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Management of Anaphylaxis
- 1. “I’m all Itchy” Anaphylaxisin the Pediatric ER Dr. Rebecca Starr Pediatric Emergency Medicine Fellow February 6, 2014 certifiedallergysa.com
- 2. Objectives Discuss themost current definition of anaphylaxis Explain the causes and pathophysiology of anaphylaxis Analyze symptoms and be able to diagnose and effectively treat anaphylaxis Review biphasic anaphylactic reactions List appropriate discharge materials from the ED
- 3. Question 1 A 5year old M who has experienced a severe allergic reaction to shrimp in the past needs a CT scan with IV and oral contrast. What precautions should you take? A. NS bolus and diphenhydramine B. NS bolus, diphenhydramine, and prednisone C. This patient can not receive contrast D. Reassurance, there is no associated risk for a reaction between shellfish and contrast
- 4. Question 2 You havebeen asked by a local school to provide recommendations about the use of self injectable epinephrine for anaphylaxis. What is the BEST response to give regarding anaphylaxis? A. A patient should not receive a second dose of epinephrine unless a physician is present B. Epinephrine reaches higher peak plasma concentrations when injected into the thigh rather than the arm C. Families should keep one epinephrine auto injector in the car in case a reaction occurs after school D. Subcutaneous injection of epinephrine is preferable to intramuscular injection
- 5. Question 3 A 14y/o M who has seasonal allergies and moderate persistent asthma is currently receiving allergen immunotherapy. Today in clinic he received his usual allergen injection, but after 10 minutes, he started coughing and complaining of dyspnea and throat swelling. On physical exam he exhibits moderate respiratory distress and has diffuse expiratory wheezing on auscultation. No oropharyngeal edema noted. Vitals signs include a pulse ox of 97%, BP of 130/70, and HR of 90. Of the following, the MOST appropriate next action is to administer: A. A short acting beta-2 agonist nebulization B. An oral antihistamine C. An oral corticosteroid D. Intramuscular epinephrine
- 6. Question 4 A 10y/o M with a history of peanut allergy presents with diffuse itching and trouble breathing after eating a friend’s candy bar that contained nuts during school lunch. At the nurse’s office the patient received IM epinephrine with his EpiPen with symptom resolution. EMS was called and the patient was brought to the local pediatric ED (about a 12 minute ride). On arrival to the ED, the patient is again complaining of itching with an urticarial rash on his chest and per EMS the patient began vomiting as they were pulling up to the ambulance bay. Arrival vitals include a pulse ox of 96%, BP of 88/67, and HR of 95. Of the following, the MOST appropriate treatment plan is: A. Intramuscular epinephrine, oral antihistamine, oral corticosteroid, and a short acting beta-2 agonist neb treatment B. Intramuscular epinephrine, IV antihistamine, IV corticosteroid, NS bolus C. Intramuscular epinephrine, IV antihistamine, IV Zantac, NS bolus D. Intramuscular epinephrine, oral antihistamine, and oral corticosteroid
- 7. What is Anaphylaxis? Big Bang
- 8. Anaphylaxis 411 “Severeallergic reaction that can be life threatening” IgE-mediated hypersensitivity reaction resulting in the release of potent chemical mediators Mast Cells Basophils Affects multiple organ systems Respiratory Cardiovascular Gastrointestinal Dermatologic Clinical Diagnosis Biphasic Reactions Russell et al.,Pediatric Emergency Care, 2010
- 9.
- 10. History First deathfrom anaphylaxis was documented in Egyptian hieroglyphics in 2641 BC Pharaoh Menes dying after a hornet sting Questionable and now not supported by historians
- 12. History First describedin scientific literature in 1902 by two French physiologists, Charles Richet and Paul Portier Prince Albert I of Monaco Investigating jellyfish toxins Initially coined “aphylaxis” with “a” meaning contrary to and “phylaxis” meaning protection Richet won the Nobel Prize in Medicine Lane et al, Pediatric Emergency Care, 2007
- 13. Pediatric Epidemiology 10.5per 100,000 Increasing over the past 4 decades 2:1 Male to female ratio 25% require admission 1500 deaths per year in US (adults and children) 40% had prior history of allergic reaction Only 20% of prior anaphylaxis patients had an Epipen available during repeat anaphylaxis encounter Lane et al, Pediatric Emergency Care, 2007 Russell et al.,Pediatric Emergency Care, 2010
- 14. Pediatric Epidemiology Severityof a previous reaction does not predict the severity of a subsequent reaction Previous anaphylactic reactions = higher risk for reoccurrence Lane et al, Pediatric Emergency Care, 2007
- 15.
- 16. Causes of Anaphylaxis Food Leading cause of all anaphylaxis in children 50% of anaphylactic triggers Peanuts, tree nuts and shellfish are the most common Usually the most life-threatening reactions Older children Milk, soy, eggs Most common in younger children Potential to outgrow Food dyes Lane et al, Pediatric Emergency Care, 2007 Russell et al.,Pediatric Emergency Care, 2010
- 17. Causes of Anaphylaxis Medications 24% of anaphylactic triggers Antibiotics most common- PCN and cross reaction drugs to PCN Penicillin-allergic individuals have a 4-10% risk of allergic reaction to a cephalosporin Only antibiotic that can have skin testing (for IgE mediated rxn) NSAIDs Latex- chronic patients and multiple surgeries IV contrast Propofol- sedative medication that contains eggs and soy Blood products, IVIG, etc Lane et al, Pediatric Emergency Care, 2007
- 18. Causes of Anaphylaxis Hymenoptera envenomation 12% of anaphylactic triggers Honeybees, yellow jackets, hornets, wasps, and fire ants Life threatening reactions require venom immunotherapy 20-60% risk per sting of anaphylaxis Lane et al, Pediatric Emergency Care, 2007
- 19. Causes of Anaphylaxis Immunizations- estimated 1.5 events per 1 million MMR and influenza are the most common Prepared using chick-derived cells AAP recommends giving MMR to children with egg sensitivity Per CDC, egg sensitivity a contraindication for influenza vaccine Unknown exposure 16% of anaphylactic triggers
- 20. Contrast Media Anaphylactoidreaction- not IgE mediated Osmolality-hypertonicity reaction Triggers degranulation of mast cells and basophils Association of shellfish allergy and contrast media (because of iodine content) is a myth Pretreatment with prednisone and diphenhydramine is only indicated in documented history of an adverse reaction to contrast media
- 21. Question 1 A 5year old M who has experienced a severe allergic reaction to shrimp in the past needs a CT scan with IV and oral contrast. What precautions should you take? A. NS bolus and diphenhydramine B. NS bolus, diphenhydramine, and prednisone C. This patient can not receive contrast D. Reassurance, there is no associated risk for a reaction between shellfish and contrast
- 22. Question 1 A 5year old M who has experienced a severe allergic reaction to shrimp in the past needs a CT scan with IV and oral contrast. What precautions should you take? A. NS bolus and diphenhydramine B. NS bolus, diphenhydramine, and prednisone C. This patient can not receive contrast. D. Reassurance, there is no associated risk for a reaction between shellfish and contrast.
- 23. Route of Exposure Insect stings and parenterally injected medication may have rapid onset of symptoms PO ingestions may develop over several minutes to hours Most symptoms occur within 5-30 minutes post exposure Lane et al, Pediatric Emergency Care, 2007
- 24. Pathophysiology First timeexposure to the allergen Specific IgE antibodies are formed around the allergen and bind to Fc receptors on mast cells Repeat allergen exposure and binding of the allergen to IgE antibodies causes degranulation of mast cell Massive release of chemical mediators including: Histamine Prostaglandin D2 Leukotrienes Platelet activating factor Tryptase Lane et al, Pediatric Emergency Care, 2007
- 25. Pathophysiology Effect ofChemical Mediators after release Increased vascular permeability Bronchospasm Vasodilatation Altered smooth muscle tone Within 10 minutes the circulating blood volume can decrease by 35% during anaphylaxis Lane et al, Pediatric Emergency Care, 2007
- 26. Symptoms Respiratory: 94% Cutaneous: 80- 90% GI: 10-46% CV: 30% Russell et al.,Pediatric Emergency Care, 2010
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- 30. IM Epinephrine Firstline therapy! Has alpha-1, beta-1, and beta-2 agonist actions Increased vascular resistance and decreased mucosal edema (alpha-1) Increased inotrophy and chronotrophy (beta-1) Increased bronchodilation and decreases release of mast cell and basophil mediators (beta-2) Only 18% reported use in pediatric anaphylaxis cases
- 31. IM vs. Sub-q IM substantially better than sub-q Faster peak plasma concentrations Anterolateral thigh (vastus lateralis)
- 32. IM Epinephrine Dose:0.01mg/kg of 1:1000 Max dose is 0.3mg May repeat every 5-15 minutes 20% require subsequent dosing EpiPen: 2 fixed doses: 0.15mg and 0.3mg < 22kg give EpiPen Jr (0.15mg) >22kg give EpiPen (0.3mg) Lane et al, Pediatric Emergency Care, 2007
- 33. EpiPen www.allergywindow.com Russell et al.,PediatricEmergency Care, 2010
- 34. Question 2 You havebeen asked by a local school to provide recommendations about the use of self injectable epinephrine for anaphylaxis. What is the BEST response to give regarding anaphylaxis? A. A patient should not receive a second dose of epinephrine unless a physician is present B. Epinephrine reaches higher peak plasma concentrations in injected into the thigh rather than the arm C. Families should keep one epinephrine auto injector in the car in case a reaction occurs after school D. Subcutaneous injection of epinephrine is preferable to intramuscular injection
- 35. Question 2 You havebeen asked by a local school to provide recommendations about the use of self injectable epinephrine for anaphylaxis. What is the BEST response to give regarding anaphylaxis? A. A patient should not receive a second dose of epinephrine unless a physician is present B. Epinephrine reaches higher peak plasma concentrations in injected into the thigh rather than the arm C. Families should keep one epinephrine auto injector in the car in case a reaction occurs after school D. Subcutaneous injection of epinephrine is preferable to intramuscular injection
- 36. Question 3 A 14y/o M who has seasonal allergies and moderate persistent asthma is currently receiving allergen immunotherapy. Today in clinic he received his usual allergen injection, but after 10 minutes, he started coughing and complaining of dyspnea and throat swelling. On physical exam he exhibits moderate respiratory distress and has diffuse expiratory wheezing on auscultation. No oropharyngeal edema noted. Vitals signs include a pulse ox of 97%, BP of 130/70, and HR of 90. Of the following, the MOST appropriate next action is to administer: A. A short acting beta-2 agonist nebulization B. An oral antihistamine C. An oral corticosteroid D. Intramuscular epinephrine
- 37. Question 3 A 14y/o M who has seasonal allergies and moderate persistent asthma is currently receiving allergen immunotherapy. Today in clinic he received his usual allergen injection, but after 10 minutes, he started coughing and complaining of dyspnea and throat swelling. On physical exam he exhibits moderate respiratory distress and has diffuse expiratory wheezing on auscultation. No oropharyngeal edema noted. Vitals signs include a pulse ox of 97%, BP of 130/70, and HR of 90. Of the following, the MOST appropriate next action is to administer: A. A short acting beta-2 agonist nebulization B. An oral antihistamine C. An oral corticosteroid D. Intramuscular epinephrine
- 38. Treatment IM Epinephrine May repeat IV fluids- 20ml/kg bolus Repeat boluses if hypotension persists IV Epinephrine for persistent hypotension/symptoms 0.01mg/kg of 1:10,000 Max dose 1gm Histamine (H1/H2) blockers Benadryl (H1) and Zantac (H2) Slow onset of action Shown to be effective on dermatologic manifestations especially in combo Albuterol treatment if indicated Russell et al.,Pediatric Emergency Care, 2010
- 39. Role of Corticosteroids? Corticosteroids NO clinical evidence-based support for steroids in acute management of anaphylaxis NO support for steroids against biphasic reactions Reported use of corticosteroids is more prevalent than IM epinephrine in anaphylaxis Lane et al, Pediatric Emergency Care, 2007 Russell et al.,Pediatric Emergency Care, 2010
- 40. Question 4 A 10y/o M with a history of peanut allergy presents with diffuse itching and trouble breathing after eating a friend’s candy bar that contained nuts during school lunch. At the nurse’s office the patient received IM epinephrine with his EpiPen with symptom resolution. EMS was called and the patient was brought to the local pediatric ED (about a 12 minute ride). On arrival to the ED, the patient is again complaining of itching with an urticarial rash on his chest and per EMS the patient began vomiting as they were pulling up to the ambulance bay. Arrival vitals include a pulse ox of 96%, BP of 88/67, and HR of 95. Of the following, the MOST appropriate treatment plan is: A. Intramuscular epinephrine, oral antihistamine, oral corticosteroid, and a short acting beta-2 agonist neb treatment B. Intramuscular epinephrine, IV antihistamine, IV corticosteroid, NS bolus C. Intramuscular epinephrine, IV antihistamine, IV Zantac, NS bolus D. Intramuscular epinephrine, oral antihistamine, oral corticosteroid
- 41. Question 4 A 10y/o M with a history of peanut allergy presents with diffuse itching and trouble breathing after eating a friend’s candy bar that contained nuts during school lunch. At the nurse’s office the patient received IM epinephrine with his EpiPen with symptom resolution. EMS was called and the patient was brought to the local pediatric ED (about a 12 minute ride). On arrival to the ED, the patient is again complaining of itching with an urticarial rash on his chest and per EMS the patient began vomiting as they were pulling up to the ambulance bay. Arrival vitals include a pulse ox of 96%, BP of 88/67, and HR of 95. Of the following, the MOST appropriate treatment plan is: A. Intramuscular epinephrine, oral antihistamine, oral corticosteroid, and a short acting beta-2 agonist neb treatment B. Intramuscular epinephrine, IV antihistamine, IV corticosteroid, NS bolus C. Intramuscular epinephrine, IV antihistamine, IV Zantac, NS bolus D. Intramuscular epinephrine, oral antihistamine, oral corticosteroid
- 42. Biphasic Reactions Delayedanaphylactic reaction developing after initial reaction has resolved About 1-20% of all anaphylactic reactions 6% in pediatric anaphylaxis Asymptomatic intervals range from 1-28 hours Can occur up to 72 hours from initial reaction Length of observation? Suggested 8-24 hours in literature “The only intervention that has been shown to reduce the prevalence and severity of biphasic allergic reactions is early treatment with IM epinephrine” Lane et al, Pediatric Emergency Care, 2007
- 43. Biphasic Reactions Lee etal, Pediatrics, 2013
- 44. Criteria for Admission Unresolved symptoms High risk for biphasic reaction Delayed epinephrine treatment Co-morbidities Social
- 45. Outpatient Management Prescriptionfor EpiPen Parents can get at our pharmacy Educate parents Symptoms of anaphylaxis Use of EpiPen Referral to allergist School forms Peds ED Portal
- 46. Patient Education Hold for10 seconds! Look at expiration date! www.drug3k.com
- 47. How to useEpiPen EpiPen Video
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- 51. Summary Anaphylaxis- acuteonset, involvement of 2 or more organ systems or presence of hypotension Severity of a previous reaction does not predict the severity of a subsequent reaction Patients with previous anaphylactic reactions are at a higher risk for reoccurrence First line treatment is IM epinephrine < 22kg give EpiPen Jr (0.15mg) >22kg give EpiPen (0.3mg) Early IM epinephrine can reduce the risk of a biphasic reaction Discharge home with EpiPen, education, allergist referral, and school forms
- 53. References Lee, J.M.and Greenes, D.S., Biphasic Anaphylactic Reactions in Pediatrics. Pediatrics. 2000;106(4):762-6. Nowak, R., Farrar, J.R., Brenner, B.E. et al., Customizing anaphylaxis guidelines for emergency medicine. The Journal of Emergency Medicine. 2013;45(2):299-305. Lane, R.D. and Bolte, R.G., Pediatric anaphylaxis. Pediatric Emergency Care. 2007;23(1):49-56. Russell, S., Monroe, K., and Losek, J., Anaphylaxis management in the pediatric emergency department. Pediatric Emergency Care. 2010;26(2):71-76.
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Editor's Notes
- #10 Met with Food Allergy and Anaphlaxis Network in July 2005. Essentially 2 or more organ systems or hypotension
- #12 Krombach et al, Allergy, 2004http://onlinelibrary.wiley.com/doi/10.1111/j.1398-9995.2004.00603.x/pdf
- #17 Allergan type does not seem to be a predictor of hospitalization
- #47 Prescription must be refilled annually. Heat, cold and sunlight can affect degradation of Epi