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Anaphylaxis
- 1. ANAPHYLAXIS BY DR MRIDULMURALI KRISHNA DNB FAMILY MEDICINE RESIDENT
- 2. Atopy The termATOPY implies a tendency to manifest asthma, rhinitis, urticaria, and atopic dermatitis alone or in combination, in association with the presence of allergen-specific IgE. However, individuals without an atopic background may also develop hypersensitivity reactions, particularly urticaria and anaphylaxis, associated with the presence of IgE.
- 3. Risk Factors MildAsthma: Relative Risk 2 Severe Asthma: Relative Risk 3 Known Food Allergy, Hymenoptera Sting allergy or medication allergy Risk factors for a poor outcome include Older age, Use of beta blockers Presence of preexisting asthma. Some individuals suffering from recurrent episodes of idiopathic anaphylaxis possess morphologically aberrant mast cells in their bone marrow that express a mutant, constitutively active form of c-kit, even without evidence of frank mastocytosis
- 4. Precautions Anaphylaxis isa life threatening condition that requires Immediate ABC Management Epinephrine injection IM Biphasic reactions occur in up to 20% of cases Second acute anaphylactic reaction despite no repeat exposure to the original allergen May be delayed up to 8 hours later (24-72 hour delay has been reported in atypical cases)
- 5. Causes Idiopathic Considermastocytosis Hymenoptera Allergy (Bees, wasps, fire ants) Food Allergy (30% of anaphylactic episodes, especially in children under age 4 years) Cow's Milk Egg whites Fish Peanuts Tree nuts Sesame Food additives Shellfish
- 6. Causes (continued) Medications(most common in age over 55 years) Penicillin Allergy (75% of anaphylactic deaths) NSAIDs or Aspirin Radiographic Intravenous Contrast Material Allopurinol ACE Inhibitors Opioids Interferon Allergic Contact Dermatits Latex Allergy Misc – Animal Dander
- 7. Signs – TypicalPresentation Urticaria and Angioedema (90% of cases) Respiratory distress Upper airway obstruction (70% of cases) Lower airway obstruction may occur, especially in Asthma Cardiovascular collapse with Hypotension (45% of cases) Gastrointestinal symptoms such as Vomiting (45% of cases) Neurologic symptoms such as Headache or Dizziness (15% of cases)
- 8. Signs - MILD General Feeling impending doom Pruritus (uncommon without rash) Metallic Taste in mouth Naso-ocular Itchy nose or eyes Sneezing Clear, watery Eye Discharge or Nasal discharge Skin (occurs) Urticaria: Hives Angioedema: Facial swelling and Lip swelling
- 9. Sign - MODERATE Neurologic Dizziness Weakness Gastrointestinal Nausea, Vomiting Bloody Diarrhea Abdominal Pain Fecal urgency or Incontinence Genitourinary Uterine cramps Urinary urgency or Incontinence
- 10. Signs – SEVERE(ANAPHYLAXIS) Airway Compromise Hoarseness or Dysphonia Stridor Inability to manage own secretions Airway posturing (sniffing position) Breathing Compromise Wheezing and bronchospasm Dyspnea Tachypnea Hypoxia Increased work of breathing
- 11. Signs – SEVERE(ANAPHYLAXIS) Circulatory compromise Hypotension Tachycardia Hypoperfusion Syncope
- 12. Labs: Confirms diagnosis Do not rely on labs to make or treat acute episode Serum histamine Requires special handling for accuracy Obtain first level within 1 hour of symptom onset Compare to baseline level Serum tryptase Levels rise 30 minutes after onset and peak at 1-2 hours Obtain level on presentation, in 1-2 hours and 24 hours after presentation
- 13. Diagnosis – If1 of the Criteria met Criteria 1: Acute illness onset within minutes to hours AND Skin or mucosal effects (e.g. Hives, Pruritus, Flushing, swollen lips/Tongue/uvula) AND Respiratory distress (e.g. Dyspnea, bronchospasm) or Cardiovascular collapse (e.g. Hypotension, Syncope)
- 14. Diagnosis – If1 of the Criteria met Criteria 2: Acute illness onset within minutes to hours after likely allergen exposure AND atleast TWO of the following Skin or mucosal effects (e.g. Hives, Pruritus, Flushing, swollen lips/Tongue/uvula) Respiratory distress (e.g. Dyspnea, bronchospasm) Cardiovascular collapse (e.g. Hypotension, Syncope) Gastrointestinal symptoms persist (e.g. abdominal cramping, Vomiting)
- 15. Diagnosis – If1 of the Criteria met Criteria 3: Hypotension within minutes to hours after likely allergen exposure Systolic Blood Pressure with 30% decrease from baseline or <90 mmHg (adults) SUMMARY Anaphylaxis is present if allergen exposure and Hypotension or two compromised organ systems
- 16. GENERAL MEASURES 1.ABC MANAGEMENT 2. SUPPLEMENTAL OXYGEN
- 17. Anaphylaxis with Airwaycompromise Epinephrine is the mainstay of Anaphylaxis management and must not be delayed Administer within 5 minutes of presentation Narrow window of opportunity with Epinephrine Prior to complete airway obstruction and cardiovascular collapse Vasoconstricts, bronchodilates and decreases airway edema Epinephrine IM is safe EVEN IN OLDER PATIENTS and should not be withheld when Anaphylaxis criteria are met
- 18. Anaphylaxis with Airwaycompromise Epinephrine (1:1000 concentration = 1 mg/ml) Intramuscular dosing preferred over subcutaneous Due to more reliable and faster rise in blood levels Typically injected in lateral thigh Repeat every 5 to 15 minutes prn up to 3 doses Cardiac monitoring required for repeat dosing Epinephrine via vial Adult: 0.5 mg (0.5 ml) of 1:1000 Epinephrine IM Child: 0.01 mg/kg (0.01 ml/kg) IM up to 0.3 mg (0.3 ml) Epinephrine Autoinjector (preferred if available, as reduces errors and speeds delivery) Adult and children over 30 kg or 66 pounds: 0.3 mg autoinjector Children under 30 kg or 66 pounds: 0.15 autoinjector
- 20. Anaphylaxis with Airwaycompromise Anaphylaxis "Dirty" Epinephrine drip ("dirty epi drip") o Indicated if repeat intramuscular Epinephrine dosing is required for Anaphylaxis o Order at the time of second Epinephrine injection o Preparation: o Aim - Epinephrine 1 mcg/ml solution o Draw up 1 mg of Epinephrine (1 ml of 1:1000 or 10 ml of 1:10000) o Inject 1 mg Epinephrine into 1 Liter bag of Normal Saline (now 1 mcg/ml Epinephrine) o Given 1 cc/20 drops AND 1 mcg/ml Epinephrine o Goal rate: 6 mcg/min o Equates to 2 drops per second
- 21. Anaphylaxis with Airwaycompromise Protocol 1: Hypotensive, unstable patient Draw into syringe, 10 ml (10 mcg) from 1 mcg/ml Epinephrine solution prepared above Inject 5 ml (5 mcg) IV (may repeat second 5 ml/5 mcg dose)
- 22. Anaphylaxis with Airwaycompromise Protocol 2: Hypotensive, unstable patient Open Epinephrine solution IV (flows at 20-50 mcg/min through 18 gauge IV) Provider stands by the bedside and closely controls infusion Titrate until patient hemodynamically stable Decrease the Epinephrine flow as patient becomes hemodynamically stable Decrease flow towards 1-4 mcg/min Wean as approach cummulative max IV Epinephrine dose Max cummulative dose: 100 mcg (3-5 min with open IV) Equivalent of the initial Anaphylaxis guideline Recommended bolus of 0.1 mg IV push over 5 minutes
- 23. Anaphylaxis with Airwaycompromise Protocol 3: Cautious titration Start infusion at 1 mcg/min and titrate to effect (typically 1-4 mcg/min)
- 24. Anaphylaxis with Airwaycompromise Unresponsive to Epinephrine Glucagon 3.5 to 5 mg IV - if patient uses Beta-Blockers May repeat if no Blood Pressure response within 10 minutes Norepinephrine may also be considered
- 25. Hypotension Due toVasodilitation and third spacing Fluid Resuscitation with isotonic saline (NS, LR) Adult: 2 Liters Normal Saline Child: 10-20 ml/kg per bolus until Hypotension improves Large volumes may be required Pressors (e.g. Norepinephrine, Dopamine) may be required Consider Epinephrine by continuous IV infusion
- 26. Respiratory Distress NebulizedBeta adrenergic agonist (e.g. Albuterol) Consider for signs of lower airway obstruction Consider Endotracheal Intubation
- 27. Urticaria, Pruritus orFlushing General: H1 Antagonists NOT a first-line agent in Anaphylaxis management Use ONLY as an ADJUNCT TO EPINEPHRINE and ABC Management Effects are delayed 1-2 hours from delivery Does not reverse upper airway obstruction or improve Hypotension Diphenhydramine (Benadryl) Chlorpheniramine Maleate 1 mg/kg intramuscular or intravenous is indicated in children even if less than 1 year of age
- 28. Severe or persistentsymptoms not resolved in 30 min CORTICOSTEROIDS NOT A FIRST-LINE AGENT in Anaphylaxis management Use ONLY as an ADJUNCT TO EPINEPHRINE AND ABC MANAGEMENT Effects are delayed 6 hours from delivery Studies proving benefit are lacking Consider for prevention of biphasic reaction, protracted reaction or in comorbid Asthma with Wheezing Hydrocortisone - 5 mg/kg IV Methylprednisolone every 6 hours Adult: - 60-125 mg IV/IM Child: - 0.5-1 mg/kg IV/IM Predisone 60 mg orally in adults (or Methyprednisolone 1-2 mg/kg orally in children)
- 29. Prevention Medical AlertBracelet should be worn Strict avoidance of allergen Epinephrine Autoinjector, home injectable devices Keep one in place where most of time spent Bring an injector when traveling Consider Allergist referral Consider Skin Testing and Desensitization therapy Indicated if re-exposure is likely or unavoidable Clinic office administration of medications and injections Should include a policy to observe patient after injection for 20-30 minutes