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Anaphylaxis - They never taught me that! Critical updates for life-threatening emergencies

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www.romduck.com What’s the difference between anaphylactic and anaphylactoid and why should I care? Can a pa-tient have a life-threatening reaction on a first exposure? What are the most important ALS medica-tions for anaphylaxis after epinephrine? How bad is it to give epinephrine for a panic attack? What the heck is Kounis syndrome? Why didn't they teach me this in class? The past 10 years have seen a dramatic increase in the number of cases of anaphylaxis across the United States. In response, the American College of Emergency Physicians and the World Allergy Organization have issued im-portant updates on initial emergency treatment for patients suffering from anaphylaxis. While epi-nephrine remains the front-line drug for all levels of care, recent studies show that in-hospital and pre-hospital providers alike aren’t giving it as often or as early as they should. This interactive case-study and pub-quiz style presentation answers these questions and many more with a focus on rapid differential of anaphylaxis and effective initial and secondary treatments to manage these immediately life-threatening emergencies.

www.romduck.com What’s the difference between anaphylactic and anaphylactoid and why should I care? Can a pa-tient have a life-threatening reaction on a first exposure? What are the most important ALS medica-tions for anaphylaxis after epinephrine? How bad is it to give epinephrine for a panic attack? What the heck is Kounis syndrome? Why didn't they teach me this in class? The past 10 years have seen a dramatic increase in the number of cases of anaphylaxis across the United States. In response, the American College of Emergency Physicians and the World Allergy Organization have issued im-portant updates on initial emergency treatment for patients suffering from anaphylaxis. While epi-nephrine remains the front-line drug for all levels of care, recent studies show that in-hospital and pre-hospital providers alike aren’t giving it as often or as early as they should. This interactive case-study and pub-quiz style presentation answers these questions and many more with a focus on rapid differential of anaphylaxis and effective initial and secondary treatments to manage these immediately life-threatening emergencies.

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Anaphylaxis - They never taught me that! Critical updates for life-threatening emergencies

  1. 1. What they DIDN’T tell you about ANAPHYLAXIS
  2. 2. A serious, life-threatening generalized or systemic hypersensitivity reaction Anaphylaxis can be unpredictable & rapidly fatal ANAPHYLAXIS
  3. 3. Usually within 20 minutes Up to 4-8 hours Can be refractory or biphasic ANAPHYLAXIS time frame
  4. 4. EPINEPHRINE ANAPHYLAXIS treatment
  5. 5. Says who?
  6. 6. Says who?
  7. 7. Clinical criteria for the diagnosis of anaphylaxis Sensitivity 96.7%, 95% CI Specificity 82.4%, 95% CI
  8. 8. Exposure to known allergen or trigger PLUS Sudden reduced BP / MAP or organ dysfunction
  9. 9. Exposure to known allergen or trigger PLUS Sudden reduced BP / MAP or organ dysfunction Adults = SBP < 90mmHg, MAP < 65mmHg or >30% drop Peds = < age specific SBP/MAP or >30% drop
  10. 10. Likely exposure to allergen or trigger PLUS ANY TWO Sudden skin / mucosal tissue Sudden reduced BP / MAP or organ dysfunction Sudden respiratory symptoms and signs Sudden gastrointestinal symptoms and signs
  11. 11. Sudden onset with involvement of the skin, mucosal tissue, or both (e.g. generalized hives, itching, flushing, swollen lips-tongue) PLUS EITHER Sudden respiratory symptoms and signs Sudden reduced BP / MAP or organ dysfunction
  12. 12. 1:15 pm 38 Capwell Ave. 14 y/o Male Bee sting with pain Case Study Urticaria but no edema of the tongue or airways Complaining of slight shortness of breath and possible wheezing Tired and slow to answer your questions T 98.8, P 120, R 39, BP 69/45 mm/Hg
  13. 13. 71 y/o female slow onset swelling of tongue No resolution after self-medication of Benadryl
  14. 14. World Allergy Organization “Failure to use epinephrine, or to use it promptly is considered to be an important and avoidable factor in fatal reactions”
  15. 15. Acute coronary syndrome (symptoms such as chest pain relating to reduced blood flow to the heart) caused by an allergic reaction or a strong immune reaction. It is a rare syndrome with authentic cases reported in 130 males and 45 females, as reviewed in 2017; however, the disorder is suspected of being commonly overlooked and therefore much more prevalent. Kounis Syndrome
  16. 16. Anaphylaxis guidelines: Summary …epinephrine is not contraindicated in the treatment of anaphylaxis in patients with known or suspected cardiovascular disease. …epinephrine actually increases coronary artery blood flow because of an increase in myocardial contractility... Concerns about the potential adverse cardiac effects of epinephrine therefore need to be weighed against concerns about the cardiac manifestations of untreated anaphylaxis.
  17. 17. Anaphylaxis and cardiovascular disease: therapeutic dilemmas. Epinephrine is life-saving in anaphylaxis; second-line medications (including antihistamines & glucocorticoids) are not. In CVD patients (especially those with ACS), the decision to administer epinephrine for anaphylaxis can be difficult, and its benefits and potential harms need to be carefully considered. Concerns about potential adverse effects need to be weighed against concerns about possible death from untreated anaphylaxis, but there is no absolute contraindication to epinephrine injection in anaphylaxis.
  18. 18. A serious, life-threatening generalized or systemic hypersensitivity reaction Anaphylaxis can be unpredictable & rapidly fatal ANAPHYLAXIS
  19. 19. Exposure + Cardiovascular = ANAPHYLAXIS
  20. 20. Exposure + (Skin, Respiratory, Cardiovascular, or GI) = ANAPHYLAXIS
  21. 21. Skin signs + (Respiratory or Cardiovascular) = ANAPHYLAXIS
  22. 22. Anaphylaxis can manifest WITHOUT skin/mucosal tissue involvement
  23. 23. You want to stay AHEAD of ANAPHYLAXIS
  24. 24. Anaphylaxis Immunologic IgE Foods, venoms, latex, some drugs Non-IgE Dextran, OSCS (heparin contaminant) Cell Mediated Contact dematitis Nonimmunologic Physical Exercise, cold Toxic Scrombroid fish poisoning Pharmacologic NSAIDS, opioids, neuromuscular block agents, radiocontrast Idiopathic
  25. 25. Primarily H1 receptors trigger inflammation Multiple pathways of inflammatory response constricting upper and lower airways Pathophysiology
  26. 26. Activation of ATP-sensitive Potassium Channels in the Plasma Membrane of the Vascular Smooth Muscle Activation of the Inducible Form of Nitric Oxide Deficiency of the Vasopressin Hormone Pathophysiology
  27. 27. ANAPHYLAXIS vs ANAPHYLACTOID presents and treats the same
  28. 28. You can have ANAPHYLAXIS without any prior exposure
  29. 29. Treatment ABCs Identify anaphylaxis Epinephrine • 0.01 mg/kg of 1:1,000 repeated PRN q 5-15 minutes, no max • 0.3 mg Adult (over 25kg /55 lbs) • 0.15 mg Child (UNDER 25kg /55 lbs) Separate patient and trigger if reasonable Pt. supine to legs comfortably elevated Supportive O2 (SpO2 94%-98%) Fluid resuscitation as needed 5-10 ml/kg initial
  30. 30. Do we give epi when we should? 32 year old patient hypotensive, with wheezing, tachycardia, tingling in his throat & hands, and hives on his chest.
  31. 31. Do we give epi when we should? Only 46.2% said Epi was initial drug in a classic case of a hypotensive, wheezing, tachycardia patient with tingling in his throat & hands, and hives on his chest. An almost equal number (40%) started with Benadryl as started with Epi (46.2%) More gave Epi SQ (58.4%) than IM (38.9%) 1.7% gave Epi IV!
  32. 32. Do we give epi when we should? Broward County, Florida EMS Retrospective review 2010 –2012 92 patients with allergic reaction 52 with anaphylaxis 18 self medicated with epi 8 (15%) given epi by medics 25 (48%) oxygen 6 (11%) IV fluids 13 (25%) steroids 10 (19%) albuterol 42 (81%) diphenhydramine
  33. 33. Do we give epi when we should? Alameda & Contra Costa County, California EMS Retrospective review 2010 –2011 205 pediatric patients with allergic reaction 98 with anaphylaxis 47 self medicated with epi 6 (12%) given epi by medics 10 (20%) diphenhydramine ONLY 9 (18%) albuterol ONLY 17 (33%) diphenhydramine & albuterol
  34. 34. EPINEPHRINE is the far and away front line drug for anaphylaxis
  35. 35. There are no contraindications at all for EPINEPHRINE for anaphylaxis
  36. 36. Pallor Anxiety Tremor Headache Dizziness
  37. 37. Ventricular Arrhythmias Hypertensive Crises Acute Coronary Syndromes
  38. 38. Supportive O2 SpO2 target 94%-99%
  39. 39. Inhaled Bronchodialators • Pros: Beta-2 Bronchodilation • Cons: Increased tremor, tachycardia, etc.
  40. 40. Isotonic fluid resus • No recommendations specific to anaphylaxis
  41. 41. H1 Antihistamines • Diphenhydramine • 25-50 mg slow adults • 1mg/kg slow peds • Chlorpheniramine • Clemastine • Ceterazine Pros: May increase patient comfort Cons: Drowsiness, Hypotension
  42. 42. Glucocorticoids (Steroids) Methyprednisolone 125 mg adults 1-2 mg/kg peds Pros: possible prevention of biphasic anaphylaxis Cons: Not proven to improve outcomes
  43. 43. All of the above Vasopressors Glucagon 1-5mg adults up to 1 mg peds Methylene blue Advanced airway Cricothyrotomy
  44. 44. Occurs within 1–72 hours Usually within 8–10 hours It occurs in up to 23% of adults and up to 11% of children. For example, patients with moderate respiratory or cardiovascular compromise should be monitored for at least 4 hours, and if indicated, for 8–10 hours or longer. Protracted uniphasic anaphylaxis is uncommon, but can last for days. Clinically important biphasic reactions are rare
  45. 45. Difficult Differential Diagnostic Dilemmas Asthma Panic attack Syncope Anaphylaxis
  46. 46. 5:43 am 621 Poplar Ave. 48 y/o Female Difficulty Breathing Case Study
  47. 47. Asthma Allergic rhinitis Atopic eczema Psychiatric illness Cardiovascular disease Conditions that may worsen anaphylaxis
  48. 48. Infants Cannot describe Sx Compensate, then decompensate quickly Adolescents Experimentation Failure to avoid triggers Failure to carry epi-pen Elderly Increased Comorbidities Decreased compensatory Pregnant Desaturate quickly Left uterine displacement Ages that may complicate anaphylaxis
  49. 49. Exercise Infection Stress Menstruation Factors that may worsen anaphylaxis
  50. 50. Exercise Infection Factors that may trigger anaphylaxis
  51. 51. Hidden Allergens Spicy foods Alcohol consumption Communication issues Late recognition Confounding factors of anaphylaxis
  52. 52. Use factors found in your assessment to rule in
  53. 53. Don’t use missing factors to rule out
  54. 54. At the hospital Treatments as above Observed 4-8 hours Longer if patient has additional factors
  55. 55. Exposure + Cardiovascular = ANAPHYLAXIS
  56. 56. Exposure + (Skin, Respiratory, Cardiovascular, or GI) = ANAPHYLAXIS
  57. 57. Skin signs + (Respiratory or Cardiovascular) = ANAPHYLAXIS
  58. 58. Anaphylaxis can manifest WITHOUT skin/mucosal tissue involvement
  59. 59. You want to stay AHEAD of ANAPHYLAXIS
  60. 60. ANAPHYLAXIS vs ANAPHYLACTOID presents and treats the same
  61. 61. You can have ANAPHYLAXIS without any prior exposure
  62. 62. EPINEPHRINE is the far and away front line drug for anaphylaxis
  63. 63. There are no contraindications at all for EPINEPHRINE for anaphylaxis
  64. 64. Use factors found in your assessment to rule in
  65. 65. Don’t use missing factors to rule out
  66. 66. Bottom Line “Failure to use epinephrine, or to use it promptly is considered to be an important and avoidable factor in fatal reactions”

Editor's Notes

  • https://aacijournal.biomedcentral.com/articles/10.1186/s13223-018-0234-0
  • https://aacijournal.biomedcentral.com/articles/10.1186/s13223-018-0234-0
  • https://aacijournal.biomedcentral.com/articles/10.1186/s13223-018-0234-0
  • https://www.acepnow.com/article/understanding-diagnostic-criteria-anaphylaxis-anaphylactic-shock-kounis-syndrome-critical-initiate-lifesaving-treatment/
    http://newsroom.acep.org/news_releases?item=122644
  • https://www.acepnow.com/article/understanding-diagnostic-criteria-anaphylaxis-anaphylactic-shock-kounis-syndrome-critical-initiate-lifesaving-treatment/
    http://newsroom.acep.org/news_releases?item=122644
  • https://aacijournal.biomedcentral.com/articles/10.1186/s13223-018-0234-0
  • <10 y/o 70 + 2x age = 2y/o = 74
    10 y/o = 90 mm/Hg
    Lieberman P, et al. J Allergy Clin Immunol. 2010;126:477-480.
  • <10 y/o 70 + 2x age = 2y/o = 74
    10 y/o = 90 mm/Hg
    Lieberman P, et al. J Allergy Clin Immunol. 2010;126:477-480.
  • 70 + 2x age = 2y/o = 74
  • 70 + 2x age = 2y/o = 74
    Involvement of skin or mucosa 80%-90% of cases
    Respiratory involvement in 70% of cases
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5875169/
  • https://www.degruyter.com/downloadpdf/j/cclm.2016.54.issue-10/cclm-2016-0010/cclm-2016-0010.pdf
    https://www.ncbi.nlm.nih.gov/pubmed/28153536
  • https://www.ncbi.nlm.nih.gov/pubmed/25711241
  • https://www.ncbi.nlm.nih.gov/pubmed/25711241
  • https://aacijournal.biomedcentral.com/articles/10.1186/s13223-018-0234-0
  • Simons FER, et al. J Allergy Clin Immunol. 2010;125:S161-S181.
  • https://aacijournal.biomedcentral.com/articles/10.1186/s13223-018-0234-0
  • https://aacijournal.biomedcentral.com/articles/10.1186/s13223-018-0234-0
  • It is a catecholamine with both α- and β-adrenergic effects. Epinephrine inhibits further vasodilating mediator release from basophils and mast cells, reduces bronchoconstriction, increases vascular tone, and improves cardiac output. 
  • 2012
  • 2012
    Jacobsen et all Anaphylaxis National Survey
    https://www.ncbi.nlm.nih.gov/pubmed/22712745
  • • N El Sanadi et al.
  • https://www.ncbi.nlm.nih.gov/pubmed/26555274
  • Chlorpheniramine. Brands include Aller-Chlor, Allergy Relief, Chlo-Amine, Chlor-Trimeton, and Efidac 24. ...
    Clemastine. Brands include Dayhist-1 and Tavist 

    Never administer H1 and H2 antihis- tamines or corticosteroids as initial therapy for anaphylaxis instead of epinephrine and consider these agents optional or adjunctive therapy. [Strong Recommendation; B Evidence]

    Anaphylaxisda practice parameter update 2015

    Evidence extrapolated from use in treatment of other diseases.
    Administering one or more second-line medications potentially delays epinephrine, the first-line treatment

  • An updated Cochrane Database systematic review found no randomized or quasi-randomized controlled trials of glucocorticoid treatment for anaphylaxis, was unable to make definitive recommendations for or against their use, and highlighted the need for a more robust evi- dence base in this area [54]. Glucocorticoids remain in use for anaphylaxis because they potentially prevent bi- phasic anaphylaxis; however, medications and dosing are extrapolated from asthma treatment and the onset of ac- tion takes several hours. They are not drugs of choice in initial anaphylaxis treatment
    World Allergy Organization Anaphylaxis Guidelines: 2013 Update of the Evidence Base

    Evidence extrapolated from use in treatment of other diseases.
    Administering one or more second-line medications potentially delays epinephrine, the first-line treatment
  • No specific fluid recommendations

    Give Vasopressin

    Rapid administration of glucagon can cause vomiting. Glucagon should be administered in this setting because it has inotropic and chronotropic effects that are not mediated through b- receptors.65 A single dose of 1 to 5 mg in adults (in children, 20 to 30 mg/kg, to a maximum of 1 mg) administered intra- venously over 5 minutes is recommended, which may be repeated or followed by an infusion of 5 to 15 mg/minute.262

    Methylene blue is a medication and dye used to treat methemoglobinemia and cyanide poisoning
    In anaphylaxis refractory to initial treatment, new interventions are needed. Infusion of methylene blue, a selective inhibitor of the nitric oxide-cyclic guanosine monophosphate pathway, has been successful, especially in patients with distributive shock and profound vasodilation (vasoplegia)

    Advanced upper airway management can use the endotracheal tube or a supraglottic airway. The incidence of com- plications is unacceptably high when endotracheal intubation is performed by an inexperienced provider or monitoring of the tube is inadequate.57
    P. Lieberman et al. / Ann Allergy Asthma Immunol 115 (2015) 341e384


  • There may be a link between inflammation and mental health
    3 A’s Asthma, Allergic rhinitis, Atopic eczema + Anxiety, Depression
    Possible link between people who have anaphylaxis and PTSD
    https://www.medicalnewstoday.com/articles/321578.php
    https://bmjopen.bmj.com/content/6/10/e012637

  • It is proposed that exercise increases GI permeability and/or allergen digestion, so the patient is exposed to greater levels of antigen [35, 53]. Exercise is a physiological state that increases release of mediators (serotonin, bradykinin and endorphins), which sensitize the calcium ion channel through which histamine works, the transient receptor potential vanilloid 1 (TRPV1) receptor [54]. This ion channel is present on both sensory nerves and mast cells. Acidosis and rise in core body temperature also directly agonize the TPRV1 ion channel to further reduce the activation threshold to allergic products [54]. ATP, which increases with exercise, inhibits the homeostatic de-activation of TRPV1 receptor [55].
  • ×