Anaphylaxis: Difference between revisions

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==Background==
==Background==
===Definition===
===Definition===
Anaphylaxis is highly likely when ANY ONE of the following criteria is fulfilled
Anaphylaxis is highly likely when ANY ONE of the following criteria is fulfilled<ref>Brown SGA, Mullins RJ and Gold MS. '''Anaphylaxis: diagnosis and management,''' ''MJA'' 2006; 185: 283–289  </ref><ref>Lieberman P et al. '''The diagnosis and management of anaphyalxis: An updated practice parameter,''' ''J Allergy Clin Immunol'' 2005;115;3:S483-S523 </ref>


'''Criterion 1 (90% of patients)'''  
'''Criterion 1 (90% of patients)'''  
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==Management==
==Management==
#'''[[Epinephrine]]'''
#'''[[Epinephrine]]'''
##1:1000 '''IM''' 0.3 - 0.5mg (0.3 - 0.5mL) every 5 - 15 minutes<ref>Dhami S. et al. Management of anaphylaxis: a systematic review. Allergy. 69 (2014) 168–175. http://onlinelibrary.wiley.com/store/10.1111/all.12318/asset/all12318.pdf?v=1&t=hrspdbpk&s=8067bfd5903c7ffebf4a274f062a71633ebe0507</ref>
##1:1000 '''IM''' 0.3 - 0.5mg (0.3 - 0.5mL) every 5 - 15 minutes<ref>Dhami S. et al. Management of anaphylaxis: a systematic review. Allergy. 69 (2014) 168–175. http://onlinelibrary.wiley.com/store/10.1111/all.12318/asset/all12318.pdf?v=1&t=hrspdbpk&s=8067bfd5903c7ffebf4a274f062a71633ebe0507</ref><ref>Sheikh A, Shehata YA, Brown SGA, Simons FER. '''Adrenaline (epinephrine) for the treatment of anaphylaxis with and without shock.''' ''Cochrane Database of Systematic Reviews'' 2008, Issue 4. Art. No.: CD006312. DOI:10.1002/14651858.CD006312.pub2</ref>
###Give as soon as possible
###Give as soon as possible
###Always IM initially  
###Always IM initially <ref>Simons FER, Gu X, Simons KJ. '''Epinephrine absorption in adults: Intramuscular versus subcutaneous injection,''' ''J Allergy Clin Immunol'' 2001;108:871-3 </ref>
###If response to IM is inadequate: give epinephrine infusion 1:10,000 2 - 10 µg/min
###If response to IM is inadequate: give epinephrine infusion 1:10,000 2 - 10 µg/min
###'''How to make a quick epi drip:''' ''Take your code-cart epi (it doesn't matter if it's 1:1,000 or 1:10,000) and inject 1mg into a liter bag of NS.  Final concentration is 1mcg/ml.  Run at 1cc/min and titrate to effect''.
###'''How to make a quick epi drip:''' ''Take your code-cart epi (it doesn't matter if it's 1:1,000 or 1:10,000) and inject 1mg into a liter bag of NS.  Final concentration is 1mcg/ml.  Run at 1cc/min and titrate to effect''.
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===Expected Course===
===Expected Course===
====Uniphasic (80-90%)====
====Uniphasic (80-90%)====
**Symptoms peak within 30 minutes to 1 hour after onset, resolve within 30 minutes to 1 hour of receiving treatment
**Symptoms peak within 30 minutes to 1 hour after onset, resolve within 30 minutes to 1 hour of receiving treatment<ref>Ewan PW. '''ABC of allergies – Anaphylaxis,''' ''BMJ'' 1998; 316: 1442-1445 </ref>
====Biphasic (10-20%)====
====Biphasic (10-20%)====
**Uniphasic response, followed by asymptomatic period of hour or more, then return of symptoms
**Uniphasic response, followed by asymptomatic period of hour or more, then return of symptoms
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*Symptom-free for at least 4 hours and mild initial presentation  
*Symptom-free for at least 4 hours and mild initial presentation  
*Send home with an epinephrine autoinjector! (Epi-Pen)
*Send home with an epinephrine autoinjector! (Epi-Pen)
*Up to 6% of the people with anaphylaxis have a repeat ED visit for anaphylaxis within 7 days<ref name="biphasic">unau BE et al. Incidence of Clinically Important Biphasic Reactions in Emergency Department Patients With Allergic Reactions or Anaphylaxis. Ann Emerg Med. 2013 Nov 13</ref>
*Up to 6% of the people with anaphylaxis have a repeat ED visit for anaphylaxis within 7 days<ref name="biphasic">Grunau BE et al. Incidence of Clinically Important Biphasic Reactions in Emergency Department Patients With Allergic Reactions or Anaphylaxis. Ann Emerg Med. 2013 Nov 13</ref>


=See Also=
=See Also=
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=Sources=
=Sources=
<references/>
<references/>
*Brown SGA, Mullins RJ and Gold MS. '''Anaphylaxis: diagnosis and management,''' ''MJA'' 2006; 185: 283–289 
 
*Ewan PW. '''ABC of allergies – Anaphylaxis,''' ''BMJ'' 1998; 316: 1442-1445
*Simons FER, Gu X, Simons KJ. '''Epinephrine absorption in adults: Intramuscular versus subcutaneous injection,''' ''J Allergy Clin Immunol'' 2001;108:871-3
*Lieberman P et al. '''The diagnosis and management of anaphyalxis: An updated practice parameter,''' ''J Allergy Clin Immunol'' 2005;115;3:S483-S523
*Sheikh A, Shehata YA, Brown SGA, Simons FER. '''Adrenaline (epinephrine) for the treatment of anaphylaxis with and without shock.''' ''Cochrane Database of Systematic Reviews'' 2008, Issue 4. Art. No.: CD006312. DOI:10.1002/14651858.CD006312.pub2
*'''Second symposium on the definition and management of anaphylaxis: summary report'''--Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network symposium.




[[Category:Airway/Resus]]
[[Category:Airway/Resus]]
[[Category:Critical Care]]
[[Category:Critical Care]]

Revision as of 23:03, 4 January 2015

Background

Definition

Anaphylaxis is highly likely when ANY ONE of the following criteria is fulfilled[1][2]

Criterion 1 (90% of patients)

  1. Acute onset of an illness involving the skin, mucosal tissue, or both AND at least one of the following:
    1. Respiratory Compromise
    2. Reduced blood pressure or associated symptoms (Syncope, Dizziness)

Criterion 2 (10-20% of pts)

  1. TWO OR MORE of the following that that occur rapidly after exposure to a LIKELY allergen for that patient
    1. Involvement of the skin-mucosal tissue (hives, swollen lips-tongue-uvula)
    2. Respiratory compromise
    3. Hypotension or associated symptoms
    4. Persistent gastrointestinal symptoms: (vomiting, diarrhea, crampy abdominal pain)

Criterion 3

  1. Hypotension after exposure to a KNOWN allergy for that patient (minutes to hours):
    1. Adults: systolic blood pressure (SBP) <90 mmHg or >30% reduction from baseline
    2. Pediatrics
      1. 1 month - 1 year: SBP <70 mmHg
      2. 1 year - 10 years: SBP <(70 mmHg + [2 x age])
      3. 11 years - 17 years: SBP <90 mmHg

Clinical Features

Raised urticaria
Angioedema of tongue
  • Cutaneous symptoms: 90%
  • Respiratory symptoms: 70%
  • Gastrointestinal symptoms: 40%
  • Cardiovascular symptoms: 35%

Differential Diagnosis

Acute allergic reaction

Management

  1. Epinephrine
    1. 1:1000 IM 0.3 - 0.5mg (0.3 - 0.5mL) every 5 - 15 minutes[3][4]
      1. Give as soon as possible
      2. Always IM initially [5]
      3. If response to IM is inadequate: give epinephrine infusion 1:10,000 2 - 10 µg/min
      4. How to make a quick epi drip: Take your code-cart epi (it doesn't matter if it's 1:1,000 or 1:10,000) and inject 1mg into a liter bag of NS. Final concentration is 1mcg/ml. Run at 1cc/min and titrate to effect.
    2. Pediatric: Epinephrine 1:1000 0.01 mg/kg (max 0.5mg) IM every 5 to 15 minutes
      1. IV infusion: 0.05 - 1 mcg/kg/min
  2. Supplemental oxygen
    1. Consider endotracheal intubation if airway edema present
  3. Normal saline bolus
    1. If unresponsive to epinephrine assume distributive shock and give 1 - 2 liters of normal saline
  4. Glucagon
    1. 1 - 2mg IV over 5 minutes followed by infusion of 5 - 15 µg/min
    2. If taking beta-blocker AND unresponsive to epinephrine
  5. Also consider
    1. Albuterol
      1. for bronchospasm resistant to IM epinephrine
    2. Antihistamines (for symptom control AFTER hemodynamically stable)
      1. Diphenhydramine: 25 to 50 mg IV
      2. Ranitidine: 50 mg IV (Has been found to improve urticaria but not angioedema at 2 hours[6])
    3. Glucocorticoid
      1. MAY blunt biphasic reaction although little evidence to support usage[7]
      2. Methylprednisolone: *125 mg IV (2mg/kg in children)
      3. Dexamethasone: 10mg IV or PO (0.6mg/kg in children)

Expected Course

Uniphasic (80-90%)

    • Symptoms peak within 30 minutes to 1 hour after onset, resolve within 30 minutes to 1 hour of receiving treatment[8]

Biphasic (10-20%)

    • Uniphasic response, followed by asymptomatic period of hour or more, then return of symptoms
    • The second phase does not necessarily resemble the first!
    • More likely with a severe initial presentation, hypotension, and recurrent epinephrine dosing requirements in the emergency department[9]
    • Little evidence to support the use of discharge steroids to prevent a biphasic reaction
    • 0.4% of patients with anaphylaxis had a rebound event while in the ED[10]

Disposition

Admit

Severe and moderate presentations especially if symptoms did not respond promptly to epinephrine or required repeat dosing

Discharge

  • Symptom-free for at least 4 hours and mild initial presentation
  • Send home with an epinephrine autoinjector! (Epi-Pen)
  • Up to 6% of the people with anaphylaxis have a repeat ED visit for anaphylaxis within 7 days[10]

See Also

Sources

  1. ↑ Brown SGA, Mullins RJ and Gold MS. Anaphylaxis: diagnosis and management, MJA 2006; 185: 283–289
  2. ↑ Lieberman P et al. The diagnosis and management of anaphyalxis: An updated practice parameter, J Allergy Clin Immunol 2005;115;3:S483-S523
  3. ↑ Dhami S. et al. Management of anaphylaxis: a systematic review. Allergy. 69 (2014) 168–175. http://onlinelibrary.wiley.com/store/10.1111/all.12318/asset/all12318.pdf?v=1&t=hrspdbpk&s=8067bfd5903c7ffebf4a274f062a71633ebe0507
  4. ↑ Sheikh A, Shehata YA, Brown SGA, Simons FER. Adrenaline (epinephrine) for the treatment of anaphylaxis with and without shock. Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD006312. DOI:10.1002/14651858.CD006312.pub2
  5. ↑ Simons FER, Gu X, Simons KJ. Epinephrine absorption in adults: Intramuscular versus subcutaneous injection, J Allergy Clin Immunol 2001;108:871-3
  6. ↑ Lin, RY et al. Improved Outcomes in Patients With Acute Allergic Syndromes Who Are Treated With Combined H1 and H2 Antagonists. Annals of Emergency Medicine. 36:5 NOVEMBER 2000.
  7. ↑ Choo KJ, Simons E, Sheikh A: Glucocorticoids for the treatment of anaphylaxis: Cochrane systematic review. Allergy 2010; 65:1205-1211.
  8. ↑ Ewan PW. ABC of allergies – Anaphylaxis, BMJ 1998; 316: 1442-1445
  9. ↑ Ellis AK, Day JH: Incidence and characteristics of biphasic anaphylaxis: A prospective evaluation of 103 patients. Ann Allergy Asthma Immunology. 2007; 98:64-69
  10. ↑ 10.0 10.1 Grunau BE et al. Incidence of Clinically Important Biphasic Reactions in Emergency Department Patients With Allergic Reactions or Anaphylaxis. Ann Emerg Med. 2013 Nov 13
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