“I’m all Itchy”

Anaphylaxis in the Pediatric ER
Dr. Rebecca Starr

Pediatric Emergency Medicine Fellow
February 6, 2014
c...
Objectives
 Discuss the most current definition of anaphylaxis
 Explain the causes and pathophysiology of anaphylaxis
 ...
Question 1
A 5 year old M who has experienced a severe allergic
reaction to shrimp in the past needs a CT scan with IV
and...
Question 2
You have been asked by a local school to provide
recommendations about the use of self injectable
epinephrine f...
Question 3
A 14 y/o M who has seasonal allergies and moderate
persistent asthma is currently receiving allergen
immunother...
Question 4
A 10 y/o M with a history of peanut allergy presents with diffuse
itching and trouble breathing after eating a ...
What is Anaphylaxis?
 Big Bang
Anaphylaxis 411
 “Severe allergic reaction that can be life threatening”
 IgE-mediated hypersensitivity reaction resulti...
Clinical Definition
History
 First death from anaphylaxis was documented in
Egyptian hieroglyphics in 2641 BC
 Pharaoh Menes dying after a h...
History
 First described in scientific literature in 1902 by two
French physiologists, Charles Richet and Paul Portier
 ...
Pediatric Epidemiology
 10.5 per 100,000
 Increasing over the past 4 decades
 2:1 Male to female ratio
 25% require ad...
Pediatric Epidemiology
 Severity of a previous reaction does not predict the
severity of a subsequent reaction
 Previous...
Causes of Anaphylaxis
Causes of Anaphylaxis
 Food
 Leading cause of all anaphylaxis in children
 50% of anaphylactic triggers

 Peanuts, tre...
Causes of Anaphylaxis
 Medications
 24% of anaphylactic triggers
 Antibiotics most common- PCN and cross reaction drugs...
Causes of Anaphylaxis
 Hymenoptera envenomation
 12% of anaphylactic triggers
 Honeybees, yellow jackets, hornets, wasp...
Causes of Anaphylaxis
 Immunizations- estimated 1.5 events per 1 million
 MMR and influenza are the most common
 Prepar...
Contrast Media
 Anaphylactoid reaction- not IgE mediated
 Osmolality-hypertonicity reaction
 Triggers degranulation of ...
Question 1
A 5 year old M who has experienced a severe allergic
reaction to shrimp in the past needs a CT scan with IV
and...
Question 1
A 5 year old M who has experienced a severe allergic
reaction to shrimp in the past needs a CT scan with IV
and...
Route of Exposure
 Insect stings and parenterally injected medication may
have rapid onset of symptoms
 PO ingestions ma...
Pathophysiology
 First time exposure to the allergen
 Specific IgE antibodies are formed around the allergen
and bind to...
Pathophysiology
 Effect of Chemical Mediators after release
 Increased vascular permeability
 Bronchospasm
 Vasodilata...
Symptoms
 Respiratory: 94%
 Cutaneous: 80- 90%

 GI: 10-46%
 CV: 30%

Russell et al.,Pediatric Emergency Care, 2010
Clinical Manifestations

www.intranet.tdmu.edu.ua
www.achesandpainsmedical.com.au
Treatment

ABC’s!!!

IM EPINEPHRINE!!!!
IM Epinephrine
 First line therapy!
 Has alpha-1, beta-1, and beta-2 agonist actions
 Increased vascular resistance and...
IM vs. Sub-q
 IM substantially better than sub-q
 Faster peak plasma concentrations
 Anterolateral thigh (vastus latera...
IM Epinephrine
 Dose: 0.01mg/kg of 1:1000
 Max dose is 0.3mg
 May repeat every 5-15 minutes
 20% require subsequent do...
EpiPen

www.allergywindow.com

Russell et al.,Pediatric Emergency Care, 2010
Question 2
You have been asked by a local school to provide
recommendations about the use of self injectable
epinephrine f...
Question 2
You have been asked by a local school to provide
recommendations about the use of self injectable
epinephrine f...
Question 3
A 14 y/o M who has seasonal allergies and moderate
persistent asthma is currently receiving allergen
immunother...
Question 3
A 14 y/o M who has seasonal allergies and moderate
persistent asthma is currently receiving allergen
immunother...
Treatment
 IM Epinephrine
 May repeat

 IV fluids- 20ml/kg bolus
 Repeat boluses if hypotension persists

 IV Epineph...
Role of Corticosteroids?
 Corticosteroids
 NO clinical evidence-based support for steroids in acute
management of anaphy...
Question 4
A 10 y/o M with a history of peanut allergy presents with
diffuse itching and trouble breathing after eating a ...
Question 4
A 10 y/o M with a history of peanut allergy presents with
diffuse itching and trouble breathing after eating a ...
Biphasic Reactions
 Delayed anaphylactic reaction developing after initial
reaction has resolved
 About 1-20% of all ana...
Biphasic Reactions

Lee et al, Pediatrics, 2013
Criteria for Admission
 Unresolved symptoms
 High risk for biphasic reaction
 Delayed epinephrine treatment

 Co-morbi...
Outpatient Management
 Prescription for EpiPen
 Parents can get at our pharmacy

 Educate parents
 Symptoms of anaphyl...
Patient Education
Hold for 10 seconds!

Look at expiration date!
www.drug3k.com
How to use EpiPen

EpiPen Video
EpiPen 2.0?

 Auvi Q
Summary
 Anaphylaxis- acute onset, involvement of 2 or more organ
systems or presence of hypotension
 Severity of a prev...
References
 Lee, J.M. and Greenes, D.S., Biphasic Anaphylactic
Reactions in Pediatrics. Pediatrics. 2000;106(4):762-6.
 ...
Any Questions?
Management of Anaphylaxis
Management of Anaphylaxis
Management of Anaphylaxis
Management of Anaphylaxis
Management of Anaphylaxis
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  • Met with Food Allergy and Anaphlaxis Network in July 2005. Essentially 2 or more organ systems or hypotension
  • Krombach et al, Allergy, 2004http://onlinelibrary.wiley.com/doi/10.1111/j.1398-9995.2004.00603.x/pdf
  • Allergan type does not seem to be a predictor of hospitalization
  • Prescription must be refilled annually. Heat, cold and sunlight can affect degradation of Epi
  • Management of Anaphylaxis

    1. 1. “I’m all Itchy” Anaphylaxis in the Pediatric ER Dr. Rebecca Starr Pediatric Emergency Medicine Fellow February 6, 2014 certifiedallergysa.com
    2. 2. Objectives  Discuss the most current definition of anaphylaxis  Explain the causes and pathophysiology of anaphylaxis  Analyze symptoms and be able to diagnose and effectively treat anaphylaxis  Review biphasic anaphylactic reactions  List appropriate discharge materials from the ED
    3. 3. Question 1 A 5 year old M who has experienced a severe allergic reaction to shrimp in the past needs a CT scan with IV and oral contrast. What precautions should you take? A. NS bolus and diphenhydramine B. NS bolus, diphenhydramine, and prednisone C. This patient can not receive contrast D. Reassurance, there is no associated risk for a reaction between shellfish and contrast
    4. 4. Question 2 You have been asked by a local school to provide recommendations about the use of self injectable epinephrine for anaphylaxis. What is the BEST response to give regarding anaphylaxis? A. A patient should not receive a second dose of epinephrine unless a physician is present B. Epinephrine reaches higher peak plasma concentrations when injected into the thigh rather than the arm C. Families should keep one epinephrine auto injector in the car in case a reaction occurs after school D. Subcutaneous injection of epinephrine is preferable to intramuscular injection
    5. 5. Question 3 A 14 y/o M who has seasonal allergies and moderate persistent asthma is currently receiving allergen immunotherapy. Today in clinic he received his usual allergen injection, but after 10 minutes, he started coughing and complaining of dyspnea and throat swelling. On physical exam he exhibits moderate respiratory distress and has diffuse expiratory wheezing on auscultation. No oropharyngeal edema noted. Vitals signs include a pulse ox of 97%, BP of 130/70, and HR of 90. Of the following, the MOST appropriate next action is to administer: A. A short acting beta-2 agonist nebulization B. An oral antihistamine C. An oral corticosteroid D. Intramuscular epinephrine
    6. 6. Question 4 A 10 y/o M with a history of peanut allergy presents with diffuse itching and trouble breathing after eating a friend’s candy bar that contained nuts during school lunch. At the nurse’s office the patient received IM epinephrine with his EpiPen with symptom resolution. EMS was called and the patient was brought to the local pediatric ED (about a 12 minute ride). On arrival to the ED, the patient is again complaining of itching with an urticarial rash on his chest and per EMS the patient began vomiting as they were pulling up to the ambulance bay. Arrival vitals include a pulse ox of 96%, BP of 88/67, and HR of 95. Of the following, the MOST appropriate treatment plan is: A. Intramuscular epinephrine, oral antihistamine, oral corticosteroid, and a short acting beta-2 agonist neb treatment B. Intramuscular epinephrine, IV antihistamine, IV corticosteroid, NS bolus C. Intramuscular epinephrine, IV antihistamine, IV Zantac, NS bolus D. Intramuscular epinephrine, oral antihistamine, and oral corticosteroid
    7. 7. What is Anaphylaxis?  Big Bang
    8. 8. Anaphylaxis 411  “Severe allergic reaction that can be life threatening”  IgE-mediated hypersensitivity reaction resulting in the release of potent chemical mediators  Mast Cells  Basophils  Affects multiple organ systems  Respiratory  Cardiovascular  Gastrointestinal  Dermatologic  Clinical Diagnosis  Biphasic Reactions Russell et al.,Pediatric Emergency Care, 2010
    9. 9. Clinical Definition
    10. 10. History  First death from anaphylaxis was documented in Egyptian hieroglyphics in 2641 BC  Pharaoh Menes dying after a hornet sting  Questionable and now not supported by historians
    11. 11. History  First described in scientific literature in 1902 by two French physiologists, Charles Richet and Paul Portier  Prince Albert I of Monaco  Investigating jellyfish toxins  Initially coined “aphylaxis” with “a” meaning contrary to and “phylaxis” meaning protection  Richet won the Nobel Prize in Medicine Lane et al, Pediatric Emergency Care, 2007
    12. 12. Pediatric Epidemiology  10.5 per 100,000  Increasing over the past 4 decades  2:1 Male to female ratio  25% require admission  1500 deaths per year in US (adults and children)  40% had prior history of allergic reaction  Only 20% of prior anaphylaxis patients had an Epipen available during repeat anaphylaxis encounter Lane et al, Pediatric Emergency Care, 2007 Russell et al.,Pediatric Emergency Care, 2010
    13. 13. Pediatric Epidemiology  Severity of a previous reaction does not predict the severity of a subsequent reaction  Previous anaphylactic reactions = higher risk for reoccurrence Lane et al, Pediatric Emergency Care, 2007
    14. 14. Causes of Anaphylaxis
    15. 15. Causes of Anaphylaxis  Food  Leading cause of all anaphylaxis in children  50% of anaphylactic triggers  Peanuts, tree nuts and shellfish are the most common  Usually the most life-threatening reactions  Older children  Milk, soy, eggs  Most common in younger children  Potential to outgrow  Food dyes Lane et al, Pediatric Emergency Care, 2007 Russell et al.,Pediatric Emergency Care, 2010
    16. 16. Causes of Anaphylaxis  Medications  24% of anaphylactic triggers  Antibiotics most common- PCN and cross reaction drugs to PCN  Penicillin-allergic individuals have a 4-10% risk of allergic reaction to a cephalosporin  Only antibiotic that can have skin testing (for IgE mediated rxn)  NSAIDs  Latex- chronic patients and multiple surgeries  IV contrast  Propofol- sedative medication that contains eggs and soy  Blood products, IVIG, etc Lane et al, Pediatric Emergency Care, 2007
    17. 17. Causes of Anaphylaxis  Hymenoptera envenomation  12% of anaphylactic triggers  Honeybees, yellow jackets, hornets, wasps, and fire ants  Life threatening reactions require venom immunotherapy  20-60% risk per sting of anaphylaxis Lane et al, Pediatric Emergency Care, 2007
    18. 18. Causes of Anaphylaxis  Immunizations- estimated 1.5 events per 1 million  MMR and influenza are the most common  Prepared using chick-derived cells  AAP recommends giving MMR to children with egg sensitivity  Per CDC, egg sensitivity a contraindication for influenza vaccine  Unknown exposure  16% of anaphylactic triggers
    19. 19. Contrast Media  Anaphylactoid reaction- not IgE mediated  Osmolality-hypertonicity reaction  Triggers degranulation of mast cells and basophils  Association of shellfish allergy and contrast media (because of iodine content) is a myth  Pretreatment with prednisone and diphenhydramine is only indicated in documented history of an adverse reaction to contrast media
    20. 20. Question 1 A 5 year old M who has experienced a severe allergic reaction to shrimp in the past needs a CT scan with IV and oral contrast. What precautions should you take? A. NS bolus and diphenhydramine B. NS bolus, diphenhydramine, and prednisone C. This patient can not receive contrast D. Reassurance, there is no associated risk for a reaction between shellfish and contrast
    21. 21. Question 1 A 5 year old M who has experienced a severe allergic reaction to shrimp in the past needs a CT scan with IV and oral contrast. What precautions should you take? A. NS bolus and diphenhydramine B. NS bolus, diphenhydramine, and prednisone C. This patient can not receive contrast. D. Reassurance, there is no associated risk for a reaction between shellfish and contrast.
    22. 22. Route of Exposure  Insect stings and parenterally injected medication may have rapid onset of symptoms  PO ingestions may develop over several minutes to hours  Most symptoms occur within 5-30 minutes post exposure Lane et al, Pediatric Emergency Care, 2007
    23. 23. Pathophysiology  First time exposure to the allergen  Specific IgE antibodies are formed around the allergen and bind to Fc receptors on mast cells  Repeat allergen exposure and binding of the allergen to IgE antibodies causes degranulation of mast cell  Massive release of chemical mediators including:  Histamine  Prostaglandin D2  Leukotrienes  Platelet activating factor  Tryptase Lane et al, Pediatric Emergency Care, 2007
    24. 24. Pathophysiology  Effect of Chemical Mediators after release  Increased vascular permeability  Bronchospasm  Vasodilatation  Altered smooth muscle tone  Within 10 minutes the circulating blood volume can decrease by 35% during anaphylaxis Lane et al, Pediatric Emergency Care, 2007
    25. 25. Symptoms  Respiratory: 94%  Cutaneous: 80- 90%  GI: 10-46%  CV: 30% Russell et al.,Pediatric Emergency Care, 2010
    26. 26. Clinical Manifestations www.intranet.tdmu.edu.ua www.achesandpainsmedical.com.au
    27. 27. Treatment ABC’s!!! IM EPINEPHRINE!!!!
    28. 28. IM Epinephrine  First line therapy!  Has alpha-1, beta-1, and beta-2 agonist actions  Increased vascular resistance and decreased mucosal edema (alpha-1)  Increased inotrophy and chronotrophy (beta-1)  Increased bronchodilation and decreases release of mast cell and basophil mediators (beta-2)  Only 18% reported use in pediatric anaphylaxis cases
    29. 29. IM vs. Sub-q  IM substantially better than sub-q  Faster peak plasma concentrations  Anterolateral thigh (vastus lateralis)
    30. 30. IM Epinephrine  Dose: 0.01mg/kg of 1:1000  Max dose is 0.3mg  May repeat every 5-15 minutes  20% require subsequent dosing EpiPen:  2 fixed doses: 0.15mg and 0.3mg  < 22kg give EpiPen Jr (0.15mg)  >22kg give EpiPen (0.3mg) Lane et al, Pediatric Emergency Care, 2007
    31. 31. EpiPen www.allergywindow.com Russell et al.,Pediatric Emergency Care, 2010
    32. 32. Question 2 You have been asked by a local school to provide recommendations about the use of self injectable epinephrine for anaphylaxis. What is the BEST response to give regarding anaphylaxis? A. A patient should not receive a second dose of epinephrine unless a physician is present B. Epinephrine reaches higher peak plasma concentrations in injected into the thigh rather than the arm C. Families should keep one epinephrine auto injector in the car in case a reaction occurs after school D. Subcutaneous injection of epinephrine is preferable to intramuscular injection
    33. 33. Question 2 You have been asked by a local school to provide recommendations about the use of self injectable epinephrine for anaphylaxis. What is the BEST response to give regarding anaphylaxis? A. A patient should not receive a second dose of epinephrine unless a physician is present B. Epinephrine reaches higher peak plasma concentrations in injected into the thigh rather than the arm C. Families should keep one epinephrine auto injector in the car in case a reaction occurs after school D. Subcutaneous injection of epinephrine is preferable to intramuscular injection
    34. 34. Question 3 A 14 y/o M who has seasonal allergies and moderate persistent asthma is currently receiving allergen immunotherapy. Today in clinic he received his usual allergen injection, but after 10 minutes, he started coughing and complaining of dyspnea and throat swelling. On physical exam he exhibits moderate respiratory distress and has diffuse expiratory wheezing on auscultation. No oropharyngeal edema noted. Vitals signs include a pulse ox of 97%, BP of 130/70, and HR of 90. Of the following, the MOST appropriate next action is to administer: A. A short acting beta-2 agonist nebulization B. An oral antihistamine C. An oral corticosteroid D. Intramuscular epinephrine
    35. 35. Question 3 A 14 y/o M who has seasonal allergies and moderate persistent asthma is currently receiving allergen immunotherapy. Today in clinic he received his usual allergen injection, but after 10 minutes, he started coughing and complaining of dyspnea and throat swelling. On physical exam he exhibits moderate respiratory distress and has diffuse expiratory wheezing on auscultation. No oropharyngeal edema noted. Vitals signs include a pulse ox of 97%, BP of 130/70, and HR of 90. Of the following, the MOST appropriate next action is to administer: A. A short acting beta-2 agonist nebulization B. An oral antihistamine C. An oral corticosteroid D. Intramuscular epinephrine
    36. 36. Treatment  IM Epinephrine  May repeat  IV fluids- 20ml/kg bolus  Repeat boluses if hypotension persists  IV Epinephrine for persistent hypotension/symptoms  0.01mg/kg of 1:10,000  Max dose 1gm  Histamine (H1/H2) blockers  Benadryl (H1) and Zantac (H2)  Slow onset of action  Shown to be effective on dermatologic manifestations especially in combo  Albuterol treatment if indicated Russell et al.,Pediatric Emergency Care, 2010
    37. 37. Role of Corticosteroids?  Corticosteroids  NO clinical evidence-based support for steroids in acute management of anaphylaxis  NO support for steroids against biphasic reactions  Reported use of corticosteroids is more prevalent than IM epinephrine in anaphylaxis Lane et al, Pediatric Emergency Care, 2007 Russell et al.,Pediatric Emergency Care, 2010
    38. 38. Question 4 A 10 y/o M with a history of peanut allergy presents with diffuse itching and trouble breathing after eating a friend’s candy bar that contained nuts during school lunch. At the nurse’s office the patient received IM epinephrine with his EpiPen with symptom resolution. EMS was called and the patient was brought to the local pediatric ED (about a 12 minute ride). On arrival to the ED, the patient is again complaining of itching with an urticarial rash on his chest and per EMS the patient began vomiting as they were pulling up to the ambulance bay. Arrival vitals include a pulse ox of 96%, BP of 88/67, and HR of 95. Of the following, the MOST appropriate treatment plan is: A. Intramuscular epinephrine, oral antihistamine, oral corticosteroid, and a short acting beta-2 agonist neb treatment B. Intramuscular epinephrine, IV antihistamine, IV corticosteroid, NS bolus C. Intramuscular epinephrine, IV antihistamine, IV Zantac, NS bolus D. Intramuscular epinephrine, oral antihistamine, oral corticosteroid
    39. 39. Question 4 A 10 y/o M with a history of peanut allergy presents with diffuse itching and trouble breathing after eating a friend’s candy bar that contained nuts during school lunch. At the nurse’s office the patient received IM epinephrine with his EpiPen with symptom resolution. EMS was called and the patient was brought to the local pediatric ED (about a 12 minute ride). On arrival to the ED, the patient is again complaining of itching with an urticarial rash on his chest and per EMS the patient began vomiting as they were pulling up to the ambulance bay. Arrival vitals include a pulse ox of 96%, BP of 88/67, and HR of 95. Of the following, the MOST appropriate treatment plan is: A. Intramuscular epinephrine, oral antihistamine, oral corticosteroid, and a short acting beta-2 agonist neb treatment B. Intramuscular epinephrine, IV antihistamine, IV corticosteroid, NS bolus C. Intramuscular epinephrine, IV antihistamine, IV Zantac, NS bolus D. Intramuscular epinephrine, oral antihistamine, oral corticosteroid
    40. 40. Biphasic Reactions  Delayed anaphylactic reaction developing after initial reaction has resolved  About 1-20% of all anaphylactic reactions  6% in pediatric anaphylaxis  Asymptomatic intervals range from 1-28 hours  Can occur up to 72 hours from initial reaction  Length of observation?  Suggested 8-24 hours in literature  “The only intervention that has been shown to reduce the prevalence and severity of biphasic allergic reactions is early treatment with IM epinephrine” Lane et al, Pediatric Emergency Care, 2007
    41. 41. Biphasic Reactions Lee et al, Pediatrics, 2013
    42. 42. Criteria for Admission  Unresolved symptoms  High risk for biphasic reaction  Delayed epinephrine treatment  Co-morbidities  Social
    43. 43. Outpatient Management  Prescription for EpiPen  Parents can get at our pharmacy  Educate parents  Symptoms of anaphylaxis  Use of EpiPen  Referral to allergist  School forms  Peds ED Portal
    44. 44. Patient Education Hold for 10 seconds! Look at expiration date! www.drug3k.com
    45. 45. How to use EpiPen EpiPen Video
    46. 46. EpiPen 2.0?  Auvi Q
    47. 47. Summary  Anaphylaxis- acute onset, involvement of 2 or more organ systems or presence of hypotension  Severity of a previous reaction does not predict the severity of a subsequent reaction  Patients with previous anaphylactic reactions are at a higher risk for reoccurrence  First line treatment is IM epinephrine  < 22kg give EpiPen Jr (0.15mg)  >22kg give EpiPen (0.3mg)  Early IM epinephrine can reduce the risk of a biphasic reaction  Discharge home with EpiPen, education, allergist referral, and school forms
    48. 48. References  Lee, J.M. and Greenes, D.S., Biphasic Anaphylactic Reactions in Pediatrics. Pediatrics. 2000;106(4):762-6.  Nowak, R., Farrar, J.R., Brenner, B.E. et al., Customizing anaphylaxis guidelines for emergency medicine. The Journal of Emergency Medicine. 2013;45(2):299-305.  Lane, R.D. and Bolte, R.G., Pediatric anaphylaxis. Pediatric Emergency Care. 2007;23(1):49-56.  Russell, S., Monroe, K., and Losek, J., Anaphylaxis management in the pediatric emergency department. Pediatric Emergency Care. 2010;26(2):71-76.
    49. 49. Any Questions?
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