What they didn't tell you about Anaphylaxis 2023.pptx

What they
DIDN’T tell you
about
ANAPHYLAXIS
Rommie L. Duckworth, MPA, LP, EFO

What is anaphylaxis?
What do we give for it?
When do we give it?
What problems can we run into?
What can we do better?

A serious, life-threatening
systemic hypersensitivity
reaction.
Anaphylaxis can be
unpredictable & rapidly fatal
ANAPHYLAXIS
Dworetzky, M., Cohen, S., Cohen, S. G., & Zelaya-Quesada, M. (2002). Portier, Richet, and the discovery of anaphylaxis: A centennial. Journal of Allergy and Clinical Immunology,
110(2), 331–336. https://doi.org/10.1016/S0091-6749(02)70118-8

Widely variable statistics reported
2005-2014:
Increased rates adults 101%, children 196%
2007-2016:
Increased rates total 377%
1.6% - 5.1% of US citizens have had anaphylaxis
ANAPHYLAXIS
Turner, P. J., Jerschow, E., Umasunthar, T., Lin, R., Campbell, D. E., & Boyle, R. J. (2017). Fatal Anaphylaxis: Mortality Rate and Risk Factors. The Journal of Allergy and Clinical
Immunology. in Practice, 5(5), 1169–1178. https://doi.org/10.1016/j.jaip.2017.06.031

Usually within 20 minutes
Up to 4-8 hours
Can be biphasic (comes back again after initial response)
Can be refractory (continues past initial management)
ANAPHYLAXIS
time frame

EPINEPHRINE
ANAPHYLAXIS
treatment

Immunologic
Anaphylaxis
Foods,
venoms, latex,
some drugs
IgE
Dextran, OSCS
(heparin
contaminant)
Non-IgE
IgG and others
Contact
dermatitis
Cell Mediated
T-Cell and B-Cell IgM
B Cells
Kemp, S. F. (2019, October 31). Pathophysiology of anaphylaxis. UpToDate. Accessed 4/12/2021

Immunologic
Anaphylaxis
Foods, venoms,
latex, some drugs
IgE
Dextran, OSCS
(heparin
contaminant)
Non-IgE
Contact dermatitis
Cell Mediated
Nonimmunologic
Anaphylactoid
Exercise, cold
Physical
Scrombroid fish
poisoning (high
histamine levels)
Toxic
NSAIDS, opioids,
neuromuscular
block agents,
radiocontrast
Pharmacologic
B Cells

Immunologic
Anaphylaxis
Foods, venoms,
latex, some drugs
IgE
Dextran, OSCS
(heparin
contaminant)
Non-IgE
Contact dermatitis
Cell Mediated
Nonimmunologic
Anaphylactoid
Exercise, cold
Physical
Scrombroid fish
poisoning (high
histamine levels)
Toxic
NSAIDS, opioids,
neuromuscular
block agents,
radiocontrast
Pharmacologic
B Cells
Mast Cells & Basophils

Immunologic
Anaphylaxis
Foods, venoms,
latex, some drugs
IgE
Dextran, OSCS
(heparin
contaminant)
Non-IgE
Contact dermatitis
Cell Mediated
Nonimmunologic
Anaphylactoid
Exercise, cold
Physical
Scrombroid fish
poisoning (high
histamine levels)
Toxic
NSAIDS, opioids,
neuromuscular
block agents,
radiocontrast
Pharmacologic
B Cells
Idiopathic

Immunologic
Anaphylaxis
Foods, venoms,
latex, some drugs
IgE
Dextran, OSCS
(heparin
contaminant)
Non-IgE
Contact dermatitis
Cell Mediated
Nonimmunologic
Anaphylactoid
Exercise, cold
Physical
Scrombroid fish
poisoning (high
histamine levels)
Toxic
NSAIDS, opioids,
neuromuscular
block agents,
radiocontrast
Pharmacologic
Histamine Tryptase Chymase Carboxypeptidase A PAF Prostaglandins Leukotrienes OTHER
B Cells
A difference between allergy and anaphylaxis is allergy is self limiting and anaphylaxis strikes pathway ”amplifiers”
Idiopathic

Immunologic
Anaphylaxis
Foods, venoms,
latex, some drugs
IgE
Dextran, OSCS
(heparin
contaminant)
Non-IgE
Contact dermatitis
Cell Mediated
Nonimmunologic
Anaphylactoid
Exercise, cold
Physical
Scrombroid fish
poisoning (high
histamine levels)
Toxic
NSAIDS, opioids,
neuromuscular
block agents,
radiocontrast
Pharmacologic
Histamine Tryptase Chymase Carboxypeptidase A PAF Prostaglandins Leukotrienes OTHER
Skin
Itching Flushing Hives Edema
Respiratory
Cough Dyspnea Hoarseness Stridor Wheeze
GI
Nausea Vomiting Diarrhea
Abdominal
pain
CV
Dizziness Hypotension Shock
CNS
Headache
Idiopathic
B Cells

Alpha-1 agonist
vasoconstrictor effects
prevent and relieve
hypotension, shock, edema
Beta-1 agonist chronotropic
and inotropic effects
increase rate and force of
cardiac contractions
Beta-2 agonist effects lead
to bronchodilation and
decreased mediator release
Brown, J. C., Simons, E., & Rudders, S. A. (2020).
Epinephrine in the Management of Anaphylaxis. The
Journal of Allergy and Clinical Immunology: In Practice,
8(4), 1186–1195.
https://doi.org/10.1016/j.jaip.2019.12.015
Why Epinephrine?

Why do some hesitate
to give Epinephrine?
Previous reactions were
not so bad
The patient didn’t use
THEIR epi-pen
The patient doesn’t
think it is needed
Cheng, Jo. (2017). Anaphylaxis: The Underrecognized
Killer. Relias Media.
https://www.reliasmedia.com/articles/141080-
anaphylaxis-the-underrecognized-killer?v=preview

Why do some hesitate
to give Epinephrine?
The symptoms appear mild
(but still meet criteria for anaphylaxis)
Not an exposure to
KNOWN anaphylaxis trigger
Perceived
contraindications:
pregnancy
old age
cardiovascular disease
Helman, A. (2016, September 13). Understanding
Diagnostic Criteria for Anaphylaxis, Anaphylactic Shock,
Kounis Syndrome Critical to Initiating Lifesaving
Treatment. ACEP Now.
https://www.acepnow.com/article/understanding-
diagnostic-criteria-anaphylaxis-anaphylactic-shock-
kounis-syndrome-critical-initiate-lifesaving-treatment/

But we should STILL
administer Epinephrine!
ED single-center retrospective observational
cohort study of epinephrine safety:
58% of 573 consecutive patients
received epinephrine for
anaphylaxis.
Only 4 of 316 patients (1%)
receiving intramuscular (IM) epi
developed adverse events.
There were no overdoses with
IM injection, versus an overdose
rate of 13% after IV epi
administration.
Campbell, R. L., Bellolio, M. F., Knutson, B. D.,
Bellamkonda, V. R., Fedko, M. G., Nestler, D. M., & Hess,
E. P. (2015). Epinephrine in anaphylaxis: Higher risk of
cardiovascular complications and overdose after
administration of intravenous bolus epinephrine
compared with intramuscular epinephrine. The Journal
of Allergy and Clinical Immunology. In Practice, 3(1),
76–80. https://doi.org/10.1016/j.jaip.2014.06.007

But we should STILL
administer Epinephrine! “Epinephrine in the
correct dose for
anaphylaxis generally
does not cause
coronary ischemia.”
“There are no absolute
contraindications to
epinephrine in severe
anaphylaxis.”

But we should STILL
administer Epinephrine!
“Failure to use
epinephrine, or to use it
promptly is considered
an important and
avoidable factor in
fatal reactions”
Simons, F. E. R., Ebisawa, M., Sanchez-Borges, M.,
Thong, B. Y., Worm, M., Tanno, L. K., Lockey, R. F., El-
Gamal, Y. M., Brown, S. G., Park, H.-S., & Sheikh, A.
(2015). 2015 update of the evidence base: World
Allergy Organization anaphylaxis guidelines. World
Allergy Organization Journal, 8(1), 1–16.
https://doi.org/10.1186/s40413-015-0080-1

When Epinephrine?
Immediately
Sooner is better
than later
Later (delayed) is
often fatal
Fleming, J. T., Clark, S., Camargo, C. A., & Rudders, S. A. (2015).
Early treatment of food-induced anaphylaxis with epinephrine is
associated with a lower risk of hospitalization. The Journal of
Allergy and Clinical Immunology. In Practice, 3(1), 57–62.
https://doi.org/10.1016/j.jaip.2014.07.004
Xu, Y. S., Kastner, M., Harada, L., Xu, A., Salter, J., & Waserman, S.
(2014). Anaphylaxis-related deaths in Ontario: A retrospective
review of cases from 1986 to 2011. Allergy, Asthma, and Clinical
Immunology: Official Journal of the Canadian Society of Allergy and
Clinical Immunology, 10(1), 38. https://doi.org/10.1186/1710-
1492-10-38

Give Epinephrine!
“The number-one
cause of death in
anaphylaxis is
failure to give
epinephrine in a
timely manner, in
the correct location,
and in the correct
dose.”

Urticaria, angioedema 85%-90% (10%-15%)
Flushing 45%-55% (45%-55%)
Dyspnea, wheezing 45%-50%
Upper airway angioedema 50%-60%
Hypotension, dizziness, or syncope
30%-35%
Nausea, vomiting, diarrhea or
abdominal cramping 25%-30%
Signs and
Symptoms

Patients may present with unexplained
urticaria
Difficulty breathing may not even be a
primary complaint
Patient may have NO cardiovascular sx
Patient will still benefit from epi admin
Bottom
Line

Inflammatory mediators can cause angioedema (swelling)
in oropharyngeal and/or laryngeal tissues
• upper airway restriction (stridor and hoarseness)
Other upper airway symptoms
• sneezing
• rhinorrhea
• sore throat
• tongue itching or swelling
• a sensation that the throat is closing or tightening
Patient Presentation

Angioedema in the lower airway
• cough
• wheezing
• mucus plugging
• pulmonary edema
• pulmonary hyperinflation
• dyspnea

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

Increased vascular permeability and capillary leak
into the soft tissues (distributive shock)
Volume shift out of vascular space can be
significant: up to 35% (hypovolemic shock)
Inflammatory mediators that cause vasodilation
also can depress myocardial function
(cardiogenic shock)

Pulmonary vasospasm
Decreased left ventricular preload
Decreased cardiac output (obstructive shock)
Theorized that these effects come
together to cause “empty ventricle”
when patient is placed upright

Nausea
Vomiting
Cramping

Dizziness
Syncope
Headache
Anxiety / doom
Agitation / Confusion

Clinical criteria for the
diagnosis of anaphylaxis
Sensitivity 96.7%, 95% CI
Specificity 82.4%, 95% CI
Simplicity: Three easy checks

ANY OF THE
FOLLOWING THREE
SCENARIOS IS
ANAPHYLAXIS

8:43 pm
1022 Chester St.
43 y/o Female
Multiple
Complaints
Case Study

Exposure to known trigger
Plus
Sudden reduced BP / MAP
or organ dysfunction
1
Lieberman P, et al. J Allergy Clin Immunol. 2010;126:477-480.

7:20 am
38-B Grove St.
Pediatrician’s office
30 month Female
Vomiting & rash
after eating
cashews
Case Study

Likely exposure to allergen or trigger
any two…
Sudden reduced BP / MAP or organ dysfunction
Sudden respiratory symptoms and signs
Sudden skin / mucosal tissue
Sudden gastrointestinal symptoms and signs
2

Thanks to the Medical College of Georgia

5:43 am
621 Poplar Ave.
51 y/o Female
Difficulty
Breathing
Case Study

Sudden skin / mucosal tissue
PLUS EITHER…
Sudden reduced BP / MAP
or organ dysfunction
Sudden respiratory symptoms and signs
3

5:43 am
621 Poplar Ave.
48 y/o Female
Difficulty
Breathing
Case Study

Known exposure + Cardiovascular = ANAPHYLAXIS
1

Suspected exposure + (Symptoms) = ANAPHYLAXIS
2

Skin signs + (Respiratory or Cardiovascular) =
ANAPHYLAXIS
3

Stay AHEAD of ANAPHYLAXIS with Epi

Rapid administration decreases risk of
hospitalization
Delayed administration increases risk of of
biphasic reaction and death
Generally only 20%-40% of cases of
anaphylaxis get epinephrine at any point
One study showed fatal cases of anaphylaxis
received epi before cardiac arrest in only 14%
of cases
Do we give
epi when
we should?
Cheng, Jo. (2017). Anaphylaxis: The Underrecognized Killer. Relias Media. https://www.reliasmedia.com/articles/141080-
anaphylaxis-the-underrecognized-killer?v=preview

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.

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!
Do we give
epi when
we should?
Jacobsen, R. C., Toy, S., Bonham, A. J., Salomone, J. A., Ruthstrom, J., & Gratton, M. (2012). Anaphylaxis knowledge among paramedics: Results of a
national survey. Prehospital Emergency Care: Official Journal of the National Association of EMS Physicians and the National Association of State EMS
Directors, 16(4), 527–534. https://doi.org/10.3109/10903127.2012.689931

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
Do we give
epi when
we should?
N El Sanadi et al. (2012). PARAMEDIC DETECTION OF SIGNS AND SYMPTOMS OF PATIENTS CALLING 911 FOR POSSIBLE
ALLERGIC REACTION AND ANAPHYLAXIS.

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
Do we give
epi when
we should?
Carrillo, E., Hern, H. G., & Barger, J. (2016). Prehospital Administration of Epinephrine in Pediatric Anaphylaxis. Prehospital Emergency Care: Official
Journal of the National Association of EMS Physicians and the National Association of State EMS Directors, 20(2), 239–244.
https://doi.org/10.3109/10903127.2015.1086843

We (all health care providers at all levels) tend to
withhold EPINEPHRINE when it is needed in
ANAPHYLAXIS

There are no contraindications for EPINEPHRINE in
ANAPHYLAXIS

Known Coronary Artery Disease?

Acute coronary syndrome caused
by an allergic reaction or a strong
immune reaction. Arterial spasm
and plaque rupture. Also affects
cerebral and mesenteric arteries.
A rare syndrome: cases in 130
males, 45 females; however,
disorder is likely overlooked and
therefore much more prevalent.
Treatments for cardiac and
anaphylactic issues may conflict.
Kounis
Syndrome
Kounis, N. G. (2016). Kounis syndrome: An update on
epidemiology, pathogenesis, diagnosis and therapeutic
management. Clinical Chemistry and Laboratory
Medicine (CCLM), 54(10), 1545–1559.
https://doi.org/10.1515/cclm-2016-0010
Abdelghany, M., Subedi, R., Shah, S., & Kozman, H.
(2017). Kounis syndrome: A review article on
epidemiology, diagnostic findings, management and
complications of allergic acute coronary syndrome.
International Journal of Cardiology, 232, 1–4.
https://doi.org/10.1016/j.ijcard.2017.01.124

-No consensus guidelines exist
for the management of patients
with acute coronary events in
the setting of anaphylaxis.
-Theoretically, epinephrine may
worsen coronary vasospasm and
worsen myocardial ischemia.
-Cardiac catheterization has been
used successfully to treat
patients with Kounis syndrome.
-Notwithstanding, epinephrine
should still be given as the initial
treatment of choice.
-In a recent case series, 25%
patients with Kounis syndrome
received epinephrine, no deaths.
Kounis
Syndrome

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.

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.

Difficult
Differential
Diagnostic
Dilemmas
Asthma
Panic
attack
Syncope
Anaphylaxis

Hidden Allergens
Spicy foods
Alcohol consumption
Communication issues
Late recognition
Confounding
factors
Red Flags
Cheng, Jo. (2017). Anaphylaxis: The Underrecognized Killer. Relias Media. https://www.reliasmedia.com/articles/141080-anaphylaxis-the-underrecognized-killer?v=preview

Exercise
Standing
Stress
Menstruation
Infection
Hiding
May worsen
anaphylaxis
Red Flags

Asthma
Allergic rhinitis
Atopic eczema
Psychiatric illness / PTSD
May worsen
anaphylaxis
Red Flags

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
Special
populations:
Red Flags

Beta blockers
ACE Inhibitors
MAO Inhibitors
NSAIDS
Problem
medications

Use factors found in your assessment to rule in

Don’t use missing factors to rule out

Example of EMS
Management of
Anaphylaxis
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

Brown, J. C., Simons, E., & Rudders, S. A. (2020). Epinephrine in the Management of Anaphylaxis. The Journal of
Allergy and Clinical Immunology: In Practice, 8(4), 1186–1195. https://doi.org/10.1016/j.jaip.2019.12.015

EPINEPHRINE
Simons, F. E. R., Ebisawa, M., Sanchez-Borges, M., Thong, B. Y., Worm, M., Tanno, L. K., Lockey, R. F., El-Gamal, Y. M., Brown, S. G.,
Park, H.-S., & Sheikh, A. (2015). 2015 update of the evidence base: World Allergy Organization anaphylaxis guidelines. World Allergy
Organization Journal, 8(1), 1–16. https://doi.org/10.1186/s40413-015-0080-1

Pallor
Anxiety
Tremor
Headache
Dizziness
Brown, J. C., Simons, E., & Rudders, S. A. (2020). Epinephrine in the Management of Anaphylaxis. The Journal of Allergy and Clinical
Immunology: In Practice, 8(4), 1186–1195. https://doi.org/10.1016/j.jaip.2019.12.015

Ventricular Arrhythmias
Hypertensive Crises
Acute Coronary Syndromes
Brown, J. C., Simons, E., & Rudders, S. A. (2020). Epinephrine in the Management of Anaphylaxis. The Journal of Allergy and Clinical
Immunology: In Practice, 8(4), 1186–1195. https://doi.org/10.1016/j.jaip.2019.12.015

Supportive O2
SpO2 target
94%-99%

Inhaled
Bronchodialators
• Pros: Beta-2
Bronchodilation
• Cons: Increased
tremor, tachycardia,
etc.

Supportive fluid resus
(follow local recommendations)
Simons, F. E. R., Ardusso, L. R., Bilò, M. B., Cardona, V., Ebisawa, M., El-Gamal, Y. M., Lieberman, P., Lockey, R. F., Muraro, A., Roberts,
G., Sanchez-Borges, M., Sheikh, A., Shek, L. P., Wallace, D. V., & Worm, M. (2014). International consensus on (ICON) anaphylaxis.
World Allergy Organization Journal, 7(1), 1–19. https://doi.org/10.1186/1939-4551-7-9

H1 Antihistamines
• Diphenhydramine
• 25-50 mg slow adults
• 1mg/kg slow peds
• Chlorpheniramine
• Clemastine
• Ceterazine
• Loratadine
Pros: May decrease minor
patient discomforts
Cons: Slow, can cause
drowsiness and hypotension
Notes: Has no effect on
leukotrienes, platelet
activating factor,
prostaglandins & more
Lieberman, P., Nicklas, R. A., Randolph, C., Oppenheimer, J., Bernstein, D., Bernstein, J., Ellis, A., Golden, D. B. K., Greenberger, P., Kemp, S., Khan, D., Ledford, D.,
Lieberman, J., Metcalfe, D., Nowak-Wegrzyn, A., Sicherer, S., Wallace, D., Blessing-Moore, J., Lang, D., … Tilles, S. A. (2015). Anaphylaxis—A practice parameter update
2015. Annals of Allergy, Asthma & Immunology, 115(5), 341–384. https://doi.org/10.1016/j.anai.2015.07.019

Westafer, L. (2022, July 9). The Death of Diphenhydramine. ACEP Now. https://www.acepnow.com/article/the-death-of-diphenhydramine/

Glucocorticoids
(Steroids)
Methyprednisolone
125 mg adults
1-2 mg/kg peds
Pros: Theoretical
prevention of biphasic
anaphylaxis
Cons: Not proven to
improve outcomes

Occurs within 1–72 hours
Usually within 8–10 hours
Up to 23% of adults
Up to 11% of children
Longer delay from onset to admin
of epi 60-190 min correlates with
biphasic reactions
Corticosteroids not shown to
reduce incidence
Protracted uniphasic anaphylaxis
uncommon, but can last for days
Clinically important biphasic
reactions are rare
Pourmand, A., Robinson, C., Syed, W., & Mazer-Amirshahi, M. (2018). Biphasic anaphylaxis: A review of the literature and implications
for emergency management. The American Journal of Emergency Medicine, 36(8), 1480–1485.
https://doi.org/10.1016/j.ajem.2018.05.009

Vasopressors
Glucagon
Inotropic & chronotropic
1-5mg adults
up to 1 mg peds
Methylene blue
Selective nitric oxide GMP
inhibitor.
Can interfere with SpO2
and cause adverse events
Advanced airway
Cricothyrotomy
ECMO

At the hospital
Treatments as already discussed
Observed 4-8 hours
Longer if patient has additional factors
Long-term management

Bottom Line
“Failure to use epinephrine,
or to use it promptly is
considered to be an
important and avoidable
factor in fatal reactions”

What they didn't tell you about Anaphylaxis 2023.pptx

What they didn't tell you about Anaphylaxis 2023.pptx

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to What they didn't tell you about Anaphylaxis 2023.pptx

Similar to What they didn't tell you about Anaphylaxis 2023.pptx (20)

More from Rommie Duckworth

More from Rommie Duckworth (20)

Recently uploaded

Recently uploaded (20)

What they didn't tell you about Anaphylaxis 2023.pptx