Anaphylaxis
The Dying Breaths
Dr Gerard Fennessy
ICU Registrar
The Royal Melbourne Hospital
Victoria, Australia
Anaphylaxis


Definition and Causes



Clinical Aspects



Investigations and Treatment



Reprise
 Starring a famous...
About me…


NZ trained
◦



Joint ICU and ED training

Royal Melbourne Hospital
Mt Ruapehu
Mt Ruapehu
…and it was a quiet day on the MV Pacific
Carnival Princess Cruise Liner…
…and it was a quiet day on the MV Pacific
Carnival Princess Cruise Liner…


A – no stridor, able to talk



B – no wheez...
Anaphylaxis: the last slide…
 Adrenaline
 Adrenaline
 Adrenaline
 Epinephrine
Presentation is
VARIABLE
Diagnosis is CLINICAL
Requires URGENT
treatment
No consensus on
definition
ERC Resuscitation 2010


hypersensitivity reaction



severe, life-threatening



generalised or systemic



may have ...
Compromise to…
Incidence
Incidence
Incidence
Adults
1:3400 per year
1:500 – 1:1000 ED presentations
Fatalities
 <1


in 1,000,000

Within 5-30 minutes of exposure
Highly Popular Disease
IgE
http://www.ifr.ac.uk/
Non-allergic anaphylaxis


“anaphylactoid reaction”



identical presentation and treatment
Causes
Food
Hymenoptera
Drugs
Cephalosporin and Penicillin
Cross-Reactivity
The Journal of Emergency Medicine, Vol. 42, No. 5, pp. 612–620, 2012
 Β-lactam

R

ring

≈ side chain
The Journal of Emergency Medicine, Vol. 42, No. 5,
pp. 612–620, 2012


Penicillin allergic patients
 more allergic to EVERYTHING



Until mid-1980s
 penicillins and cephalorsporins made
u...


Cross reactivity:


1% who state penicillin allergy



2% with confirmed penicillin allergy



1st and 2nd generatio...
Negligible cross-reactivity with
3rd and 4th generation
cephalosporins
The Journal of Emergency Medicine, Vol. 42, No. 5,
...
Cephalosporins and Penicillin
Negligible Cross-reactivity


MOST 1st and 2nd generation

(cefaclor, cefalexin etc)

and
...
Clinical findings


Mild
◦



Moderate
◦



Skin, angioedema

Dyspnoea, stridor, wheeze, GI upset

Severe
◦

Cyanosis, ...
Clinical – Cutaneous 80-90%


Urticaria



Pruritis



Erythema



Angioedema
Respiratory


Hoarseness



Stridor



Wheeze



Bronchospasm



Hypoxia
Patrick J. Lynch, medical illustrator; C. Ca...
Cardiovascular


Hypotension



Tachycardia



Arrythmia



Syncope



Myocardial Depression
Investigations
Tryptase


Mast cell tryptase
◦

1-6 hours after event

◦

not sensitive or specific

◦

serial measurements may be usefu...
Treatment
 Adrenaline
 Adrenaline
 Adrenaline
 Epinephrine
Adrenaline


Airway swelling



Bronchospasm



Hypotension


Give it EARLY



IM
◦

0.3-0.5mg
 Repeat PRN



IV
◦



10-20 mcg/min

Nebulised


http://www.firstaidforlife.org.uk/courses/acute-allergic-reaction-and-how-to-use-and-epipen/
Uncertain Benefit
 Antihistamines
 Steroids
 Glucagon
A bit of light entertainment…
References and
Acknowledgements


Brown A. Current management of anaphylaxis. Emergencias 2009; 21: 213-223.



Campagna...
Gerard Fennessy: Anaphylaxis - the dying breaths
Gerard Fennessy: Anaphylaxis - the dying breaths
Gerard Fennessy: Anaphylaxis - the dying breaths
Gerard Fennessy: Anaphylaxis - the dying breaths
Gerard Fennessy: Anaphylaxis - the dying breaths
Gerard Fennessy: Anaphylaxis - the dying breaths
Gerard Fennessy: Anaphylaxis - the dying breaths
Gerard Fennessy: Anaphylaxis - the dying breaths
Gerard Fennessy: Anaphylaxis - the dying breaths
Gerard Fennessy: Anaphylaxis - the dying breaths
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Gerard Fennessy: Anaphylaxis - the dying breaths

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Fennessy adds an unexpected high note to the topic of managing the anaphylactic patient.

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Gerard Fennessy: Anaphylaxis - the dying breaths

  1. 1. Anaphylaxis The Dying Breaths Dr Gerard Fennessy ICU Registrar The Royal Melbourne Hospital Victoria, Australia
  2. 2. Anaphylaxis  Definition and Causes  Clinical Aspects  Investigations and Treatment  Reprise  Starring a famous movie star
  3. 3. About me…  NZ trained ◦  Joint ICU and ED training Royal Melbourne Hospital
  4. 4. Mt Ruapehu
  5. 5. Mt Ruapehu
  6. 6. …and it was a quiet day on the MV Pacific Carnival Princess Cruise Liner…
  7. 7. …and it was a quiet day on the MV Pacific Carnival Princess Cruise Liner…  A – no stridor, able to talk  B – no wheeze, sats 100%  RR 14  C – PR 100  BP 140/100  Would you give her adrenaline?
  8. 8. Anaphylaxis: the last slide…  Adrenaline  Adrenaline  Adrenaline  Epinephrine
  9. 9. Presentation is VARIABLE
  10. 10. Diagnosis is CLINICAL
  11. 11. Requires URGENT treatment
  12. 12. No consensus on definition
  13. 13. ERC Resuscitation 2010  hypersensitivity reaction  severe, life-threatening  generalised or systemic  may have skin and mucosal changes European Resuscitation Council Guidelines for Resuscitation 2010. Resuscitation 81 (2010) 1219–1276
  14. 14. Compromise to…
  15. 15. Incidence
  16. 16. Incidence
  17. 17. Incidence Adults 1:3400 per year 1:500 – 1:1000 ED presentations
  18. 18. Fatalities  <1  in 1,000,000 Within 5-30 minutes of exposure
  19. 19. Highly Popular Disease
  20. 20. IgE http://www.ifr.ac.uk/
  21. 21. Non-allergic anaphylaxis  “anaphylactoid reaction”  identical presentation and treatment
  22. 22. Causes
  23. 23. Food
  24. 24. Hymenoptera
  25. 25. Drugs
  26. 26. Cephalosporin and Penicillin Cross-Reactivity
  27. 27. The Journal of Emergency Medicine, Vol. 42, No. 5, pp. 612–620, 2012
  28. 28.  Β-lactam R ring ≈ side chain The Journal of Emergency Medicine, Vol. 42, No. 5, pp. 612–620, 2012
  29. 29.  Penicillin allergic patients  more allergic to EVERYTHING  Until mid-1980s  penicillins and cephalorsporins made using the same mold The Journal of Emergency Medicine, Vol. 42, No. 5, pp. 612–620, 2012
  30. 30.  Cross reactivity:  1% who state penicillin allergy  2% with confirmed penicillin allergy  1st and 2nd generation only The Journal of Emergency Medicine, Vol. 42, No. 5, pp. 612–620, 2012
  31. 31. Negligible cross-reactivity with 3rd and 4th generation cephalosporins The Journal of Emergency Medicine, Vol. 42, No. 5, pp. 612–620, 2012
  32. 32. Cephalosporins and Penicillin Negligible Cross-reactivity  MOST 1st and 2nd generation (cefaclor, cefalexin etc) and  ALL 3rd and 4th generation (ceftriaxone)
  33. 33. Clinical findings  Mild ◦  Moderate ◦  Skin, angioedema Dyspnoea, stridor, wheeze, GI upset Severe ◦ Cyanosis, hypotension, collapse
  34. 34. Clinical – Cutaneous 80-90%  Urticaria  Pruritis  Erythema  Angioedema
  35. 35. Respiratory  Hoarseness  Stridor  Wheeze  Bronchospasm  Hypoxia Patrick J. Lynch, medical illustrator; C. Carl Jaffe, MD, cardiologist
  36. 36. Cardiovascular  Hypotension  Tachycardia  Arrythmia  Syncope  Myocardial Depression
  37. 37. Investigations
  38. 38. Tryptase  Mast cell tryptase ◦ 1-6 hours after event ◦ not sensitive or specific ◦ serial measurements may be useful
  39. 39. Treatment
  40. 40.  Adrenaline  Adrenaline  Adrenaline  Epinephrine
  41. 41. Adrenaline  Airway swelling  Bronchospasm  Hypotension
  42. 42.  Give it EARLY  IM ◦ 0.3-0.5mg  Repeat PRN  IV ◦  10-20 mcg/min Nebulised
  43. 43.  http://www.firstaidforlife.org.uk/courses/acute-allergic-reaction-and-how-to-use-and-epipen/
  44. 44. Uncertain Benefit  Antihistamines  Steroids  Glucagon
  45. 45. A bit of light entertainment…
  46. 46. References and Acknowledgements  Brown A. Current management of anaphylaxis. Emergencias 2009; 21: 213-223.  Campagna JD, Bond MC, Schabelman E, Hayes BD. The use of cephalosprins in penicillin allergic patients: a literature review. Journal of Emergency Medicine 2012. 42(5); 612–620.  deShazo R. Anaphylaxis: My “Top 10′′ List. Southern Medical Journal 2007: 100(3), 233­234.  Dewachter P, Mouton-Faivre C, Emala CW. Anaphylaxis and Anesthesia, Controversies and New Insights. Anesthesiology 2009; 111:1141–50.  Worth A, Soar J, Sheikh A. Management of anaphylaxis in the emergency setting. Expert Rev. Clin. Immunol; 2010. 6(1), 89–100.  Not sponsored by Epipen nor Zovirax nor Seasame Street  Thanks to Stephen Odgers (backing vocals and guitar) and Jim Henson
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