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ANAPHYLAXIS

History of anaphylaxis

First description of anaphylaxis came from experiments on dogs in 1900s


Anaphylaxis means the opposite of protection
Medical Emergency requiring immediate diagnosis and treatment
1% ED visits

Triggers
i. Food (most common in children/teens)
ii. Medications (most common in adults)
iii. Stinging insects

Diagnosis involves 3 criteria, only have to meet one:


i.

Sudden onset of illness (minutes hours) w/involvement of skin/mucosa &


either the upper/lower respiratory or cardiovascular systems
2 or more of the following that occur suddenly after exposure to a known or
likely antigen:

ii.
1.
2.
3.
4.

Skin or mucosa involvement


Respiratory symptoms
Cardiovascular symptoms
GI symptoms

iii.
Hypotension after exposure to a known antigen for that patient (SBP <90 or
30% decrease from baseline)

Pathophysiology
Multiple types of shock at play in anaphylaxis

Distributive
Hypovolemic (Patients lose about 35% of blood volume into interstitial tissue)
Cardiogenic (High concentration of mast cells around coronary vessels,
Exposure causes release of mediators that cause coronary vasospasm, This
leads to cardiac dysfunction, Reversible with treatment)

Labs
Limited role (histamine/tryptase levels), Clinical diagnosis

Treatment
1.

Oxygen with 100% non-rebreather

2.
3.

Lay them supine (Literature says that sitting patients up increases risk of
cardiac arrest)
Fluid rehydration

4.

Epinephrine

i.
ii.
iii.
iv.

Treatment of choice is Epinephrine/ Adrenaline


Intramuscularly is superior to subcutaneous (IM > SC)
Should be placed in the anterolateral thigh
Dose 1:1000 concentration IM 0.3-0.5 mL , Stocking the Epipen helps lessen
the confusion, Can be repeated for a second/third dose q5-10min

Epinephrine should be administered to anyone showing signs of anaphylaxis,


Delaying the administration has shown to increase mortality
Dont wait until they become hypotensive!
IV route is not highly recommended (Should be used if patient is refractory to the IM
route, when using prefer IV drip > bolus)

5.

Secondary medications

H1-blockers (diphenhydramine, cetirizine)


i.

No high quality studies prove usefulness in anaphylaxis /Take 1-2 hours to


work
Decrease itching, urticaria, and nasal symptoms

ii.

H2-blockers (ranitidine)
i.
ii.
iii.
iv.

No high quality studies prove usefulness in anaphylaxis


Enhance the relief of urticaria & tachycardia
Ranitidine 50mg IV or 1mg/kg over 15 minutes
Combination of H1 and H2 blockers more effective than either alone

Glucocorticoids (methylprednisolone, prednisone)


i.
ii.

No high quality studies prove usefulness in anaphylaxis/ Take hours to work


In theory, may reduce risk of protracted and biphasic symptoms

Other adjuncts: Beta2 /Anticholinergic Nebs, MgSo4


Glucagon
i.
ii.

For patients who have anaphylaxis and are on a beta-blocker, should


consider giving glucagon because epinephrine may not work
1mg q5min until hypotension resolves then 5-15mcg/min

Secondary medications should not be given before or instead of epinephrine


1. Antihistamines have been shown to be helpful with only skin manifestations,
not shown to be helpful with respiratory or cardiovascular manifestations
2. Corticosteroid use comes from asthma literature, Not a lot of studies showing
efficacy in anaphylaxis

Disposition
Controversy surrounds how long to observe patients to monitor for the biphasic
reaction (? 6 -8 12hrs or ADMIT)
~5% of patients will develop a biphasic reaction (re-develop symptoms after
resolution of initial symptoms)
1.
2.
3.

Remember exposure may still be ongoing (i.e. ingestions)


Should also be taught how to use an Epipen
Age and comorbidities should play a role in decision-making
Discharge with 3-5 day course of H1/H2 blockers/Steroids.

BOTTOM LINE
1. Dont be afraid of epinephrine! Its the only drug that will save a life in
anaphylaxis.
2. Discharge with H1/H2 blockers/Steroids/Epinephrine prescription!

Further Reading:
https://www.aaaai.org/Aaaai/media/MediaLibrary/PDF%20Documents/Practice%20a
nd%20Parameters/Anaphylaxis-Practice-Parameter-2014.pdf
Zilberstein J, McCurdy MT, Winters ME. Anaphylaxis. J Emerg Med. 2014 Aug; 47(2):182-7.
Nowak R, Farrar JR, Brenner BE, et al. Customizing anaphylaxis guidelines for emergency
medicine. J Emerg Med. 2013 Aug; 45(2): 299-306.
Grunau BE, Li J, Yi TW, et al. Incidence of clinically important biphasic reactions in
emergency department patients with allergic reactions or anaphylaxis. Ann Emerg Med. 2014
Jun; 63(6): 736-44.

Questions/Comments/ Feedback

Lakshay Chanana MB BS, FEM (Vellore), MCEM (UK)
drlakshay_em@yahoo.com
EM Academy @ Facebook
Twitter: EMDidactic