anaphylaxis is an antibody antigen reaction and commonly seen in the ER and ICU setup. in this presentation, there are updates regarding anaphylaxis (& shock) treatement.

1. Case
Dr Surjeet Acharya
Senior Resident
Department of Emergency Medicine
Max Super Speciality Hospital

3. A 32 year healthy man (name with held) was wheeled into the Emergency Room accompanied
by her wife with history of multiple bee stings in his body around 40 minutes back.
On examination, he was able to talk in full sentences.
RR- 24/min , CRT - < 3 seconds, GCS - 15/15, RBS - 98 mg/dL, Pupils - NSNR
HR -100/min, BP- 110/70 mmHg, EKG - normal sinus rythm.
He was found to have multiple bee stingers over the bilateral lower limbs & upper limbs , head
and neck.

4. He was fine a while ago when he took home remedies for local irritation
and burning sensation after stings.
The patient started having difficulty in breathing for last 30 minutes, and
was rushed to the ED for further care.

5. Individual stingers were removed one by one.
The patient was advised for admission in Intensive care unit.
He was given 2 shots of Inj Adrenaline 1:1000 (0.5 mg IM, 5 minutes apart on
contralateral thighs ), IV fluids and oxygen.
The patient condition initially improved after the Adrenaline administration.

6. As the patient was waiting in ER for
admission in critical care unit,
the patient started complaining
of severe breathing difficulty
with “air hunger” and was
profusely sweating and had a facial flush.

7. The patient was rushed into the resuscitation bay within ER where his vitals were:
RR - 30 /min
SpO2 - 60 % on high flow nasal mask
PR - 116/min
BP - 70/40 mmHg
RBS - 100 mg/dL
The patient was immediately diagnosed to have ?
Anaphylactic
Shock

8. Video Laryngoscopy was done to secure the airway

9. STEPS TAKEN IN ANAPHYLACTIC SHOCK
1. Emergency endotracheal intubation via Video Laryngoscope
as all other emergency airway secure measures failed.
After taking informed consent from the patient wife, the procedure was started. It was “difficult
intubation” because the patient was having swelling of tongue (?anaphylaxis induced) and thus,
video laryngoscopy was carried out for securing the airway of the patient.
2. Alongside securing the airway, the patient another peripheral access was taken and patient was
started on Inj Adrenaline infusion.
3. 1 litre of Normal saline (IV fluid).

10. 4. Patient was also taken on adrenaline nebuliser via the ET tube.
5. Other infusion like Inj Noradrenaline and Inj Vasopressin was started (in view of
hypotension) after adrenaline infusion
6. Nebulization with Salbutamol was given (after adrenaline nebulization).

11. After successful endotracheal intubation, the repeat BP was still not satisfactory,
the patient was started on Adrenaline infusion followed by infusions of Inj
Noradrenaline and Inj Vasopressin (after poor MAP response to Inj
Noradrenaline). The patient was shifted to the Intensive care unit.
After 3 days of hospitalization, the patient was discharged home satisfactorily in
stable condition.
The next follow-up’s were uneventful and patient recovered well.

12. ALARM BELLS :
● Any anaphylaxis can lead to anaphylactic shock
● Careful about “Bi-Phasic” reaction
● ONLY ADRENALINE WORKS
BI-PHASIC
REACTION

13. The newer concept of Bi-phasic reaction occurrence is 6 hours only with previous
history of allergy or exposure to allergen
Use of drugs like chloropheniramine maleate and other antihistamines (like
cetrizine, fexofenadine), H1 antagonists (like ranitidine) and steroids (like
hydrocortisone) has completely been out of favour.
Several studies has identified that steroids has no role in Biphasic reaction and
anaphylaxis shock per se.
WHY ONLY ADRENALINE?

15. OLDER GUIDELINES
NEWER GUIDELINES

16. Take Home Message
❖ Anaphylaxis can have biphasic reaction - depending on symptoms of presentation, so it is
necessary to observe the patient.
❖ Beware of anaphylactic shock which can happen without any intimation or even after primary
management.
❖ ONLY AND ONLY Adrenaline (in all forms) is the “drug of choice” in Anaphylaxis reaction.
❖ NO ROLE OF STEROIDS, ANTIHISTAMINES AND H2 BLOCKERS IN ANAPHYLACTIC
SHOCK.

18. Thank You