URTICARIA, ANGIOEDEMA   นสพ.อาทิ ต ย์ เชยคาดี      AND ANAPHYLAXIS
URTICARIADefinition Urtica in Latin is Nettle rash Urticaria (or hives)    irregularly shaped wheal with a blanched ce...
URTICARIA
URTICARIAClassification Spontaneous urticaria  Acute Urticaria    Episodes of hives that continue for <6 wk  Chronic ...
URTICARIAClassification  Physical urticaria    Cold contact urticaria    Delayed pressure urticaria    Heat contact u...
ETIOLOGY OF ACUTE URTICARIA Foods Egg, milk, wheat, peanuts Medications Suspect all medications Insect stings Hymenopte...
ETIOLOGY OF CHRONIC URTICARIA Idiopathic 75–90% Rheumatologic   Systemic lupus erythematosus   Juvenile rheumatoid art...
URTICARIA - MECHANISMSImmunologic IgE-mediated – histamine, PAF, PGD 2, LTC, LTD   Foods/food additives   Medications ...
MECHANISMS OF URTICARIANon-Immunologic Direct mast cell activation   Radio contrast dye, opiates, polymyxin Modulation...
DIFFERENTIAL DIAGNOSIS OF URTICARIA Urticaria pigmentosa Urticaria Vasculitis Erythema multiforme Insect bite reaction...
DIFFERENTIAL DIAGNOSIS OF URTICARIA Juvenile rheumatoid arthritis Kawasaki disease Viral examthems Acute febrile neutr...
Urticaria pigmentosa   Urticaria Vasculitis
Erythema multiforme                      Sweet’s syndrome
Erythema annulare centrifugum   larva currens
DIAGNOSIS
ANGIOEDEMADefinition Angioedema is the swelling of deep dermis,  subcutaneous, or submucosal tissue due to  vascular lea...
ANGIOEDEMA
ANGIOEDEMA Hereditary   Type I   Type II   Hereditary angioedema with normal C1 INH in woman Acquired     Allergic :...
ANGIOEDEMA Acquired     Angioedema associated with allergic contact urticaria     Angioedema associated with urticarial...
ANGIOEDEMA Normal or elevated serum complement levels   IgE-mediated (atopic, specific antigen, exercise)   Induced by ...
HEREDITARY ANGIOEDEMA Autosomal dominant with incomplete penetrance.    Spontaneous mutations in 50%    Diminished C4 b...
DIFFERENTIAL DIAGNOSIS OF ANGIOEDEMACHFLymphedemaThrombophlebitisErysipelasCellulitisChild abuseNephrotic syndrome
DIFFERENTIAL DIAGNOSIS OF ANGIOEDEMASuperior vena cava syndromeMyxedema from congenital hypothyroidismDermatomyositisS...
ThrombophlebitisCellulitis
DIAGNOSIS OF URTICARIA/ANGIOEDEMAHistory  Time of onset of disease  Frequency and Duration of healing  Size, shape, ar...
DIAGNOSIS OF URTICARIA/ANGIOEDEMAHistory  Drug used history  Food  Smoking  Occupation  Relati onship to the menstru...
Urticaria/angioedema           superficial                                            deep> 24 hr.                 < 24 hr...
MANAGEMENTIdentification and elimination of the underlying cause and/or triggerSymptomatic therapy  Drug  Cold pack  ...
MANAGEMENT First-line drug therapies   Antihistamine     H1 –antihistamine first generation       Chlopheniramine     ...
MANAGEMENTSecond-line drug therapies  H2 –antihistamine      Cimetidine      Ranitidine Tricyclic antidepressant    ...
MANAGEMENTThird-line therapies Cyclosporine 2.5-5mg/kg/day Intravenous immnuoglobulin Immunosuppressive drugs    meth...
Acute urticaria                      •   History talking                          •    Infection, drug, food, insect,     ...
ผู้ป่วยมีภาวะ Anxiety หรื อผื่นเห่อช่วงกลางคืน        ใช่                                                          ไม่ใช่S...
ยังควบคุมโรคไม่ได้ หมด       ใช่                                                       ไม่ใช่     Add Leukotriene         ...
ยังควบคุมโรคไม่ได้ หมด         ใช่                                                    ไม่ใช่ยาทางเลือกอื่นๆ เช่น cyclospor...
CHRONIC URTICARIA
TREATMENT OF HEREDITARY         ANGIOEDEMA Patient education very important; test family No regular medication needed in...
SUMMARY OF TREATMENTS FOR C1 ESTERASE INHIBITOR DEFICIENCY
CASE STUDY
CASE ผู้ป่ วยเด็ ก ชายไทย อายุ 12 ปี ภู มิ ลาเนา จัง หวัด แพร่ CC : ปากบวมมี ผื่ น คั น หลั ง ฉี ด ยา 5 นาที PI : 1 วั ...
CASE Physical examination   V/S BT = 38.5 C , PR 120/min, RR = 20 /min, BP =80/40mmHg   BW = 20 kg , Height 155 cm   G...
CASE Positive finding   Fever   Tachycardia   Hypotension   Hx of Drug allery   Angioedema   Urticaria   expirator...
CASE Problem list   Angioedema with generalize urticaria rash with anaphylaxis   Fever with mucous diarrhea
PROVISIONAL DIAGNOSISAnaphylactic shockAcute gastroenteritis
TREATMENT IN THIS CASEStop ceftriaxoneAdrenaline (1:1000) IM0.9 % NaCl IV loadingAntihistamine
ANAPHYLAXIS
DEFINITION OF ANAPHYLAXIS systemic, immediate hypersensitivity   Affects body as a whole   Multiple organ systems may b...
ANAPHYLACTOID REACTIONS Non–IgE-mediated    Complement-mediated       Anaphylatoxins, eg, blood products    Direct sti...
COMMON TRIGGERS OF PEDIATRIC            ANAPHYLAXIS Foods (most common cause in children) – Milk, eggs,  wheat, soy, fish...
CLINICAL MANIFESTATIONS OF ANAPHYLAXIS Skin: Flushing, pruritus, urticaria, angioedema Upper respiratory: Congestion, rh...
CLINICAL MANIFESTATIONS OF              ANAPHYLAXISGastrointestinal tract:  Oral pruritus  Cramps, nausea, vomiting, di...
CRITERIA FOR ANAPHYLAXISCriterion 1 – Acute onset of an illness involving the skin, mucous membranes at least one of the...
CRITERIA FOR ANAPHYLAXISCriterion 2 – Two or more of the following that occur rapidly after exposure to an allergen that ...
CRITERIA FOR ANAPHYLAXISCriterion 3 – Decreased blood pressure after exposure of a known allergen for that patient  Decr...
DIFFERENTIAL DIAGNOSIS Vasovagal reactions Flush syndrome   Carcinoid   Pheochromcytoma   Medullary thyroid carcinoma...
DIFFERENTIAL DIAGNOSIS Acute respiratory failure   Status asthmaticus   Foreign body aspiration   Pulmonary embolism  ...
LAB INVESTIGATION Serum tryptase     Peak at 60- 90 min     > 10 nanogram/ml     > 1.4 times or 2 nanogram/ml at 1-2 w...
TREATMENT Support the airway and ventilation; and Give  supplementary oxygen. Intramuscular 1: 1000 (1 mg/ml) adrenaline...
TREATMENT Antihistamine   Chlorpheniramine 0.1mg/kg q 6 hr.   Cimetidine 4mg/kg max 300mg q 8-12 hr. Refractory anaphy...
PREVENTION Agents causing anaphylaxis should be identified when possible  and avoided Individuals at high risk for anaph...
PREVENTION Patients with egg allergy should be tested before receiving  measles, influenza or yellow fever vaccines which...
REFERENCE Zuberbier T, Bindslev-Jensen C, Canonica W, Grattan CE, Greaves  MW, Henz BM, et al. EAACI/GA2LEN/EDF guideline...
Topic urticaria, angioedema and anaphylaxis final
Topic urticaria, angioedema and anaphylaxis final
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Topic urticaria, angioedema and anaphylaxis final

  1. 1. URTICARIA, ANGIOEDEMA นสพ.อาทิ ต ย์ เชยคาดี AND ANAPHYLAXIS
  2. 2. URTICARIADefinition Urtica in Latin is Nettle rash Urticaria (or hives)  irregularly shaped wheal with a blanched center surrounded by a red flare  itchy rash consisting of a raised  Rapid disappear to normal skin in 1-24 hr.  But can appear in other area
  3. 3. URTICARIA
  4. 4. URTICARIAClassification Spontaneous urticaria Acute Urticaria  Episodes of hives that continue for <6 wk Chronic Urticaria  persist for >6 wk  Chronic continuous urticaria  Chronic recurrent urticaria
  5. 5. URTICARIAClassification  Physical urticaria  Cold contact urticaria  Delayed pressure urticaria  Heat contact urticaria  Solar urticaria  Urticaria factitia/dermographic urticaria  Vibratory urticaria/angioedema  Aquagenic urticaria  Cholinergic urticaria  Contact urticaria  Exercise-induced urticaria
  6. 6. ETIOLOGY OF ACUTE URTICARIA Foods Egg, milk, wheat, peanuts Medications Suspect all medications Insect stings Hymenoptera (honeybee, yellow jacket, hornets, wasp, fire ants), biting insects ( papular urticaria) Infections Contact allergy Latex, pollen, animal saliva, nettle plants, caterpillars Transfusion reactions Blood, blood products, or IV immunoglobulin administration Idiopathic EBV, Epstein-Barr virus.
  7. 7. ETIOLOGY OF CHRONIC URTICARIA Idiopathic 75–90% Rheumatologic  Systemic lupus erythematosus  Juvenile rheumatoid arthritis Endocrine Hyperthyroidism  Hypothyroidism Neoplastic Lymphoma  Mastocytosis  Leukemia Angioedema Hereditary angioedema  Acquired angioedema  Angiotensin-converting enzyme inhibitors
  8. 8. URTICARIA - MECHANISMSImmunologic IgE-mediated – histamine, PAF, PGD 2, LTC, LTD  Foods/food additives  Medications  Hymenoptera venom Complement system activation  Blood/blood products Neuropeptides  Substance-P, Somatostatin, VIP Cytokines
  9. 9. MECHANISMS OF URTICARIANon-Immunologic Direct mast cell activation  Radio contrast dye, opiates, polymyxin Modulation of the mast cell responsiveness  Arachidonic acid metabolism (NSAIDs, Aspirin) Miscellaneous  Physical, Cold, Pressure
  10. 10. DIFFERENTIAL DIAGNOSIS OF URTICARIA Urticaria pigmentosa Urticaria Vasculitis Erythema multiforme Insect bite reaction = papular urticaria Collagen vascular Immunobullous disease  Bullous pemphigoid Annular erythema  Erythema marginatum  Pityriasis Rosea  Guttate psoriasis  Erythema annulare centrifugum  Erythema chronicum migrans
  11. 11. DIFFERENTIAL DIAGNOSIS OF URTICARIA Juvenile rheumatoid arthritis Kawasaki disease Viral examthems Acute febrile neutrophilic dermatosis (Sweet’s syndrome) Scabies Parasite  S.stercoralis  larva currens
  12. 12. Urticaria pigmentosa Urticaria Vasculitis
  13. 13. Erythema multiforme Sweet’s syndrome
  14. 14. Erythema annulare centrifugum larva currens
  15. 15. DIAGNOSIS
  16. 16. ANGIOEDEMADefinition Angioedema is the swelling of deep dermis, subcutaneous, or submucosal tissue due to vascular leakage Pain > itchy Often at Mucous membrane Recovery slower than wheal Duration 72 hr.
  17. 17. ANGIOEDEMA
  18. 18. ANGIOEDEMA Hereditary  Type I  Type II  Hereditary angioedema with normal C1 INH in woman Acquired  Allergic : food, drug, insect venoms, radiocontrast media etc.  Idiopathic angioedema  Drug : NSAID induced  Angioedema associated with idiopathic or autoimmune urticaria  Angioedema associated with enzyme-inhibitor-induced  Angioedema associated with eosinophilia  Angioedema associated with physical urticaria and with cholinergic urticaria
  19. 19. ANGIOEDEMA Acquired  Angioedema associated with allergic contact urticaria  Angioedema associated with urticarial vasculitis  Angioedema associated with infection and infestation  Acquired C1 INH deficiency
  20. 20. ANGIOEDEMA Normal or elevated serum complement levels  IgE-mediated (atopic, specific antigen, exercise)  Induced by physical agents  Drug : Aspirin, NSAID, contrast media, opiates, polyanionic antibiotic Low serum complement levels  Low C1 INH  Genetic (Hereditary C1 INH deficiency; HAE)  C1 INH deficiency type I and II  Acquired (Acquired C1 INH deficiency; AAE)  Lyphoproliferative disorders  Anti-C1 INH antibodies  Normal C1 INH  Serum sickness, blood product reaction  Necrotizing vasculitis  Dyes : contrast media  Idiosyncratic
  21. 21. HEREDITARY ANGIOEDEMA Autosomal dominant with incomplete penetrance.  Spontaneous mutations in 50%  Diminished C4 between attacks  Very low C4 during attacks HAE I  Low levels of C1 esterase inhibitor HAE II  Dysfunctional C1 INH HAE III (estrogen-dependent angioedema)  Normal C1 INH amount and function  Normal complement levels
  22. 22. DIFFERENTIAL DIAGNOSIS OF ANGIOEDEMACHFLymphedemaThrombophlebitisErysipelasCellulitisChild abuseNephrotic syndrome
  23. 23. DIFFERENTIAL DIAGNOSIS OF ANGIOEDEMASuperior vena cava syndromeMyxedema from congenital hypothyroidismDermatomyositisSclerodermaParasite  Trichinella spiralisAllergic contact dermatitisCrohn’s diseaseMelkersson-Rosenthal syndromeCheilitis granulomatosa
  24. 24. ThrombophlebitisCellulitis
  25. 25. DIAGNOSIS OF URTICARIA/ANGIOEDEMAHistory  Time of onset of disease  Frequency and Duration of healing  Size, shape, area and distribution  Urticaria and angioedema  Pruritus or pain  Family history (atopy)  Present illness and past history about allergy  Physical stimulation or exercise
  26. 26. DIAGNOSIS OF URTICARIA/ANGIOEDEMAHistory  Drug used history  Food  Smoking  Occupation  Relati onship to the menstrua l cycle  Travel  Surgical implantations  Insect bite  Stress  Response to treatment
  27. 27. Urticaria/angioedema superficial deep> 24 hr. < 24 hr. + Urticaria - Urticaria Biopsy Urticaria+angioedema Unknown /phatology cause < 6 WK > 6 WK Vasculitis Abnormal Pressure Drug C1INH test + Yes No History/ Demographism test Delayed HAE AAE Urticaria pressure Vasculitis urticaria Acute urticaria Work up / Physical / Cholinergic Chronic urticaria autoimmune urticaria
  28. 28. MANAGEMENTIdentification and elimination of the underlying cause and/or triggerSymptomatic therapy  Drug  Cold pack  Avoid drug is trigger urticaria (NSAID, morphine, ACE inhibitor, ingredient  alcohol )
  29. 29. MANAGEMENT First-line drug therapies  Antihistamine  H1 –antihistamine first generation  Chlopheniramine  Diphenhydramine  Hydroxyzine  H1 –antihistamine second generation  Cetirizine  Desloratadine  Fexofenadine  Ketotifen  Loratadine  Levocetirizine
  30. 30. MANAGEMENTSecond-line drug therapies  H2 –antihistamine  Cimetidine  Ranitidine Tricyclic antidepressant  Doxepin Corticosteroids Leukotriene receptor antagonist  Montelukast
  31. 31. MANAGEMENTThird-line therapies Cyclosporine 2.5-5mg/kg/day Intravenous immnuoglobulin Immunosuppressive drugs  methotrexate
  32. 32. Acute urticaria • History talking • Infection, drug, food, insect, physical • Physical examination • Severity • LAB investigation • Eliminate underlying cause Not severe Severe Epinephine inj,- H1 antagonist Anaphylaxis ? chlorpheniramine inj, Admit- Soothing lotion dexamethasone inj
  33. 33. ผู้ป่วยมีภาวะ Anxiety หรื อผื่นเห่อช่วงกลางคืน ใช่ ไม่ใช่Sedating H1-antihistamine Non-sedating H1- antihistamine มีอาการมาก มี Angioedema ใช่ ไม่ใช่เพิ่ม prednisolone 25mg/day ให้ antihistamine ต่อ แล้ วหยุดยาใน 1-2 สัปดาห์ ยังควบคุมไม่ได้ หมด
  34. 34. ยังควบคุมโรคไม่ได้ หมด ใช่ ไม่ใช่ Add Leukotriene ให้ antihistamine ยังควบคุมไม่ได้ ใช่ ไม่ใช่เพิ่ม prednisolone 25mg/day Anti histamine + ลดลงจนควบคุมอาการได้ leukotriene ยังควบคุมไม่ได้ หมด
  35. 35. ยังควบคุมโรคไม่ได้ หมด ใช่ ไม่ใช่ยาทางเลือกอื่นๆ เช่น cyclosporine Anti histamine + corticosteroid
  36. 36. CHRONIC URTICARIA
  37. 37. TREATMENT OF HEREDITARY ANGIOEDEMA Patient education very important; test family No regular medication needed in many cases Prophylactic stanozolol or danozol Fresh frozen plasma before emergency surgery C1 inhibitor Symptomatic treatment during attacks Steroids and antihistamines are NOT effective
  38. 38. SUMMARY OF TREATMENTS FOR C1 ESTERASE INHIBITOR DEFICIENCY
  39. 39. CASE STUDY
  40. 40. CASE ผู้ป่ วยเด็ ก ชายไทย อายุ 12 ปี ภู มิ ลาเนา จัง หวัด แพร่ CC : ปากบวมมี ผื่ น คั น หลั ง ฉี ด ยา 5 นาที PI : 1 วั น ก่ อ นมาโรงพยาบาล มี ไ ข้ ถ่ า ยอุ จ จาระเหลวเป็ นมู ก ปริ ม าณไม่ ม ากวั น ละ 3 – 4 ครั ง มี อ าการอ่ อ นเพลี ย ได้ มาตรวจและแพทย์ ใ ห้ admit รั ก ษาด้ วยการให้ ้ สารน ้าทางหลอดเลื อ ดดาและยาฉี ด ceftriaxone 500 mg IV q 12 hr. หลั ง ฉี ด ยา5 นาที ผู้ ป่ วยมี ริ ม ฝี ปากบวม ผื่ น แดงคั น ตามตั ว และเวี ย นศี ร ษะคล้ ายจะ เป็ นลม PH : ปฏิ เ สธโรคประจาตั ว แต่ เ มื่ อ 1 ปี ก่ อ น เคยกิ น ยาฆ่ า เชื อ รั ก ษาอาการเจ็ บ คอ ้ กิ น แล้ วมี ผื่ น ขึ น ตามตั ว อาการไม่ รุ น แรง หายไปเอง ไม่ ไ ด้ ไปพบแพทย์ ไม่ มี ป ระวั ติ แ พ้ ้ ยาในครอบครั ว
  41. 41. CASE Physical examination  V/S BT = 38.5 C , PR 120/min, RR = 20 /min, BP =80/40mmHg  BW = 20 kg , Height 155 cm  GA : A thai boy with good consciousness, no pallor, no jaundice, no cyanosis  Skin : dry and swollen lips, flushing, generalized urticaria rash with facial angioedema  Heart : tachycardia wit normal S1 S2, no murmur  Lungs : expiratory Wheezing on both lungs, no crepitation  Other : unremarkable
  42. 42. CASE Positive finding  Fever  Tachycardia  Hypotension  Hx of Drug allery  Angioedema  Urticaria  expiratory Wheezing on both lungs Negative finding  No stress  No redness of body  No brown macule  No hx of psychological disorder
  43. 43. CASE Problem list  Angioedema with generalize urticaria rash with anaphylaxis  Fever with mucous diarrhea
  44. 44. PROVISIONAL DIAGNOSISAnaphylactic shockAcute gastroenteritis
  45. 45. TREATMENT IN THIS CASEStop ceftriaxoneAdrenaline (1:1000) IM0.9 % NaCl IV loadingAntihistamine
  46. 46. ANAPHYLAXIS
  47. 47. DEFINITION OF ANAPHYLAXIS systemic, immediate hypersensitivity  Affects body as a whole  Multiple organ systems may be involved  Onset generally acute  Manifestations vary from mild to fatal  immunoglobulin E (IgE)-mediated Anaphylatoid  Non – immunoglobulin E (IgE)-mediated
  48. 48. ANAPHYLACTOID REACTIONS Non–IgE-mediated  Complement-mediated  Anaphylatoxins, eg, blood products  Direct stimulation  eg, radiocontrast media  Mechanism unknown  Exercise  NSAIDs
  49. 49. COMMON TRIGGERS OF PEDIATRIC ANAPHYLAXIS Foods (most common cause in children) – Milk, eggs, wheat, soy, fish, shellfish, Medicinals – Antibiotics (penicillins, cephalosporins), local anesthetics, NSAID, opiates,dextran, radiocontrast media Biologics – Venoms (bee sting, ant or snake bite), blood and blood products, vaccines, allergen extracts Preservatives and additives – Metabisulfite, monosodium glutamate Other – Latex, unknown/idiopathic
  50. 50. CLINICAL MANIFESTATIONS OF ANAPHYLAXIS Skin: Flushing, pruritus, urticaria, angioedema Upper respiratory: Congestion, rhinorrhea Lower respiratory: Bronchospasm, throat or chest tightness, hoarseness, wheezing, shortness of breath, cough
  51. 51. CLINICAL MANIFESTATIONS OF ANAPHYLAXISGastrointestinal tract: Oral pruritus Cramps, nausea, vomiting, diarrheaCardiovascular system: Tachycardia, bradycardia, hypotension/shock, arrhythmias, ischemia, chest pain
  52. 52. CRITERIA FOR ANAPHYLAXISCriterion 1 – Acute onset of an illness involving the skin, mucous membranes at least one of the following: Respiratory compromise Decreased blood pressure or associated symptoms of end-organ dysfunction
  53. 53. CRITERIA FOR ANAPHYLAXISCriterion 2 – Two or more of the following that occur rapidly after exposure to an allergen that is likely for that patient Involvement of the skin and/or mucous membranes Respiratory compromise Decreased blood pressure or associated symptoms Persistent gastrointestinal symptoms
  54. 54. CRITERIA FOR ANAPHYLAXISCriterion 3 – Decreased blood pressure after exposure of a known allergen for that patient  Decreased blood pressure is defined in adults as a systolic BP of less than 90 mmHg or >30% decrease from that patient’s baseline.  In infants and children, decreased BP is defined as low systolic  BP of less than 70 mmHg from one month up to one year  less than (70mmHg + [2 x age]} from one to ten years  less than 90 mmHg from 11 to 17 years.
  55. 55. DIFFERENTIAL DIAGNOSIS Vasovagal reactions Flush syndrome  Carcinoid  Pheochromcytoma  Medullary thyroid carcinoma Resturant syndrome  Monosodium glutamate Excessive production of histamine  Systemic maastocytosis  Basophilic leukemia Shock  Hemorrhagic / hypovolemic  Cardiogenic  Septic
  56. 56. DIFFERENTIAL DIAGNOSIS Acute respiratory failure  Status asthmaticus  Foreign body aspiration  Pulmonary embolism  Epiglottitis Non organic disease  Panic attack  Munchausen’s stridor  Vocal cord dysfunction Other  Red man syndrome (Vancomycin)  Hereditary angioedema
  57. 57. LAB INVESTIGATION Serum tryptase  Peak at 60- 90 min  > 10 nanogram/ml  > 1.4 times or 2 nanogram/ml at 1-2 wk after anaphylaxis  Sensitivity 73% specific 98 %  In some case are normal but mastocytosis  rise Specific – IgE  Skin test 6 wk after anaphylaxis  Serum specific IgE antibody
  58. 58. TREATMENT Support the airway and ventilation; and Give supplementary oxygen. Intramuscular 1: 1000 (1 mg/ml) adrenaline at a dose of 0.01 mg/kg (0.01 ml/kg) body weight up to a maximum dose of 0.5 mg (0.5 ml) Resuscitate with intravenous saline (20 ml/kg body weight) Bronchodilator Systemic corticosteroid  Hydrocortisone (5mg/kg q 6 hr.)  Methylprednisolone (1mg/kg q 6 hr.)
  59. 59. TREATMENT Antihistamine  Chlorpheniramine 0.1mg/kg q 6 hr.  Cimetidine 4mg/kg max 300mg q 8-12 hr. Refractory anaphylaxis in patient used beta -blocker  Glucagon 20-30 mcg/kg max 1 mg slow push in 5 min and IV drip 5-15 mcg/min until BP stable Bradycardia  Atropine 0.5 mg q 10 min cumulative dose 2 mg
  60. 60. PREVENTION Agents causing anaphylaxis should be identified when possible and avoided Individuals at high risk for anaphylaxis should be issued epinephrine syringes for self -administration and instructed in their use Beta-adrenergic antagonists should be avoided, whenever possible. Children and their care -givers should be offered a written emergency plan in case of accidental ingestion. Pre-treatment with glucocorticosteroids and H1 and H2 antihistamines when used radio contrast media in some case
  61. 61. PREVENTION Patients with egg allergy should be tested before receiving measles, influenza or yellow fever vaccines which contain egg protein. In cases of food-associated exercise-induced anaphylaxis, children must not exercise within 4 hours of ingesting the triggering food Reactions to medications can be reduced and minimized by using oral medications in preference to injected forms. The use of powder-free, low allergen gloves and materials should be used in children undergoing multiple surgeries.
  62. 62. REFERENCE Zuberbier T, Bindslev-Jensen C, Canonica W, Grattan CE, Greaves MW, Henz BM, et al. EAACI/GA2LEN/EDF guideline: definition, classifica tion and diagnosis of urticaria. Allergy 2006; 61:316-20. Zuberbier T, Bindslev-Jensen C, Canonica W, Grattan CE, Greaves MW, Henz BM, et al. EAACI/GA2LEN/EDF guideline: management of urticaria. Allergy 2006; 61:321-31. Grattan CEH, Humphreys. Guidelines for evaluation and management of urticaria in adults and children. Br J Dermatol 2007; 157: 1116-23. M. Scott Linscott, Anaphylaxis: Diagnosis and Management in the Rural Emergency Department. American Journal of Clinical Medicine 2012 ; 91. Donald Y.M. Leung, Stephen C. Dreskin. Urticaria (Hives) and Angioedema. In: Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics. 18th ed. Philadelphia PA: W.B. Saunders; 2007. Elham Hossny. Anaphylaxis in children. Egypt J Pediatr Allergy Immunol 2007; 5(2): 47-54.

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