a presentation I did for fellow registrars..

1. Anaphylaxis
and some angioedema
Jonathan Cheah
Logan Hospital
21 July 2016

2.  Why… is it important
 Who…does it involve ?
 What…to give
 Where…to give
 When…. Not to give

5. AIHW and ABS – 323 fatalities from 1997-2013
 Medication----------------------------- 52cases
 Insect sting/tick bites --------------- 21 cases
 Food ------------------------------------- 23 cases
--increased from 0.05 > 0.09/100,000
--increased 6.2% per year
 Serum -------------------------------------3 cases
 UNSPECIFIED------------------------- 224 cases
Statistics

8.  What is the common cause for anaphylaxis in
Emergency department in australia ?
 What types of anaphylaxis are there ?

9.  11 year old boy, known to be allergic to banana.
Complains of itchy and tight throat with difficulty
swallowing, persistent cough and chest tightness after
consuming ice cream.
NO RASH.
 This is not anaphylaxis. True or false ?
Question

10. False.
 Cutaneous symptoms maybe transient or may not
precede anaphylaxis
 1 out of 6 fatal food-induced anaphylaxis cases,
severe CVS symptoms developed without
skin or respi symptoms.

11.  25 year old female, not known to be allergic to anything.
Presents w facial urticaria and itch. c/o of itchy sensation at
back of throat.
 O/e well. No stridor. Just welts on face (but no
angioedema…)
 A. ? Give IM adrenaline
 B. ? Give oral pred + antihistamine
 C. ? Stop using cheap soap !
 D. Admit to SSU
Question 2

12. 0.01mg/kg
Remember

13.  ADULTS – 0.5mg (yes…it is 0.01mg/kg too)
 PAEDIATRICS – 0.01mg/kg…

14.  How about…pregnant women ?
 Use 0.3mg
 How about…the elderly ?

16. Thirteen men (26 ± 2 years; weight, 85 ± 5 kg [range, 62
-114 kg]; BMI, 36.6 ± 4.6 [range, 20-64]) completed the study

18.  peanut/tree nut allergy (adolescents)
 Pre-existing heart/lung disease
 Asthma
 Delayed administration of adrenaline
 Previous biphasic reactions
 Advanced age
 Mast Cell disease
Patients at risk of severe anaphylaxis

19.  1mg in 1000mls
Start at ~5 mL/kg/hour (~0.1 microgram/kg/minute) using a
pump
If no pump :~20 drops per ml; Therefore, start at ~2 drops per
second for an adult.
 1mg in 100mls normal saline (or 5% dextrose)
Start at 0.5 mL/kg/hour.
Should only be given by infusion pump
IV Adrenaline

20.  Usual ICU recipe is 6mg in 100mls 5% dextrose
 Final concentration 60mcg/ml ;
 1ml/hour === 1mcg/min
 Usual dose range 1-20ml/hour (1-20mcg/min)
 And we want : ~0.1mcg/kg/min i.e. 7ml
IV Adrenaline

21.  Antihistamines and/or steroids if used quickly at the
first sign of allergic reaction can prevent food
anaphylaxis.
 TRUE or FALSE
Steroids occasionally have a role as a second-line agent in biphasic or prolonged
anaphylactic reactions, which are both rare in paediatric food anaphylaxis.

23. No Short Stay Beds….
A 30 year old man has been in SSU since 8pm post
adrenaline IM for accidental ingestion of curry….
To discharge or not…?
Its 2330 and its handover time

24. Relapse, protracted and/or biphasic reactions may occur.
Patients require overnight observation if they:
 Had a severe or protracted anaphylaxis (e.g. required repeated
doses of adrenaline or IV fluid resuscitation), OR
 Have a history of asthma or severe/protracted anaphylaxis, OR
 Have other concomitant illness (e.g. asthma, history or
arrhythmia), OR
 Live alone or are remote from medical care, OR –
 Present for medical care late in the evening.
Guidelines state :

26.  self-limited, localized subcutaneous (or submucosal)
swelling, which results from extravasation of fluid
into interstitial tissues.
 occur in isolation, accompanied by urticaria, or as a
component of anaphylaxis.
Angioedema

27.  affects areas with loose connective tissue, such as
the face, lips, mouth, and throat, larynx, uvula,
extremities, and genitalia.
 Bowel wall angioedema presents as colicky
abdominal pain

28.  Mast cell-mediated angioedema; usually begins
within minutes of exposure to the allergen, builds
over a few hours, and resolves in 24 to 48 hours
 Angioedema may also be histamine-mediated
(histaminergic) without clear evidence of mast cell
degranulation. >>>idiopathic (also known as
spontaneous) angioedema.
Types of angioedema

29.  Bradykinin-induced angioedema is not associated with
urticaria, bronchospasm, or other symptoms of allergic
reactions. more prolonged time course, usually developing
over 24 to 36 hours and resolving within two to four days .
relationship between the trigger and the onset of symptoms
is often not apparent. E.g. ACE inhibitor-induced
angioedema, swelling may appear within a week of starting
or increasing the medications or after years of use.
3rd type of angioedema

34.  If signs and symptoms of mast cell activation
are absent and
if the angioedema is unaccompanied by urticaria and
nonresponsive to antihistamines, then :
 bradykinin-mediated angioedema, such as that
caused by ACE inhibitors and the rare disorder
hereditary or acquired C1 inhibitor deficiency, should
be considered

36.  Recurrent episodes of angioedema without urticaria or pruritus,
lasting two to five days (without treatment).
 Unexplained recurrent episodes of self-limited, colicky,
abdominal pain (typically lasting one to three days), especially in
patients who also have had cutaneous angioedema.
 Unexplained laryngeal edema (even a single episode).
 Angioedema episodes in the absence of angiotensin-converting
enzyme (ACE) inhibitors, nonsteroidal anti-inflammatory drugs
(NSAIDs), or history to suggest an allergic cause.
 A family history of angioedema.
 A low complement component 4 (C4) level in a patient with
angioedema
Hereditary Angioedema (HAE)

37.  Indications….
 Testing : C4 (low during attacks), but 2% normal
between attacks…
 Serum C1 INH level
Testing for HAE

38.  Icatibant (Firazyr®) is now listed on the Pharmaceutical Benefits Scheme
(PBS) for emergency treatment of acute angioedema in patients with
known HAE, and can in suitable circumstances be self-administered at home.
 Purified C1 INH (Berinert®, Cinryze®) is available for IV use in the hospital
setting or possibly at home for severe attacks and is preferable for use in
pregnancy and children and can also be used for short-term prophylaxis
prior to procedures.
 long term prophylaxis --- danazol and tranexamic acid, which are limited,
respectively, by side effects/intolerance and relative lack of efficacy.
Treatment for HAE

43.  Learn how to write up adrenaline infusion
 Thighs!
 Angioedema ; be careful (look for the ACE
inhibitor…)
 Adrenaline doses
 Add Hereditary Angioedema to your list of
differentials for that recurring abdominal pain
 Talk to immunologist; after securing airway.