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ANAPHYLAXIS

History of anaphylaxis

First description of anaphylaxis came from experiments on dogs in 1900’s

Anaphylaxis means “the opposite of protection”

Medical Emergency requiring immediate diagnosis and treatment

1% ED visits

Triggers

i. Food (most common in children/teens)

ii. Medications (most common in adults)

iii. Stinging insects

Diagnosis involves 3 criteria, only have to meet one:

i. Sudden onset of illness (minutes – hours) w/involvement of skin/mucosa & either the upper/lower respiratory or cardiovascular systems

ii. 2 or more of the following that occur suddenly after exposure to a known or likely antigen:

1. Skin or mucosa involvement

2. Respiratory symptoms

3. Cardiovascular symptoms

4. GI symptoms

iii. Hypotension after exposure to a known antigen for that patient (SBP <90 or

30% decrease from baseline)

Pathophysiology

Multiple types of shock at play in anaphylaxis

Distributive

Hypovolemic (Patients lose about 35% of blood volume into interstitial tissue)

Cardiogenic (High concentration of mast cells around coronary vessels, Exposure causes release of mediators that cause coronary vasospasm, This leads to cardiac dysfunction, Reversible with treatment)

Labs

Limited role (histamine/tryptase levels), Clinical diagnosis

Treatment

2.

Lay them supine (Literature says that sitting patients up increases risk of cardiac arrest)

3.

Fluid rehydration

4.

Epinephrine

i. Treatment of choice is Epinephrine/ Adrenaline

ii. Intramuscularly is superior to subcutaneous (IM > SC)

iii. Should be placed in the anterolateral thigh

iv. Dose 1:1000 concentration IM 0.3-0.5 mL , Stocking the Epipen helps lessen the confusion, Can be repeated for a second/third dose q5-10min

Epinephrine should be administered to anyone showing signs of anaphylaxis, Delaying the administration has shown to increase mortality

Don’t wait until they become hypotensive!

IV route is not highly recommended (Should be used if patient is refractory to the IM route, when using prefer IV drip > bolus)

5. Secondary medications

H1-blockers (diphenhydramine, cetirizine)

i. No high quality studies prove usefulness in anaphylaxis /Take 1-2 hours to work

ii. Decrease itching, urticaria, and nasal symptoms

H2-blockers (ranitidine)

i.

No high quality studies prove usefulness in anaphylaxis

ii.

Enhance the relief of urticaria & tachycardia

iii.

Ranitidine 50mg IV or 1mg/kg over 15 minutes

iv.

Combination of H1 and H2 blockers more effective than either alone

Glucocorticoids (methylprednisolone, prednisone)

i. No high quality studies prove usefulness in anaphylaxis/ Take hours to work

ii. In theory, may reduce risk of protracted and biphasic symptoms

Other adjuncts: Beta2 /Anticholinergic Nebs, MgSo4

Glucagon

i. For patients who have anaphylaxis and are on a beta-blocker, should consider giving glucagon because epinephrine may not work

Secondary medications should not be given before or instead of epinephrine

1. Antihistamines have been shown to be helpful with only skin manifestations, not shown to be helpful with respiratory or cardiovascular manifestations

2. Corticosteroid use comes from asthma literature, Not a lot of studies showing efficacy in anaphylaxis

Disposition

Controversy surrounds how long to observe patients to monitor for the biphasic reaction (? 6 -8 – 12hrs or ADMIT)

~5% of patients will develop a biphasic reaction (re-develop symptoms after resolution of initial symptoms)

1. Remember exposure may still be ongoing (i.e. ingestions)

2. Should also be taught how to use an Epipen

3. Age and comorbidities should play a role in decision-making

Discharge with 3-5 day course of H1/H2 blockers/Steroids.

BOTTOM LINE

1. Don’t be afraid of epinephrine! It’s the only drug that will save a life in anaphylaxis.

2. Discharge with H1/H2 blockers/Steroids/Epinephrine prescription!

Further Reading:

https://www.aaaai.org/Aaaai/media/MediaLib rary/PDF%20Documents/Practice%20a nd%20Parameters/Anaphylaxis - Practice - Parameter - 2014.pdf

Zilberstein J, McCurdy MT, Winters ME. Anaphylaxis. J Emerg Med. 2014 Aug; 47(2):182-7.

Nowak R, Farrar JR, Brenner BE, et al. Customizing anaphylaxis guidelines for emergency medicine. J Emerg Med. 2013 Aug; 45(2): 299-306. Grunau BE, Li J, Yi TW, et al. Incidence of clinically important biphasic reactions in emergency department patients with allergic reactions or anaphylaxis. Ann Emerg Med. 2014 Jun; 63(6): 736-44.

Questions/Comments/ Feedback

Lakshay Chanana MB BS, FEM (Vellore), MCEM (UK) drlakshay_em@yahoo.com EM Academy @ Facebook Twitter: EMDidactic