Anaphylaxis: Difference between revisions
Line 38: Line 38:
==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><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>
#*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 <ref>Simons FER, Gu X, Simons KJ. '''Epinephrine absorption in adults: Intramuscular versus subcutaneous injection,''' ''J Allergy Clin Immunol'' 2001;108:871-3 </ref>
#**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''.
##Pediatric: [[Epinephrine]] '''1:1000 0.01 mg/kg (max 0.5mg) IM''' every 5 to 15 minutes
#*Pediatric: [[Epinephrine]] '''1:1000 0.01 mg/kg (max 0.5mg) IM''' every 5 to 15 minutes
###IV infusion: 0.05 - 1 mcg/kg/min
#**IV infusion: 0.05 - 1 mcg/kg/min
#'''Supplemental oxygen'''
#'''Supplemental oxygen'''
##''Consider [[Intubation|endotracheal intubation]] if airway edema present''
#*''Consider [[Intubation|endotracheal intubation]] if airway edema present''
#'''Normal saline bolus'''
#'''Normal saline bolus'''
##If unresponsive to [[epinephrine]] assume distributive [[Shock|shock]] and give 1 - 2 liters of normal saline
#*If unresponsive to [[epinephrine]] assume distributive [[Shock|shock]] and give 1 - 2 liters of normal saline
#'''[[Glucagon]]'''
##1 - 2mg IV over 5 minutes followed by infusion of 5 - 15 µg/min
##If taking beta-blocker AND unresponsive to [[Epi|epinephrine]]
#'''Also consider'''
#'''Also consider'''
##[[Albuterol]]
##[[Albuterol]]
###for bronchospasm resistant to IM epinephrine
##*for bronchospasm resistant to IM epinephrine
##[[Antihistamines]] (for symptom control AFTER hemodynamically stable)
##[[Antihistamines]] (for symptom control AFTER hemodynamically stable)
###[[Diphenhydramine]]: 25 to 50 mg IV
##*[[Diphenhydramine]]: 25 to 50 mg IV
###[[Ranitidine]]: 50 mg IV (Has been found to improve urticaria but not angioedema at 2 hours<ref>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.</ref>)
##*[[Ranitidine]]: 50 mg IV (has been found to improve urticaria but not angioedema at 2 hours<ref>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.</ref>)
##Glucocorticoid
##Glucocorticoid
###MAY blunt biphasic reaction although little evidence to support usage<ref>Choo KJ, Simons E, Sheikh A: Glucocorticoids for the treatment of anaphylaxis: Cochrane systematic review. Allergy 2010; 65:1205-1211.</ref>
##*MAY blunt biphasic reaction although little evidence to support usage<ref>Choo KJ, Simons E, Sheikh A: Glucocorticoids for the treatment of anaphylaxis: Cochrane systematic review. Allergy 2010; 65:1205-1211.</ref>
###[[Methylprednisolone]]: *125 mg IV (2mg/kg in children)
##*[[Methylprednisolone]]: 125 mg IV (2mg/kg in children)
###[[Dexamethasone]]: 10mg IV or PO (0.6mg/kg in children)
##*[[Dexamethasone]]: 10mg IV or PO (0.6mg/kg in children)
##Consider '''vasopressin 2-8 units''' for persistent refractory shock (case series only)<ref>Schummer et al. The Pivotal Role of Vasopressin in Refractory Anaphylactic Shock. Anesthesia & Analgesia: August 2008 - Volume 107 - Issue 2 - pp 620-624.</ref><ref>Dünser et al. Treatment of Anaphylactic Shock: Where Is the Evidence? Anesthesia & Analgesia: August 2008 - Volume 107 - Issue 2 - pp 359-361</ref>
##[[Glucagon]]
##*1 - 2mg IV over 5 minutes followed by infusion of 5 - 15 µg/min
##*If taking beta-blocker AND unresponsive to [[Epi|epinephrine]]
##Consider adding additional pressor support if persistent hypotension present
##Consider adding additional pressor support if persistent hypotension present
##*For example: '''vasopressin 2-8 units''' for persistent refractory shock (case series only)<ref>Schummer et al. The Pivotal Role of Vasopressin in Refractory Anaphylactic Shock. Anesthesia & Analgesia: August 2008 - Volume 107 - Issue 2 - pp 620-624.</ref><ref>Dünser et al. Treatment of Anaphylactic Shock: Where Is the Evidence? Anesthesia & Analgesia: August 2008 - Volume 107 - Issue 2 - pp 359-361</ref>


==Expected Course==
==Expected Course==

Revision as of 23:29, 27 March 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

Shock

Management

  1. Epinephrine
    • 1:1000 IM 0.3 - 0.5mg (0.3 - 0.5mL) every 5 - 15 minutes[3][4]
      • Give as soon as possible
      • Always IM initially [5]
      • 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.
    • Pediatric: Epinephrine 1:1000 0.01 mg/kg (max 0.5mg) IM every 5 to 15 minutes
      • IV infusion: 0.05 - 1 mcg/kg/min
  2. Supplemental oxygen
  3. Normal saline bolus
    • If unresponsive to epinephrine assume distributive shock and give 1 - 2 liters of normal saline
  4. Also consider
    1. Albuterol
      • for bronchospasm resistant to IM epinephrine
    2. Antihistamines (for symptom control AFTER hemodynamically stable)
    3. Glucocorticoid
      • MAY blunt biphasic reaction although little evidence to support usage[7]
      • Methylprednisolone: 125 mg IV (2mg/kg in children)
      • Dexamethasone: 10mg IV or PO (0.6mg/kg in children)
    4. Glucagon
      • 1 - 2mg IV over 5 minutes followed by infusion of 5 - 15 µg/min
      • If taking beta-blocker AND unresponsive to epinephrine
    5. Consider adding additional pressor support if persistent hypotension present
      • For example: vasopressin 2-8 units for persistent refractory shock (case series only)[8][9]

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[10]

Biphasic (10-20%)

Biphasic reactions are rare and can occur anywhere from 10 minutes up to six days after an initial reaction.[11]

    • 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[12]
    • 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[13]

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[13]

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. ↑ Schummer et al. The Pivotal Role of Vasopressin in Refractory Anaphylactic Shock. Anesthesia & Analgesia: August 2008 - Volume 107 - Issue 2 - pp 620-624.
  9. ↑ Dünser et al. Treatment of Anaphylactic Shock: Where Is the Evidence? Anesthesia & Analgesia: August 2008 - Volume 107 - Issue 2 - pp 359-361
  10. ↑ Ewan PW. ABC of allergies – Anaphylaxis, BMJ 1998; 316: 1442-1445
  11. ↑ Milne K. Biphasic Allergic Reactions: Observation, Treatment Guidelines http://www.acepnow.com/article/biphasic-allergic-reactions-observation-treatment-guidelines/
  12. ↑ Ellis AK, Day JH: Incidence and characteristics of biphasic anaphylaxis: A prospective evaluation of 103 patients. Ann Allergy Asthma Immunology. 2007; 98:64-69
  13. ↑ 13.0 13.1 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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