Anaphylaxis resident survival guide: Difference between revisions
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{{familytree | | | | | | | | H01 | | H02 | | |H01=No |H02=<div style="float: left; text-align: left"> ❑ Establish IV access <br> ❑ Give 1-2 litres of 0.9% saline rapidly, 5-10 ml/Kg in first 5-10 mins <br> ❑ Give vasopressors (dopamine) 400mg in 500ml of 5% dextrose at 2-20 mg/kg/min to maintain a target systolic BP > 90 mm Hg </div> }} | {{familytree | | | | | | | | H01 | | H02 | | |H01=No |H02=<div style="float: left; text-align: left"> ❑ Establish IV access <br> ❑ Give 1-2 litres of 0.9% saline rapidly, 5-10 ml/Kg in first 5-10 mins <br> ❑ Give vasopressors (dopamine) 400mg in 500ml of 5% dextrose at 2-20 mg/kg/min to maintain a target systolic BP > 90 mm Hg </div> }} | ||
{{familytree | | | | | | | | |!| | | |!| | | | }} | {{familytree | | | | | | | | |!| | | |!| | | | }} | ||
{{familytree | | | | | | | | I01 |-|-|'| | | |I01=<div style="float: left; text-align: left"> Secondary therapy after epinephrine '''(evidence not clear)''' <br> H1 antihistaminics: <br> ❑ Diphenhydramine IM or slow intravenous infusion - 25 to 50 mg in adults, and 1 mg/kg up to 50 mg in children | {{familytree | | | | | | | | I01 |-|-|'| | | |I01=<div style="float: left; text-align: left"> Secondary therapy after epinephrine '''(evidence not clear)'''<ref name="Mayumi-1987">{{Cite journal | last1 = Mayumi | first1 = H. | last2 = Kimura | first2 = S. | last3 = Asano | first3 = M. | last4 = Shimokawa | first4 = T. | last5 = Au-Yong | first5 = TF. | last6 = Yayama | first6 = T. | title = Intravenous cimetidine as an effective treatment for systemic anaphylaxis and acute allergic skin reactions. | journal = Ann Allergy | volume = 58 | issue = 6 | pages = 447-50 | month = Jun | year = 1987 | doi = | PMID = 3592313 }}</ref> | ||
<ref name="Lin-2000">{{Cite journal | last1 = Lin | first1 = RY. | last2 = Curry | first2 = A. | last3 = Pesola | first3 = GR. | last4 = Knight | first4 = RJ. | last5 = Lee | first5 = HS. | last6 = Bakalchuk | first6 = L. | last7 = Tenenbaum | first7 = C. | last8 = Westfal | first8 = RE. | title = Improved outcomes in patients with acute allergic syndromes who are treated with combined H1 and H2 antagonists. | journal = Ann Emerg Med | volume = 36 | issue = 5 | pages = 462-8 | month = Nov | year = 2000 | doi = 10.1067/mem.2000.109445 | PMID = 11054200 }}</ref> | |||
<ref name="Runge-1992">{{Cite journal | last1 = Runge | first1 = JW. | last2 = Martinez | first2 = JC. | last3 = Caravati | first3 = EM. | last4 = Williamson | first4 = SG. | last5 = Hartsell | first5 = SC. | title = Histamine antagonists in the treatment of acute allergic reactions. | journal = Ann Emerg Med | volume = 21 | issue = 3 | pages = 237-42 | month = Mar | year = 1992 | doi = | PMID = 1536481 }}</ref> | |||
<ref name="Lieberman-2010">{{Cite journal | last1 = Lieberman | first1 = P. | last2 = Nicklas | first2 = RA. | last3 = Oppenheimer | first3 = J. | last4 = Kemp | first4 = SF. | last5 = Lang | first5 = DM. | last6 = Bernstein | first6 = DI. | last7 = Bernstein | first7 = JA. | last8 = Burks | first8 = AW. | last9 = Feldweg | first9 = AM. | title = The diagnosis and management of anaphylaxis practice parameter: 2010 update. | journal = J Allergy Clin Immunol | volume = 126 | issue = 3 | pages = 477-80.e1-42 | month = Sep | year = 2010 | doi = 10.1016/j.jaci.2010.06.022 | PMID = 20692689 }}</ref> | |||
<br> H1 antihistaminics: <br> ❑ Diphenhydramine IM or slow intravenous infusion - 25 to 50 mg in adults, and 1 mg/kg up to 50 mg in children | |||
---- | ---- | ||
H2 antihistaminics: <br> ❑ Ranitidine - 1 mg/kg in adults, and 12.5 to 50 mg in children IV or IM </div>}} | H2 antihistaminics: <br> ❑ Ranitidine - 1 mg/kg in adults, and 12.5 to 50 mg in children IV or IM </div>}} | ||
| Line 69: | Line 73: | ||
❑ Provide auto-injectable epinephrine and action plan for future events at discharge </div> }} | ❑ Provide auto-injectable epinephrine and action plan for future events at discharge </div> }} | ||
{{familytree/end}} | {{familytree/end}} | ||
==References== | ==References== | ||
Revision as of 14:41, 17 January 2014
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Vidit Bhargava, M.B.B.S [2]
Definition
An acute, severe, potentially life threatening type 1 hypersensitivity reaction, following repeated exposure to an allergen to which an individual is already sensitised.
Causes
Life Threatening Causes
Any of the factors precipitating anaphylaxis can be life threatening. The list of substances that cause anaphylaxis is non-exhaustive and it is beyond our scope to mention all. Use caution:
- Food: Peanuts, Tree nuts, walnuts, pecans, milk, soyabean, wheat, eggs, pistachios, filberts, cashews, almonds, etc.
- Shellfish: crab, crayfish, prawns, shrimp, lobster, etc.
- Medications: Penicillin, Sulfa antibiotics, Allopurinol, and many other drugs
- Diagnostic materials: IV contrast material and dyes
- Insect venom: including bees, wasps, ants
- Natural rubber latex
- Idiopathic/ Coital anaphylaxis
Diagnostic Criteria
It is diagnosed with one of the following criteria:[1]
♦ Acute onset of a reaction (mins to hours) involving skin, mucous membrane or both. Additionally including atleast one of the following:
- Respiratory compromise or
- Cardiovascular compromise/Evidence of end organ dysfunction.
♦ 2 or more of the following in a patient known to come in contact with an established allergen:
- Skin/mucosal tissue involvement
- Respiratory compromise
- Reduced blood pressure
- Gastrointestinal manifestations
♦ Reduced blood pressure after exposure to a known allergen.
Management
Shown below is an algorithm summarizing the approach to [[Anaphylaxis]].
Characterize the symptoms & signs: Skin, subcutaneous tissue and mucosa: ❑ Flushing, itching, urticaria, angioedema, rash, piloerection ❑ Periorbital itching, erythema and edema; conjunctival erythema, tearing Respiratory: Gastrointenstinal: Cardiovascular: Central nervous system: ❑ Anxiety, irritability ❑ Throbbing headache ❑ Altered vision and mental status | |||||||||||||||||||||||||||||||||
Consider alternative diagnosis: ❑ Acute asthma ❑ Anxiety/Panic attack ❑ Syncope | |||||||||||||||||||||||||||||||||
| Remove patient from exposure/trigger | |||||||||||||||||||||||||||||||||
Do all 3 simultaneously ❑ Call for help ❑ Inject aqueous epinephrine (adrenaline) IM in the mid-anterolateral aspect of the thigh, 0.01 mg/kg of a 1:1,000 (1 mg/mL) solution Maximum dose 0.5 mg (adult) or 0.3 mg (child) Record the time of the dose and repeat it in 5-10 minutes, if needed or ❑ Intravenous epinephrine: In patients with hypotension/cardiorespiratory arrest and those not responding
| |||||||||||||||||||||||||||||||||
| Yes | Patient has one of the following? ❑ Respiratory distress ❑ Recieved repeated doses of epinephrine ❑ Asthma/other respiratory disease ❑ Co-existing cardiovascular disease | ||||||||||||||||||||||||||||||||
| ❑ Give high flow supplemental oxygen (6-8 L/min) | No | ||||||||||||||||||||||||||||||||
| Patient hypotensive despite epinephrine? | Yes | ||||||||||||||||||||||||||||||||
| No | ❑ Establish IV access ❑ Give 1-2 litres of 0.9% saline rapidly, 5-10 ml/Kg in first 5-10 mins ❑ Give vasopressors (dopamine) 400mg in 500ml of 5% dextrose at 2-20 mg/kg/min to maintain a target systolic BP > 90 mm Hg | ||||||||||||||||||||||||||||||||
❑ Observe the patient for biphasic anaphylaxis
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References
- ↑ Sampson, HA.; Muñoz-Furlong, A.; Campbell, RL.; Adkinson, NF.; Bock, SA.; Branum, A.; Brown, SG.; Camargo, CA.; Cydulka, R. (2006). "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". J Allergy Clin Immunol. 117 (2): 391–7. doi:10.1016/j.jaci.2005.12.1303. PMID 16461139. Unknown parameter
|month=ignored (help) - ↑ Mayumi, H.; Kimura, S.; Asano, M.; Shimokawa, T.; Au-Yong, TF.; Yayama, T. (1987). "Intravenous cimetidine as an effective treatment for systemic anaphylaxis and acute allergic skin reactions". Ann Allergy. 58 (6): 447–50. PMID 3592313. Unknown parameter
|month=ignored (help) - ↑ Lin, RY.; Curry, A.; Pesola, GR.; Knight, RJ.; Lee, HS.; Bakalchuk, L.; Tenenbaum, C.; Westfal, RE. (2000). "Improved outcomes in patients with acute allergic syndromes who are treated with combined H1 and H2 antagonists". Ann Emerg Med. 36 (5): 462–8. doi:10.1067/mem.2000.109445. PMID 11054200. Unknown parameter
|month=ignored (help) - ↑ Runge, JW.; Martinez, JC.; Caravati, EM.; Williamson, SG.; Hartsell, SC. (1992). "Histamine antagonists in the treatment of acute allergic reactions". Ann Emerg Med. 21 (3): 237–42. PMID 1536481. Unknown parameter
|month=ignored (help) - ↑ Lieberman, P.; Nicklas, RA.; Oppenheimer, J.; Kemp, SF.; Lang, DM.; Bernstein, DI.; Bernstein, JA.; Burks, AW.; Feldweg, AM. (2010). "The diagnosis and management of anaphylaxis practice parameter: 2010 update". J Allergy Clin Immunol. 126 (3): 477-80.e1-42. doi:10.1016/j.jaci.2010.06.022. PMID 20692689. Unknown parameter
|month=ignored (help)