These preparations are usually prescription items. Avoid using antibiotic or antihistamine creams, which can increase the sen­sitivity. If itching is a problem —as it often is—the best relief is through the use of oral antihistamines. In the late stages of eczema, the skin becomes tender, swollen, and less red while some scaling of tissue occurs. The itchy scales can be removed with a cotton swab moistened with olive or mineral oil. Lotions may be changed to creams, particularly those containing steroids. If the itching continues, antihistamines should be taken every six to eight hours. In cases that do not respond to this treat­ment, healing is usually aided by steroids taken orally or by injection. Such therapy, however, must be supervised by a physician. Prevention is important in this group of skin diseases. The allergens involved can often be identified, and should be carefully avoided. The most common allergens that cause eczema are foods such as milk and other dairy products (infants are particularly sensitive), eggs, oranges, and wheat products. Contact dermatitis is caused by the resins of such plants as poison ivy, poison oak, sumac, primrose, and ragweed, as well as by chemicals in cosmetics, clothing, shoes, and jewelry. Hives can be provoked by drugs, especially penicillin, aspirin, codeine, and certain foods. Other causes of hives are para­sitic worm infections and insect stings. Some people develop hives from physical pressure on the skin or from extremes of hot or cold. Although the causes of many forms of eczema and hives are not yet known, you should make a concerted effort to identify the causes, and thus prevent a recurrence. People suffering from colds, skin infections, chicken pox, or herpes viral infections should be avoided, since their organisms can contaminate allergic dermatitis. Because hives are often generalized, and the skin covering them is intact, the use of skin preparations will have less effect than when they are used for eczema or contact dermatitis. Itching and swelling usually respond well to oral antihistamines. Ephedrine, an adren­ergic drug available in 25-milligram doses without prescription, is used to reduce the swelling. If hives increase, and if angioedema is severe, injectable epinephrine should be taken. A dose of 0.2 to 0.3 milliliter of epinephrine 1:1,000 injected subcutaneously, as in asthma or anaphylaxis, is recommended.

who has suffered an anaphylactic reaction—whether to a food, insect sting, drug, or medical procedure—is susceptible to other attacks. Although an anaphylactic reaction may never recur, that person cannot be certain of always avoiding concealed food, a drug accidentally administered, a medical procedure, or the sudden sting of an insect. Once an anaphylactic reaction begins, the best treatment is an injection of epinephrine (Adrenalin) . The drug works within minutes, tightening the blood vessels to prevent serum from escaping, and thus preventing edema. The same action tends to maintain blood pressure while acting simultaneously to keep the airways open. The injection procedure is not difficult to learn. Before prescribing the self-medication of Adrenalin, a physician should demonstrate its proper use and allow the patient to practice the self-injection pro­cedure. First-aid kits containing epinephrine (the generic name for Adren­alin) are available in various forms. The Emergency Ana-Kit (manufactured by Hollister-Stier in Spokane, Washington) contains 1 preloaded syringe containing a 0.3-milliliter (5 milliliters equals 1 teaspoon) dose of epinephrine in a red plastic box 4Vi inches long, one and three-fourths inches wide, and an inch deep; four chewable doses of the antihistamine Chlorpheniramine (2 milligrams each) in a sealed, clear plastic wrap; two wrapped, isopropyl alcohol swabs, and a thin string-type tourniquet. The Insect Sting First Aid Kit, sold by Center Laboratories in Port Washington, New York, is a box approximately 6 by 2 г А by 1 inch and containing a prefilled syringe containing a 1:1,000 solution of epinephrine, an alcohol pad, a tourni­quet, antihistamine tablets of Chlorpheniramine (4 milligrams each), and 2 ephedrine-phenobarbital tablets. Some other manufacturers market prefilled syringes of epinephrine, which can be injected auto­matically (Epi. Pen. Center Laboratories). The needle is injected into the fatty tissue under the skin —not in a muscle, vein, or artery. The usual dose is 0.3 milliliter of a 1:1,000 solution of epinephrine. It is best to administer a smaller dose, preferably 0.2 milliliter, to patients under age seven, to those who weigh less than forty pounds, or to adults with heart irregulari­ties or coronary vessel disease. This step is followed by taking an antihistamine tablet. Among adults, 50 milligrams of Benadryl or 4 of Chlortrimeton (Chlor­pheniramine) is commonly used. Children under the age of seven should take half this dosage. If an anaphylactic reaction has not begun to subside within twenty minutes, the dose should be repeated. Epinephrine is also available in a metered, self-administered aerosol activated by hand while the user inhales. Such preparations as Medihalor-Epi, manufactured by Riker Laboratories in Northridge, California, are available without prescription. Although not a sub­stitute for injectable epinephrine in cases of anaphylaxis, Medihalor-Epi may be helpful as a backup treatment for the throat (laryngeal edema) or for bronchial swelling (asthma), either of which may occur alone or as a manifestation of anaphylaxis. Portable and virtually indestructible, these devices can be carried in automobiles, briefcases, handbags, and so on. The kits should be checked every month to make sure the clear epinephrine solution has not discolored (usually becoming amber). Such change, accelerated by sunlight, indicates decreased potency. The aerosol should be activated periodically to determine whether the valve opening is still free of dust. If it is not, cleaning with soapy water or ammonia will remove the dust. If an allergen —for example, food or medicine—causing the ana­phylaxis has been ingested, remove as much of the material as pos­sible by spitting or rinsing it out, making sure that you do not swallow. If necessary, vomiting can usually be induced by placing one or two fingers at the rear of the mouth. If the allergen has been injected into the arm, a tourniquet should be applied tightly between the site of the injection and the shoulder. Tourniquets are available in first-aid kits, or they can be purchased separately or improvised from shoestrings, cord, or large rubber bands. Tourniquets placed between the injection site and the heart will slow the absorption and circulation of such allergens as bee or wasp venom.

An integral part of coping with allergic emergencies is their prevention. Regarding stinging insects, the following information should be helpful. It has been prepared by the American Academy of Allergy and is excerpted with the academy’s permission. Obvi­ously, people who are allergic to bees, hornets, wasps, or yellow jackets should do everything practicable to avoid being stung. The chance of being stung can be lessened by taking the simple precau­tions described in the following paragraphs. Preventive methods at home Food attracts the Hymenoptera (bees, hornets, wasps, and yellow jackets), as do outdoor cooking and eating, feeding pets outdoors, and partially filled garbage cans. Even dribble from a child’s popsiscle will attract insects. Keeping food covered until the moment of disposal, meticulous cleanliness about garbage areas, and the occasional spraying of patio and garbage cans with insecticides will contribute to keeping insects away. Gardening should be done cautiously. Cutting the grass with a scythe or sling blade, running a power mower over an underground yellow jacket nest, penetrating a bumble bee’s nest with a trowel, and clipping a hedge are all risky activities for people sensitive to insect stings. Finally, vines that can conceal nests or hives should be re­moved. Personal methods of prevention Perfume, hairspray, hair tonic, suntan lotion, and many other cosmetics attract insects. Loose cloth­ing in which insects might become trapped, bright colors, flowery prints, and the color black should all be avoided. Light colors—for example, white, green, tan, and khaki—are not considered attractive or antagonistic to bees. Any object, no matter how lightly it is touched, should be checked first for bees, hornets, wasps, or yellow jackets. Children should be taught not to pick up a wagon handle (or any toy, for that matter) without first looking for an insect on it. For instance, idly kicking a rotted log can send vibrations into the ground that disturb nearby yellow jackets. Public trash cans should be avoided. An insecticide bomb kept in a car’s glove compartment may be used when a stray insect flies in. Shoes or sneakers should be worn at all times when one is outdoors. Even hard beach sand should be suspect; one type of wasp spends most of its life on dune grass. Sandals do not provide adequate protection. Immediate removal of a stinger The honeybee is the only insect that leaves its stinger (with venom sac attached) in the victim. Be­cause it takes two to three minutes for all the venom to be injected, quick removal of the stinger and the sac will prevent much of the poison’s harmful effect. This is done with one swift scrape of the fingernail. The sac should not be picked up between thumb and forefinger; that merely squeezes in more venom. Hornets, wasps, and yellow jackets do not lose their stinger and should be brushed off promptly. Although some Hymenoptera are more combative than others, any insect will sting if its hive is disturbed. Thus, while it is important to destroy hives and nests, this should never be done by or in the presence of someone who is allergic to Hymenoptera. Instead, a hive or nest should be removed by an exterminator or at least by someone not allergic to stings. Nests and their removal Wasps build open-comb nests under eaves, behind shutters, in carports, shrubs, and woodpiles —in fact, almost any place that is protected. Nests can be destroyed by hosing, carefully knocking them down with a stick or broom handle, or scraping them into a jar (which should then be covered quickly). The area should be sprayed with an insecticide once daily for two to three days to discourage rebuilding at the same site. Jet sprays can reach twelve to fifteen feet. Yellow jackets build in the ground and emerge through a small hole, which should be marked during the day with a thin stick. At dusk, when all the insects have returned for the night, a liberal amount of gasoline, lye, or kerosene should be poured into the hole. Do not light the gasoline or kerosene, though. This procedure should be repeated the next evening to make sure the fumes have thoroughly penetrated the holes. A water hose should never be pointed at the hole; that will merely cause the insects to attack the person holding the hose. Hornets build a gray hive shaped like a football, usually in a shrub or high in a tree. If you can’t reach the nest with a flame or trap the insects in a jar, bucket, or metal drum, a pest exterminator or the fire department should be called in. Whether swarming on a twig or nesting in a hollow tree, honeybees may be removed by following one or more of the methods described above. They can also be removed by a beekeeper, who is frequently glad to acquire another colony. When a nest is out of reach, help from the fire department or a county agent of the Department of Agriculture should be considered. In conclusion, the allergic person should use common sense —keep calm and act quickly, avoid situations in which insects have been known to attack, and keep a sharp lookout when outdoors.