Anaphylaxis medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1], Associate Editor(s)-in-Chief: Dushka Riaz, MD
Overview
Anaphylaxis is a medical emergency and requires prompt treatment as it can progress to fatal anaphylactic shock. Because it has variable diagnostic criteria that can carry an unpredictable course, the most important point of treatment is not to delay. Intramuscular epinephrine is the medication of choice and should be used promptly. Long-term management includes avoidance of triggers after confirmation for the cause from an allergist. Patients should be advised to carry self-injectable epinephrine in case of recurrent episodes. [1]
Medical Therapy
Anaphylaxis is a life-threatening medical emergency because of rapid constriction of the airway, and can lead to respiratory failure. The first step is to remove the patient from exposure to the potential allergen. The patient should then be evaluated for airway, breathing and cardiovascular compromise. [2] [3] [4] [5]
Another treatment for anaphylaxis is the administration of epinephrine (adrenaline). This is the treatment of choice. Epinephrine acts on Beta-2 adrenergic receptors in the lung as a powerful bronchodilator. Tachycardia can result from stimulation of Beta-1 adrenergic receptors. [6] [7] [8] [9] After administration of epinephrine, the patient should be placed supine and their vital signs should be monitored. If supplemental oxygen and intravenous fluid are indicated they should be administered. [10] [11]
Repetitive administration of epinephrine can cause tachycardia which can be fatal. Therefore protocols advise intramuscular injection of only 0.3–0.5mL of a 1:1,000 dilution. Some patients with severe allergies carry preloaded syringes containing epinephrine, diphenhydramine, and dexamethasone which can prevent anaphylactic reactions. [12] [13] [1] [14] [15]
Paramedic treatment in the field includes administration of epinephrine, Benadryl IM, steroids, IV Fluid administration, and vasopressors such as dopamine for hypotension, administration of oxygen, and intubation during transport to advanced medical care. [15] [16] [17]
Antihistamine drugs such as Benadryl (which inhibit the effects of histamine at histamine receptors) are continued but are usually not sufficient in anaphylaxis, and high doses of intravenous corticosteroids such as Decadron or Solu-Medrol are often required. Hypotension is treated with intravenous fluids and vasopressor drugs. For bronchospasm, bronchodilator drugs such as albuterol are used. Supportive care with mechanical ventilation may be required. [1] [18] [19]
The possibility of recurrence of anaphylaxis requires that patients be monitored after stabalization. [20] [3]
References
- ↑ 1.0 1.1 1.2 Alvarez-Perea A, Tanno LK, Baeza ML (2017). "How to manage anaphylaxis in primary care". Clin Transl Allergy. 7: 45. doi:10.1186/s13601-017-0182-7. PMC 5724339. PMID 29238519.
- ↑ Dhami S, Panesar SS, Roberts G, Muraro A, Worm M, Bilò MB; et al. (2014). "Management of anaphylaxis: a systematic review". Allergy. 69 (2): 168–75. doi:10.1111/all.12318. PMID 24251536.
- ↑ 3.0 3.1 Simons FE, Ebisawa M, Sanchez-Borges M, Thong BY, Worm M, Tanno LK; et al. (2015). "2015 update of the evidence base: World Allergy Organization anaphylaxis guidelines". World Allergy Organ J. 8 (1): 32. doi:10.1186/s40413-015-0080-1. PMC 4625730. PMID 26525001.
- ↑ Simons FE (2010). "Anaphylaxis". J Allergy Clin Immunol. 125 (2 Suppl 2): S161–81. doi:10.1016/j.jaci.2009.12.981. PMID 20176258.
- ↑ Dhami S, Sheikh A, Muraro A, Roberts G, Halken S, Fernandez Rivas M; et al. (2017). "Quality indicators for the acute and long-term management of anaphylaxis: a systematic review". Clin Transl Allergy. 7: 15. doi:10.1186/s13601-017-0151-1. PMC 5442671. PMID 28546858.
- ↑ Sheikh A, Ten Broek V, Brown SG, Simons FE (2007). "H1-antihistamines for the treatment of anaphylaxis: Cochrane systematic review". Allergy. 62 (8): 830–7. doi:10.1111/j.1398-9995.2007.01435.x. PMID 17620060.
- ↑ Kemp SF, Lockey RF, Simons FE, World Allergy Organization ad hoc Committee on Epinephrine in Anaphylaxis (2008). "Epinephrine: the drug of choice for anaphylaxis. A statement of the World Allergy Organization". Allergy. 63 (8): 1061–70. doi:10.1111/j.1398-9995.2008.01733.x. PMID 18691308.
- ↑ McLean-Tooke AP, Bethune CA, Fay AC, Spickett GP (2003). "Adrenaline in the treatment of anaphylaxis: what is the evidence?". BMJ. 327 (7427): 1332–5. doi:10.1136/bmj.327.7427.1332. PMC 286326. PMID 14656845.
- ↑ Campbell RL, Bellolio MF, Knutson BD, Bellamkonda VR, Fedko MG, Nestler DM; et al. (2015). "Epinephrine in anaphylaxis: higher risk of cardiovascular complications and overdose after administration of intravenous bolus epinephrine compared with intramuscular epinephrine". J Allergy Clin Immunol Pract. 3 (1): 76–80. doi:10.1016/j.jaip.2014.06.007. PMID 25577622.
- ↑ Muraro A, Roberts G, Worm M, Bilò MB, Brockow K, Fernández Rivas M; et al. (2014). "Anaphylaxis: guidelines from the European Academy of Allergy and Clinical Immunology". Allergy. 69 (8): 1026–45. doi:10.1111/all.12437. PMID 24909803.
- ↑ Kanwar M, Irvin CB, Frank JJ, Weber K, Rosman H (2010). "Confusion about epinephrine dosing leading to iatrogenic overdose: a life-threatening problem with a potential solution". Ann Emerg Med. 55 (4): 341–4. doi:10.1016/j.annemergmed.2009.11.008. PMID 20031267.
- ↑ Pumphrey RS (2003). "Fatal posture in anaphylactic shock". J Allergy Clin Immunol. 112 (2): 451–2. doi:10.1067/mai.2003.1614. PMID 12897756.
- ↑ Soar J, Pumphrey R, Cant A, Clarke S, Corbett A, Dawson P; et al. (2008). "Emergency treatment of anaphylactic reactions--guidelines for healthcare providers". Resuscitation. 77 (2): 157–69. doi:10.1016/j.resuscitation.2008.02.001. PMID 18358585.
- ↑ Simons FE (2004). "First-aid treatment of anaphylaxis to food: focus on epinephrine". J Allergy Clin Immunol. 113 (5): 837–44. doi:10.1016/j.jaci.2004.01.769. PMID 15131564.
- ↑ 15.0 15.1 Simons KJ, Simons FE (2010). "Epinephrine and its use in anaphylaxis: current issues". Curr Opin Allergy Clin Immunol. 10 (4): 354–61. doi:10.1097/ACI.0b013e32833bc670. PMID 20543673.
- ↑ Nurmatov UB, Rhatigan E, Simons FE, Sheikh A (2014). "H2-antihistamines for the treatment of anaphylaxis with and without shock: a systematic review". Ann Allergy Asthma Immunol. 112 (2): 126–31. doi:10.1016/j.anai.2013.11.010. PMID 24468252.
- ↑ Choo KJ, Simons E, Sheikh A (2010). "Glucocorticoids for the treatment of anaphylaxis: Cochrane systematic review". Allergy. 65 (10): 1205–11. doi:10.1111/j.1398-9995.2010.02424.x. PMID 20584003.
- ↑ Ring J, Beyer K, Biedermann T, Bircher A, Duda D, Fischer J; et al. (2014). "Guideline for acute therapy and management of anaphylaxis: S2 Guideline of the German Society for Allergology and Clinical Immunology (DGAKI), the Association of German Allergologists (AeDA), the Society of Pediatric Allergy and Environmental Medicine (GPA), the German Academy of Allergology and Environmental Medicine (DAAU), the German Professional Association of Pediatricians (BVKJ), the Austrian Society for Allergology and Immunology (ÖGAI), the Swiss Society for Allergy and Immunology (SGAI), the German Society of Anaesthesiology and Intensive Care Medicine (DGAI), the German Society of Pharmacology (DGP), the German Society for Psychosomatic Medicine (DGPM), the German Working Group of Anaphylaxis Training and Education (AGATE) and the patient organization German Allergy and Asthma Association (DAAB)". Allergo J Int. 23 (3): 96–112. doi:10.1007/s40629-014-0009-1. PMC 4479483. PMID 26120521.
- ↑ "StatPearls". 2021. PMID 29489197.
- ↑ Manivannan V, Campbell RL, Bellolio MF, Stead LG, Li JT, Decker WW (2009). "Factors associated with repeated use of epinephrine for the treatment of anaphylaxis". Ann Allergy Asthma Immunol. 103 (5): 395–400. doi:10.1016/S1081-1206(10)60358-4. PMC 3723113. PMID 19927537.
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