Emergency treatment

of
anaphylactic reactions

Anaphylaxis is a severe, lifethreatening, generalized or

systemic hypersensitivity
reaction.
This is characterized by rapidly developing
life-threatening airway and/or breathing
and/or circulation problems usually
associated with skin and mucosal
changes.

Triggers

The patient will feel and look

unwell.
Most reactions occur over several
minutes. Rarely, reactions may
be slower in onset.
The time of onset of an
anaphylactic reaction depends on
the type of trigger.

An intravenous trigger will cause a

more rapid onset of reaction than
stings which, in turn, tend to cause
a more rapid onset than orally
ingested triggers.
The patient is usually anxious and
can experience a sense of
impending doom.

TREATMENT
(for the exam, please start the
presentation with pharmacological
treatment!!!!)

All patients should be placed in a

comfortable position.
Patients with Airway and Breathing
problems may prefer to sit up as this will
make breathing easier.
Lying flat with or without leg elevation is
helpful for patients with a low blood
pressure
Patients who are unconscious should be
placed on their side (recovery position).
Pregnant patients should lie on their left
side to prevent caval compression.

Removing the trigger for an anaphylactic

reaction.
Stop any drug suspected of causing an
anaphylactic reaction (e.g., stop intravenous
infusion of drug).
Remove the stinger after a bee sting. Early
removal is more important than the method of
removal.
After food-induced anaphylaxis, attempts
to make the patient vomit are not
recommended.
Do not delay definitive treatment if
removing the trigger is not feasible .

ADRENALINE

is the most important drug for the treatment of

an anaphylactic
As an alpha-receptor agonist, it reverses
peripheral vasodilation and reduces oedema.
Its beta-receptor activity dilates the bronchial
airways, increases the force of myocardial
contraction, and suppresses histamine and
leukotriene release.
There are also beta-2 adrenergic receptors on
mast cells that inhibit activation, and so early
adrenaline attenuates the severity of IgEmediated allergic reactions.

ADRENALINE

Adrenaline seems to work best

when given early after the onset
of the reaction but it is not
without risk of myocardial
ischaemia, particularly when
given intravenously.

ADRENALINE
The intramuscular (IM) route is the
best for most individuals who have
to give adrenaline to treat an
anaphylactic reaction.
The best site for IM injection is the
anterolateral aspect of the middle
third of the thigh.

CORTICOSTEROIDS have no
immediate effect on anaphylaxis.
Administer them early to try to
prevent a potential late-phase
reaction (biphasic anaphylaxis).

Administer an H1 blocker and an H2 blocker,

because the combination is superior to an H1 blocker
alone. Chlorphenamine (H1 blocker, first generation)
and cimetidine (H2 blocker) 300mg iv n 3 5 min
are an appropriate combination.
It is recommended that H1 blockers treatment
should be continued for several days after leaving the
hospital. Second-generation H1 blockers, lesssedating agents may be preferable for the following
days because of decreased adverse effects.

fexofenadine (Allegra) at 180 mg/d

loratadine (Claritin) at 10 mg/d
cetirizine (Zyrtec) at 10 mg/d
desloratadine (Clarinex) at 5 mg/d
levocetirizine (Xyzal) at 5 mg/d.

Other drugs:
Bronchodilators
salbutamol (inhaled or IV)
ipratropium (inhaled)
aminophylline (IV)

Calcium gluconate 12 vials, intravenously slow

Glucagon can be useful to treat an
anaphylactic reaction in a patient taking a betablocker.

SHORT-TERM DESENSITIZATION
(not for exam just for your information)
Consult an allergist-immunologist skilled in
desensitization procedures to perform these
protocols.
Most protocols require the patient to be in an
ICU setting throughout the procedure and to
have established IV access and Adrenalina at
the bedside before the procedure starts.

SHORT-TERM DESENSITIZATION
(not for exam just for your information)
A typical desensitization protocol for betalactam antibiotics provides the patient a starting
dose that is 6-7 logs below the usual
therapeutic dose and increases the dose by 1
log every 20-30 minutes.
A typical desensitization regimen involves
administering the antibiotic of choice in an initial
dose of 0.01 mg. While observing the patient,
double the dose every 20-30 minutes until a full
dose has been administered.

ADMINISTRATION OF ANTI-IGE
Anti-IgE (omalizumab) keeps IgE from
binding to its receptors.
It does not remove IgE bound to
receptors and can take several weeks to
months to have a substantial effect.

Patients who have had a suspected

anaphylactic reaction should be treated and
then observed for at least 6 hours in a clinical
area with facilities for treating life-threatening
ABC problems.
Patients with a good response to initial
treatment should be warned of the possibility of
an early recurrence of symptoms and in some
circumstances should be kept under
observation for up to 24 hours.

Patients at risk for recurrent anaphylaxis

should consider wearing a MedicAlert
bracelet.

They should also avoid the use of beta-blockers if at all possible since
this class of medication may not only increase the risk of anaphylaxis, but
also block the effects of adrenaline.

ACE inhibitors have also been theorized to potentially increase the risk of
anaphylaxis.

Tricyclic antidepressants and monoamine oxidase inhibitors should also

be avoided because of potential drug interactions with necessary
therapies.

PATIENTS EDUCATION

Patients need to know the allergen

responsible and how to avoid it.
If the allergen is a drug or food, they
need to know what products are likely
to contain it, and all the names that can
be used to describe it.
Where possible they also need to know
how to avoid situations that could
expose them to the allergen.

Patients need to be able to

recognize the early symptoms of
anaphylaxis, so that they can
summon help quickly and prepare
to use their emergency medication.
Patients at risk are usually advised
to carry their adrenaline autoinjector with them at all times.

Auto-injectors are often given to

patients at risk of anaphylaxis for
their own use.
There are only two doses of
adrenaline auto-injector commonly
available: 0.15 and 0.3 mg.