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Anaphylaxis
 

Anaphylaxis

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  • National institute of allergy and infectious diseasesassociated symptoms of organ dysfunction – hypotonia , syncope , incontinence
  • Food commonest,1/3,peanuts and crustaceans commonest,wasp and bee stings ,antibiotics first,pencillin,next goes to rcm,1/3 unidentified.
  • Mild to fatal
  • Alpha 1 and beta 2 agonistic action,alpha action increases pvr and reverse peripheral vasodialation,vascularpermeability,and systemic hypotension.b agonist effect produces bronchodialation,cause positive ionotropic and chromotropic cardiac activity,and result in increased production of camp.epinephrine therefore reverses bronchospasm,stimulates increased cardiac output,and inhibits further mediator releaseExcessive alpha agonist activity can result in hypertensive crisis excessive b agonist activity can result in increse myocardial oxygen consumption,through increased wall tension,contractility and chronotropism and can produce hemodynamically significant supraventricular and ventricular dysrhytmias.
  • 1 ml of in 1;1000 in 500 ml of d5w oor ns and running at a rate of 1-4 mic/min(0.5 -2ml/min)
  • Usually single dose will be sufficient
  • As early as possible,no gastric lavage
  • Distributive shock
  • To prevenr biphasic reaction and recurrences,prednisolone for 7-10 days,onset of action 4-6 hrs
  • Diphenhydramine 25-50 mg,cpm 10 -20 mg,blocks action of circulating histamine on target tissue,h2 blockers effectson effect of histamine on myocardial and peripheral vascular tissue.
  • Mgso4 1-2 gnm iv over 30 mins
  • Causes positive ionotropism by augmenting camp synthesis through a noradrenergic pathway

Anaphylaxis Anaphylaxis Presentation Transcript

  • Dr.Soma Sekhara Reddy.kEmergency Physician
  • OBJECTIVES Definition Epidemiology Pathophysiology Clinical features Management prevention
  • AGAINST PROTECTION ANA - Against PHYLAX - Guard Pharoh Menes - 2641 BC
  • DEFNITION Serious allergic reaction that is rapid in onset and may causedeath. Multi organ involvement Precipitated with in minutes of exposure to a particular allergen In a sensitized patient
  • Clinical criteria for Anaphylaxis1.Acute onset of illness with involvement of skin and/ormucosal tissue along withResp.compromise / hypotension / associated symptomsof organ dysfunction2.Rapid onset of 2 0r more of the following after exposure tolikely allergen:Involvement of skin and/or mucosal tissueResp.compromiseHypotensionG I symptoms3. Known allergen with hypotension
  • EPIDEMIOLOGY Food Insect stings Pharmacological agents Latex Exercise Unidentified – Idiopathic anaphylaxis
  • RISK FACTORS Low in very young and very old Dose,frequency,route Poorly controlled asthma Previous anaphylaxis
  • PATHOPHYSIOLOGYTwo staged process: Sensitization Degranulation
  • SENSITIZATION
  • DEGRANULATION Re –exposure mast cell degranulates Releases several chemicals Acts on target organs Clinical syndrome of anaphylaxis
  • TARGET ORGANS Rich in mast cells Skin Eye Nose Resp tract GIT CVS
  • CHEMICAL MEDIATORS Histamine Tryptase Chymase Cathepsin G TNF Proteoglycans
  • CLINICAL MANIFESTATIONS- RS Rhinitis Pharyngeal and laryngeal edema Cough Broncospasm Dyspnea / chest tightness
  • CLINICALMANIFESTATIONS - CVS• Dysrhythmia Hypotension Cardiac arrest
  • CLINICALMANIFESTATIONS - skin Generalized warmth and tingling Pruritis Urticaria flushing Angioedema
  • CLINICALMANIFESTATIONS - GIT Abdominal pain / cramps Nausea Vomiting Diarrhea ? Gi bleed
  • TREATMENT FIRST LINE SECOND LINE
  • FIRST LINE THERAPY Airway Breathing Circulation IV O2 monitor
  • FIRST LINE THERAPY EPINEPHRINE Drug of choice IV/IM
  • EPINEPHRINE IV Severe upper airway obstruction Acute respiratory failure Shock Caution but not contra indicated..
  • EPINEPHRINE Dose 100 microgram (0.1 mg) bolus over 5 to 10 mins 0.1 ml of 1:1000 diluted in 10 ml NS Start infusion if there is no response (1-4 mic/min) 0.1 mic/kg/min in children Stop if chest pain or arrhythmia occurs
  • EPINEPHRINE IM LESS SEVERE SYMPTOMS Dose: 0.3 -0.5 ml of 1:1000 May be repeated every 5 to 10 mins Antero lateral thigh is preferred over deltoid
  • FIRST LINE THERAPY Decontamination
  • FIRST LINE THERAPYFLUIDS 1-2 L of NS bolus 20 ml/kg bolus in children
  • SECOND LINE THERAPYCORTICOSTEROIDS Methyl prednisolone 80 -125 mg IV (2mg/kg) Hydrocortisone 250- 500 mg IV (5 -10 mg/kg) Oral prednisolone
  • SECOND LINE THERAPYANTI HISTAMINES H1 blocker- Diphenhydramine/CPM 25 – 50 mg IV H2 blocker - Ranitidine 50 mg IV Avoid cimetidine
  • SECOND LINE THERAPYAEROSOLISED BETA AGONISTS Salbutamol Levosalbutamol Ipratropium bromide Severe persistent cases magnesium may be used
  • SECOND LINE AGENTSGLUCAGON Reserved for patients on beta blockers and refractory to initialmeasures 1 mg IV every 5 minutes until hypotension resolves followed by5 – 15 mics / min infusion. Side effects: Hypokalemia , hyperglycemia , nausea , vomiting.
  • PREVENTION Allergy history Label all loaded syringes Give drugs in distal extremity whenever possible Ensure all patients wait in ED for atleast 30 mins after any drugadministration
  • PREVENTION Warning identification Avoid any known allergens Epipen Use allergy bands for all predisposed patients.
  • TAKE HOME Always ABC first Epinephrine is the drug of choice Anaphylaxis is very near to severe allergic reactions Change beta blockers Put on long term steroids if it is idiopathic anaphylaxis Educate every patient about prevention
  • Thank you