Anaphylaxis - Cancer Therapy Advisor

1/27/2021 Anaphylaxis - Cancer Therapy Advisor
Home » Decision Support in Medicine » Hospital Medicine
Hospital Medicine
Anaphylaxis
Inas Abuali
Anaphylaxis
I. Problem/Condition.
Anaphylaxis is a severe allergic reaction that is acute and potentially fatal. It is a clinical diagnosis that
requires prompt identi cation and management.
‫اﻓﺿل ﻋروض اﻟﺳﯾﺎرات ﻧﻘد و ﺗﻘﺳﯾط‬

‫أﻣﺗﻠك ﺳﯾﺎرﺗك اﻵن ﺑﺄﻓﺿل ﺳﻌر وﺧدﻣﺎت ﻣﺎ‬
‫ﺑﻌد اﻟﺑﯾﻊ اﻟﻣﻣﯾزة وﺗﺄﻛد أن اﺳﻌﺎرﻧﺎ وﻋروﺿﻧﺎ‬
‫ھﻲ اﻷﻓﺿل‬
As the presentation is variable, three clinical criteria have been established to aid in diagnosis. Any patient
meeting one of these would be de ned as having anaphylaxis:
The acute onset of a reaction (minutes to hours) involving the skin, mucosal tissue, or both, and at
least one of the following: respiratory compromise, reduced blood pressure (BP), or symptoms of end-
organ dysfunction.
https://www.cancertherapyadvisor.com/home/decision-support-in-medicine/hospital-medicine/anaphylaxis-2/ 1/11
Two or more of the following that occur rapidly after exposure to a potential allergen, including
involvement of the skin/mucosal tissue, respiratory compromise, reduced BP or associated
symptoms, and/or persistent gastrointestinal symptoms.
Reduced BP after exposure to a known allergen (minutes to hours).
II. Diagnostic Approach

A. What is the differential diagnosis for this problem?
As anaphylaxis is a systemic reaction, it by de nition can involve multiple organ systems. Thus, when faced
with the possibility of anaphylaxis, there are multiple other alternative diagnoses that should also be
considered.
Pulmonary causes
Asthma exacerbation
Pulmonary embolism
Foreign body in lung
Stridor
Vocal cord dysfunction
Angioedema (hereditary or medication-induced)
Cardiac causes
Syncope/presyncope
Myocardial infarction
Arrhythmias
Gastrointestinal causes
Food poisoning
Dermatologic causes
Hives
Urticaria
Systemic mastocytosis
B. Describe a diagnostic approach/method to the patient with

this problem
The key to approaching a patient with suspected anaphylaxis is performing a rapid assessment including key
historical points that will aid in narrowing your differential, along with a physical exam that identi es
potential areas of involvement.
1. Historical information important in the diagnosis of this

problem.
When inquiring into the possibility of anaphylaxis, there are essential components needed to aid in the
diagnosis:
Any potential allergen exposure, including timing/duration of exposure.
Presence of any cutaneous manifestations.
Any signs of airway obstruction (upper/lower airway).
Any syncope or presyncopal symptoms.
Presence of gastrointestinal symptoms.
Any treatment given prior to presentation.
Recurrence of symptoms after remission (if currently in remission).
Prior history of anaphylaxis.
Identifying speci c patient populations that are at higher risk for anaphylaxis is also important:
Teenagers/young adults are at increased risk for food-allergen induced anaphylaxis.
Patients with asthma and/or cardiovascular disease are at increased risk of mortality in anaphylaxis.
Elderly patients are at increased risk due to other comorbidities (e.g. chronic obstructive pulmonary
disease (COPD), coronary artery disease) that may complicate the clinical presentation.
Certain medications that a patient is taking may confound the presentation and impede prompt
recognition of anaphylaxis (e.g. beta-blockers, antihistamines).
Patients experiencing symptoms quickly after exposure (within 30 minutes) are more likely to have a
severe reaction.
2. Physical Examination maneuvers that are likely to be useful

in diagnosing the cause of this problem.
There are no speci c maneuvers that aid in the diagnosis of anaphylaxis. It is through recognition of the
involvement of certain organ systems that aids in the diagnosis.
Anaphylaxis will affect two or more of ve major organ systems:
Skin
Flushing
Pruritus
Urticaria
Angioedema
Pulmonary
Congestion
Hoarseness
Stridor
Dyspnea
Wheezing
Gastrointestinal
Nausea
Vomiting
Abdominal pain/cramping
Oral pruritus
Cardiovascular
Tachycardia/bradycardia or other arrhythmia
Hypotension
Syncope
Chest pain
Neurologic
Headache
Confusion
Irritability
Dizziness
Of these, pulmonary and cutaneous manifestations are the most common seen in patients with anaphylaxis.
3. Laboratory, radiographic and other tests that are likely to be

useful in diagnosing the cause of this problem.
Given the wide spectrum of the differential in the diagnosis of anaphylaxis, there has been further inquiry
into possible laboratory studies that would assist in con rming the diagnosis. The most widely
recommended test is the serum tryptase. Peak levels of serum tryptase are found within 2 hours of
exposure, and have been found to persist up to 6 hours or longer.
Other tests to assist in narrowing the differential include:
Laboratory studies
Plasma histamine levels may be utilized when anaphylaxis occurs in the hospital setting. Blood sample
should be obtained within one hour.
Complete blood count (CBC), cardiac enzymes (creatine kinase (CK), troponin), D-dimer
Radiographic
Chest x-ray (evaluate for stridor, foreign body, pneumothorax)
Computed tomography (scan) (rule out pulmonary embolism (PE))
Other
Electrocardiogram (ECG) (rule out myocardial infarction (MI), arrhythmia)
C. Criteria for Diagnosing Each Diagnosis in the Method Above.

N/A
D. Over-utilized or “wasted” diagnostic tests associated with the

evaluation of this problem.
While there are no over-utilized tests in the diagnosis of anaphylaxis, the important principle is that testing
should not delay treatment when there is suspicion of anaphylaxis.
Tryptase levels may help in con rming a diagnosis, but anaphylaxis is a clinical diagnosis. As such, a tryptase
level may not always be readily available and is not necessary to initiate prompt treatment.
III. Management while the Diagnostic Process is Proceeding

A. Management of anaphylaxis.
While obtaining a thorough history and performing a physical exam is important, time is of the essence if
anaphylaxis is suspected. Therefore, the clinician must act quickly in initiating measures to stabilize the
patient who may be clinically unstable at time of presentation.
Airways, breathing and circulation
The patient’s airway should be determined to be adequate, with preparations for

establishing/maintaining an airway in case of respiratory compromise.
During physical examination, the patient’s breathing pattern should be evaluated and monitored as
an indicator of possible progression of symptoms.
Evaluation of the patient’s circulatory status (heart rate, BP, perfusion) is also important, as it will also
assist in determining next steps in management.
Intravenous, oxygen, monitor
Obtain adequate intravenous (IV) access (2 large-bore, 16/18 gauge if possible), as the need for
crystalloids or even vasopressor therapy may arise in a patient who may be or will become
hemodynamically unstable. Fluid therapy should be initiated immediately in hypotensive patients as
massive uid shifts may occur in anaphylaxis.
Supplemental O2 should be placed supportively in case of respiratory distress, keeping SpO2 greater
than 92%.
Continuous cardiopulmonary monitoring is essential to stay apprised of the patient’s clinical status; it
may also provide insight on potential alternative diagnoses (e.g. arrhythmia).
Medications
Epinephrine
When anaphylaxis is suspected, the rst-line of treatment in all patients is epinephrine. This should be given
rst, with continuous monitoring of the patient to determine if further dosing is indicated.
While there are alternative methods of administration, intramuscular (IM) is preferred over subcutaneous
(SQ) injection, associated with higher plasma concentration levels and improved survival. Meanwhile, IV
formulations are associated with tachyarrhythmia and myocardial infarction, so are mainly used if the
patient is found to be in shock.
The recommended dose for adults is 0.3-0.5 mg per single dose (1 mg per ml) injected intramuscularly into
the mid-outer thigh. Caution must be utilized to ensure using the correct epinephrine dilution.
If the patient has reportedly received an autoinjector of epinephrine (e.g. EpiPen®), this should not prohibit
repeated therapy, especially if the patient is still exhibiting symptoms. In fact, up to 40% of patients may
require an additional dose of epinephrine.
Antihistamines
Despite lack of any randomized, controlled trials to support the use of antihistamines in anaphylaxis, they
are commonly used as adjunctive therapy. They mainly alleviate skin symptoms especially when a
combination of H1 (e.g., diphenhydramine) and H2 (e.g., ranitidine) blockers are used.
– Diphenhydramine IV/IM/ per os (PO): 25-50mg (adults), 1.25mg/kg (pediatric) per dose
– Ranitidine IV/PO: 50mg IV/150mg PO (adults), 1.25mg/kg IV or 2mg/kg PO (pediatric) per dose
Corticosteroids
While there is a lack of any randomized, controlled studies demonstrating effectiveness of corticosteroids,
they are commonly used to prevent biphasic anaphylaxis.
– Methylprednisolone (IV) daily dose: 125mg (adults), 1mg/kg up to 60mg (pediatric)
– Prednisone (PO) daily dose: 50mg (adults), 1mg/kg up to 60mg (pediatric)
Steroids should be stopped after one or two days without a taper.
Beta 2-agonists
Use of inhaled beta-2 agonist bronchodilators (e.g., albuterol) is recommended in all patients exhibiting
evidence of bronchospasm, especially with a history of pulmonary disease (asthma, COPD). Continuous
monitoring (using a cardiopulmonary monitor and pulmonary exam reassessment) of the patient’s response
to treatment will determine if further bronchodilator therapy is indicated.
– Albuterol (inhaled): 10-15mg/hour by continuous nebulization (adults), 0.5mg/kg/hour by continuous

nebulization, up to adult dose (pediatric).
– IM Dosing: 1:1000 dilution, 0.3-0.5ml (adults), 0.01ml/kg, up to 0.3ml (children)
– Can be repeated every 5-15 minutes as needed
– 20-40% of patients may require an additional dose, patients should be observed for a minimum of 4-6
hours after symptom resolution.
B. Common Pitfalls and Side-Effects of Management of this

Clinical Problem
Management points not to be missed
While pulmonary and cutaneous manifestations are most common in anaphylaxis, it is noteworthy that up
to 20% of cases may not have cutaneous ndings. This is important to consider when a patient may have
other ndings suggestive of an anaphylactic reaction and should not deter the clinician from empirically
treating while obtaining more data in con rming the diagnosis.
Patients found to have anaphylaxis and appropriately treated on presentation should be observed, ideally
for at least 4-6 hours after the patient is symptom-free. The reasoning for this is the risk of a biphasic
anaphylactic reaction can occur in up to 20% of patients leading to a potentially worse reaction, especially if
the patient has already been discharged.
Side effects of medications
Epinephrine is the mainstay of treatment in anaphylaxis. However, it does have side effects (elevation of BP,
tachycardia) that cause providers to take pause prior to initiating therapy. However, the bene ts of
epinephrine therapy outweigh the risks. Delayed use (within 30 minutes) of epinephrine in anaphylaxis is
associated with poor outcomes, including mortality. There are no contraindications to the administration of
epinephrine in anaphylaxis.
Tricyclic antidepressants and monoamine oxidase inhibitors can potentiate the effect of epinephrine, and
therefore contribute to an increased risk of cardiac arrhythmia. Cocaine sensitizes the heart to
catecholamines and thereby potentiates the effects of epinephrine. If a patient’s history includes active use
of these substances, closer monitoring should be initiated.
Beta-blockers may actually inhibit the bene ts of epinephrine therapy, while also causing unopposed alpha
stimulation, leading to hypertension and tachycardia. Glucagon administration is useful in those patients
(dose: 1-5 mg in adults, IV over 5 minutes).
IV. What's the evidence?

Lieberman, P, Nicklas, RA, Oppenheimer, J. “The diagnosis and management of anaphylaxis practice
parameter: 2010 update”. J Allergy Clin Immunol. vol. 126. 2010. pp. 477-480.
Lieberman, P, Kemp, SF, Oppenheimer, J. “The diagnosis and management of anaphylaxis: an updated
practice parameter”. J Allergy Clin Immunol. vol. 15. 2005. pp. S483-S523.
Terr, AI. “Anaphylaxis”. Clin Rev Allergy. vol. 3. 1985. pp. 3-23.
Simons, FE. “Anaphylaxis”. J Allergy Clin Immunol. vol. 125. 2010. pp. S161-S181.
Enrique, E, Garcia-Ortega, P, Sotorra, O. “Usefulness of UniCAP- tryptase uoroimmunoassay in the
diagnosis of anaphylaxis”. Allergy. vol. 54. 1999. pp. 602-6.
Ellis, AK, Day, JH. “Diagnosis and management of anaphylaxis”. CMAJ. vol. 169. 2003. pp. 307-312.
Simons, FE, Ardusso, LR, Bilò, BM. “World Allergy Organization Guidelines for the Assessment and
Management of Anaphylaxis”. World Allergy Organ J. vol. 4. 2011. pp. 13-37.
Kelso, JM. “A second dose of epinephrine for anaphylaxis: How often needed and how to carry”. J Allergy
Clin Immunol. vol. 117. 2006. pp. 464-564.
Sheikh, A, Ten Broek, V, Brown, SG, Simons, FE. “H1-antihistamines for the treatment of anaphylaxis:
Cochrane systematic review”. Allergy. vol. 62. 2007. pp. 830
Lin, RY, Curry, A, Pesola, GR. “Improved outcomes in patients with acute allergic syndromes who are
treated with combined H1 and H2 antagonists”. Ann Emerg Med. vol. 36. 2000. pp. 462
Choo, KJ, Simons, FE, Sheikh, A. “Glucocorticoids for the treatment of anaphylaxis”. Cochrane Database
Syst Rev. vol. 4. 2012. pp. CD007596
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1/27/2021 Anaphylaxis - Cancer Therapy Advisor

Home » Decision Support in Medicine » Hospital Medicine

‫اﻓﺿل ﻋروض اﻟﺳﯾﺎرات ﻧﻘد و ﺗﻘﺳﯾط‬

Reduced BP after exposure to a known allergen (minutes to hours).

II. Diagnostic Approach

Foreign body in lung

Vocal cord dysfunction

Angioedema (hereditary or medication-induced)

B. Describe a diagnostic approach/method to the patient with

1. Historical information important in the diagnosis of this

Any potential allergen exposure, including timing/duration of exposure.

Presence of any cutaneous manifestations.

Any signs of airway obstruction (upper/lower airway).

Any syncope or presyncopal symptoms.

Presence of gastrointestinal symptoms.

Any treatment given prior to presentation.

Recurrence of symptoms after remission (if currently in remission).

Prior history of anaphylaxis.

Teenagers/young adults are at increased risk for food-allergen induced anaphylaxis.

2. Physical Examination maneuvers that are likely to be useful

Anaphylaxis will affect two or more of ve major organ systems:

Tachycardia/bradycardia or other arrhythmia

3. Laboratory, radiographic and other tests that are likely to be

Other tests to assist in narrowing the differential include:

Chest x-ray (evaluate for stridor, foreign body, pneumothorax)

Computed tomography (scan) (rule out pulmonary embolism (PE))

Electrocardiogram (ECG) (rule out myocardial infarction (MI), arrhythmia)

C. Criteria for Diagnosing Each Diagnosis in the Method Above.

D. Over-utilized or “wasted” diagnostic tests associated with the

III. Management while the Diagnostic Process is Proceeding

Airways, breathing and circulation

The patient’s airway should be determined to be adequate, with preparations for

Intravenous, oxygen, monitor

– Methylprednisolone (IV) daily dose: 125mg (adults), 1mg/kg up to 60mg (pediatric)

– Prednisone (PO) daily dose: 50mg (adults), 1mg/kg up to 60mg (pediatric)

Steroids should be stopped after one or two days without a taper.

– Albuterol (inhaled): 10-15mg/hour by continuous nebulization (adults), 0.5mg/kg/hour by continuous

– IM Dosing: 1:1000 dilution, 0.3-0.5ml (adults), 0.01ml/kg, up to 0.3ml (children)

– Can be repeated every 5-15 minutes as needed

B. Common Pitfalls and Side-Effects of Management of this

Side effects of medications

IV. What's the evidence?

Powered By Decision Support in Medicine.

CancerTherapyAdvisor.com is a free online resource that offers oncology healthcare professionals a

OTHER HAYMARKET MEDICAL WEBSITES

Clinical Pain Advisor

Infectious Disease Advisor

McKnight’s Long Term Care News

McKnight’s Senior Living

Oncology Nurse Advisor

Renal and Urology News

The Cardiology Advisor

Copyright © 2020 Haymarket Media, Inc. All Rights Reserved

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