Anaphylaxis: Difference between revisions
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==Background==
=Definition=
===Definition===
Anaphylaxis is highly likely when ANY ONE of the following criteria is fulfilled
Highly likely when ANY ONE of the following criteria is fulfilled:
#Criterion 1 (90% of pts)
##Acute onset of an illness involving the skin, mucosal tissue, or both AND at least one of the following:
###Respiratory Compromise
###Reduced BP or associated symptoms ([[Syncope]], [[Dizziness]])
#Criterion 2 (10-20% of pts)
##TWO OR MORE of the following that that occur rapidly after exposure to a LIKELY allergen for that pt
###Involvement of the skin-mucosal tissue (hives, swollen lips-tongue-uvula)
###Respiratory Compromise
###[[Reduced BP]] or associated symptoms
###Persistent GI symptoms ([[Vomiting]], [[Diarrhea]], crampy [[Abd Pain]])
#Criterion 3
##[[Reduced BP]] after exposure to a KNOWN allergy for that pt (minutes to hours):
###Adults
####Systolic < 90 or > 30% from baseline
###Peds
####Less than 70 mmHg from 1 month up to 1 year
####Less than (70 mmHg + [2 x age]) from 1 to 10 years
####Less than 90 mmHg from 11 to 17 years


===Course===
Criterion 1 (90% of patients)
#Uniphasic (80-90%)
#Acute onset of an illness involving the skin, mucosal tissue, or both AND at least one of the following:
##Symptoms peak within 30min-1hr after onset, resolves within 30min-1hr of receiving Tx
##Respiratory Compromise
#Biphasic (10-20%)
##Reduced blood pressure or associated symptoms ([[Syncope]], [[Dizziness]])
##Uniphasic response, followed by asymptomatic period of hour or more, then return of symptoms
 
##The second phase does not necessarily resemble the first!
Criterion 2 (10-20% of pts)
##Possible risk factors
#TWO OR MORE of the following that that occur rapidly after exposure to a LIKELY allergen for that patient
###Severe initial symptoms
##Involvement of the skin-mucosal tissue (hives, swollen lips-tongue-uvula)
###Late administration of epi
##Respiratory compromise
###Delayed resolution of initial symptoms
##[[Reduced BP|Hypotension]] or associated symptoms
##Little evidence that glucocorticoids blunt a biphasic presentation
##Persistent gastrointestinal symptoms: ([[Vomiting|vomiting]], [[Diarrhea|diarrhea]], crampy [[Abd Pain|abdominal pain]])
#Protracted (case reports)
 
##Lasts hours to days without resolving completely
Criterion 3
#[[Reduced BP|Hypotension]] after exposure to a KNOWN allergy for that patient (minutes to hours):
##Adults: systolic blood pressure (SBP) <90 mmHg or >30% reduction from baseline
##Pediatrics
###1 month - 1 year: SBP <70 mmHg
###1 year - 10 years: SBP <(70 mmHg + [2 x age])
###11 years - 17 years: SBP <90 mmHg


==DDX==
=Differential Diagnosis=
#Generalized urticaria
#Generalized urticaria
#[[Angioedema]]
#[[Angioedema]]
#[[Asthma]] exacerbation
#[[Asthma]] exacerbation
#Anxiety attack
#Anxiety attack
#[[MI]]
#[[MI|Acute Coronary Syndromes]]
#Scombroidosis  
#Scombroidosis  
#Other forms of shock
#Other forms of shock


==Diagnosis==
=Presentation=
===Presentation===
*Cutaneous symptoms: 90%
* Cutaneous symptoms - 90%
*Respiratory symptoms: 70%
* Respiratory symptoms - 70%
*Gastrointestinal symptoms: 40%
* GI symptoms - 40%
*Cardiovascular symptoms: 35%
* Cardiovascular symptoms - 35%


==Treatment==
=Treatment=
#[[Epinephrine]] 1:1000 '''IM''' 0.3-0.5mg (0.3-0.5mL) Q5-15min
#[[Epinephrine]] 1:1000 '''IM''' 0.3 - 0.5mg (0.3 - 0.5mL) every 5 - 15 minutes
##Give as soon as possible
##Give as soon as possible
##Always IM initially  
##Always IM initially  
##Start epinephrine infusion 1:10,000 2-10µg/min if inadequate response to IM
##If response to IM is inadequate: give epinephrine infusion 1:10,000 2 - 10 µg/min
##Peds
#Pediatric:[[Epinephrine]] 1:1000 '''IM''' 0.01 mg/kg (max 0.5mg) every 5 to 15 minutes
###IM - 0.01mg/kg/dose (max 0.5mg)
##IV infusion: 0.05 - 1 mcg/kg/min
###IV infusion - 0.05-1 mcg/kg/min
#Supplemental oxygen
#Oxygen
##Consider [[Intubation|endotracheal intubation]] if airway edema present
##Consider [[Intubation]] if e/o airway edema
#Normal saline bolus
#NS bolus
##If unresponsive to [[Epi]|epinephrine] assume distributive [[Shock|shock]] and give 1 - 2 liters of normal saline
##If unresponsive to [[Epi]] assume distributive [[Shock]] (give NS 1-2L)
#Glucagon 1 - 2mg IV over 5 minutes followed by infusion of 5 - 15 µg/min
#Glucagon 1-2mg IV over 5 min followed by infusion of 5-15µg/min
##If taking beta-blocker AND unresponsive to [[Epi|epinephrine]]  
##If on B-blocker AND unresponsive to [[Epi]]  
#Also consider:
#Also consider:
##Albuterol: For bronchospasm resistant to IM epinephrine
##Albuterol: for bronchospasm resistant to IM epinephrine
##Antihistamines
##Antihistamines: only for sympton control (hives, itching) AFTER hemodynamically stable
###Only for sympton control (hives, itching) AFTER hemodynamically stable
###Diphenhydramine 25 to 50 mg IV
####Diphenhydramine 25 to 50 mg IV
###Ranitidine 50 mg IV (minimal evidence to support this)
####Ranitidine 50 mg IV (minimal evidence to support this)
##Glucocorticoid: MAY blunt biphasic reaction
##Glucocorticoid: May blunt biphasic reaction
###Methylprednisolone 125 mg IV (2mg/kg in children)
###Methylprednisolone 125 mg IV (2mg/kg in peds)
###Three days oral steroid: biphasic reaction always occurs within 72 hours
###Three day PO course (biphasic reaction always occurs within 72hrs)
 
=Course=
#Uniphasic (80-90%)
##Symptoms peak within 30 minutes to 1 hour after onset, resolve within 30 minutes to 1 hour of receiving treatment
#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!
##Possible risk factors
###Severe initial symptoms
###Late administration of epineprhine
###Delayed resolution of initial symptoms
##Little evidence that glucocorticoids blunt a biphasic presentation
#Protracted (case reports)
##Lasts hours to days without resolving completely


==Disposition==
=Disposition=
#Admit: Severe and moderate (especially if symptoms did not respond promptly to epi)
#Admit: Severe and moderate, especially if symptoms did not respond promptly to epinephrine
#Home: Symptom-free for at least 4hr
#Home: Symptom-free for at least 4 hours
##Send home with an epi autoinjector!
##Send home with an epinephrine autoinjector! (Epi-Pen, Auvi-Q, etc)


==See Also==
=See Also=
*[[Allergic Reaction]]
*[[Allergic Reaction]]
*[[Angioedema (Upper Airway)]]
*[[Angioedema (Upper Airway)]]


==Sources==
=Sources=
* Brown SGA, Mullins RJ and Gold MS, Anaphylaxis: diagnosis and management, MJA 2006; 185: 283–289   
*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  
*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  
*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  
*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 Reviews2008, Issue 4. Art. No.: CD006312. DOI:10.1002/14651858.CD006312.pub2
*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.
*'''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.
* Tintinalli's  Emergency Medicine
*Tintinalli's  Emergency Medicine


[[Category:Airway/Resus]]
[[Category:Airway/Resus]]

Revision as of 12:29, 25 August 2013

Definition

Anaphylaxis is highly likely when ANY ONE of the following criteria is fulfilled

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

Differential Diagnosis

  1. Generalized urticaria
  2. Angioedema
  3. Asthma exacerbation
  4. Anxiety attack
  5. Acute Coronary Syndromes
  6. Scombroidosis
  7. Other forms of shock

Presentation

  • Cutaneous symptoms: 90%
  • Respiratory symptoms: 70%
  • Gastrointestinal symptoms: 40%
  • Cardiovascular symptoms: 35%

Treatment

  1. Epinephrine 1:1000 IM 0.3 - 0.5mg (0.3 - 0.5mL) every 5 - 15 minutes
    1. Give as soon as possible
    2. Always IM initially
    3. If response to IM is inadequate: give epinephrine infusion 1:10,000 2 - 10 µg/min
  2. Pediatric:Epinephrine 1:1000 IM 0.01 mg/kg (max 0.5mg) every 5 to 15 minutes
    1. IV infusion: 0.05 - 1 mcg/kg/min
  3. Supplemental oxygen
    1. Consider endotracheal intubation if airway edema present
  4. Normal saline bolus
    1. If unresponsive to [[Epi]|epinephrine] assume distributive shock and give 1 - 2 liters of normal saline
  5. Glucagon 1 - 2mg IV over 5 minutes followed by infusion of 5 - 15 µg/min
    1. If taking beta-blocker AND unresponsive to epinephrine
  6. Also consider:
    1. Albuterol: for bronchospasm resistant to IM epinephrine
    2. Antihistamines: only for sympton control (hives, itching) AFTER hemodynamically stable
      1. Diphenhydramine 25 to 50 mg IV
      2. Ranitidine 50 mg IV (minimal evidence to support this)
    3. Glucocorticoid: MAY blunt biphasic reaction
      1. Methylprednisolone 125 mg IV (2mg/kg in children)
      2. Three days oral steroid: biphasic reaction always occurs within 72 hours

Course

  1. Uniphasic (80-90%)
    1. Symptoms peak within 30 minutes to 1 hour after onset, resolve within 30 minutes to 1 hour of receiving treatment
  2. Biphasic (10-20%)
    1. Uniphasic response, followed by asymptomatic period of hour or more, then return of symptoms
    2. The second phase does not necessarily resemble the first!
    3. Possible risk factors
      1. Severe initial symptoms
      2. Late administration of epineprhine
      3. Delayed resolution of initial symptoms
    4. Little evidence that glucocorticoids blunt a biphasic presentation
  3. Protracted (case reports)
    1. Lasts hours to days without resolving completely

Disposition

  1. Admit: Severe and moderate, especially if symptoms did not respond promptly to epinephrine
  2. Home: Symptom-free for at least 4 hours
    1. Send home with an epinephrine autoinjector! (Epi-Pen, Auvi-Q, etc)

See Also

Sources

  • 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.
  • Tintinalli's Emergency Medicine
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