Anaphylaxis - Dr. Patty Eaton

Anaphylaxis - Dr. Patty Eaton

• 1.
  Anaphylaxis Patricia Eaton, DO PediatricEmergency Medicine Fellow Arnold Palmer Hospital for Children
• 2.
  Anaphylaxis • A seriousallergic or hypersensitivity reaction that is rapid in onset and may cause death
• 3.
  Diagnostic Criteria • Acuteonset • Skin and/or mucosal tissue PLUS – Respiratory compromise OR – Reduced blood pressure or signs of end-organ dysfunction • Two or more of the following occurring rapidly after exposure to a LIKELY allergen – Skin/mucosal involvement – Respiratory compromise – Reduced BP or associated signs – Persistent gastrointestinal symptoms • Reduced BP after exposure to a KNOWN allergen
• 5.
  Fatal Anaphylaxis • Deathusually from asphyxiation due to upper or lower airway obstruction or from cardiovascular collapse • Time from onset of symptoms to respiratory or cardiac arrest – 5 minutes for iatrogenic causes – 15 minutes in stinging insect venom – 30 minutes in food-induced
• 6.
  Initial Management • Removalof inciting antigen if possible • IM epinephrine • Supine or semi-recumbent with lower extremities elevated • O2 • Airway management – Marked stridor – Edema of tongue/facial/neck tissues – Respiratory arrest • IVF
• 7.
  Epinephrine • **The ONLYmed that prevents/reverses obstruction to airflow in upper and lower respiratory tracts AND prevents cardiovascular collapse**
• 8.
  Epinephrine: mechanism ofaction • Alpha-1 adrenergic agonist – Vasoconstriction, increased peripheral vascular resistance, decreased mucosal edema • Beta-1 adrenergic agonist – Increased inotropy and chronotropy • Beta-2 adrenergic agonist – Bronchodilation and decreased release of inflammatory mediators from mast cells and basophils
• 9.
  Epinephrine: side effects •Fight or Flight • Anxiety • Restlessness • Headache • Dizziness • Palpitations • Pallor • Tremor
• 10.
  Epinephrine • 1:1000 • 1mg/mL •IM route preferred • Mid-outer thigh • Adults: 0.3-0.5mg • Children: 0.01mg/kg • May be repeated q5-15min • Autoinjectors – <25kg: 0.15mg – >25kg: 0.3mg
• 11.
  Epinephrine • The failureto administer epinephrine early consistently contributes to anaphylaxis deaths • In children, receiving epinephrine prior to arrival in ED associated with lower risk of hospitalization and shorter ED stay
• 12.
  Epinephrine • NO contraindications
• 13.
  Adjunctive Agents • Notintended as initial or sole treatment • Do not relieve upper or lower respiratory tract obstruction, hypotension or shock • NOT lifesaving!
• 14.
  Adjunctive Agents • H1antihistamines – Relieve itch and hives – Onset 30-40 minutes – Side effects: hypotension – Benadryl • Adults: 25-50mg IV • Children: 1mg/kg
• 15.
  Adjunctive Agents • H2antihistamines – Additional relief of hives – Ranitidine • Adults: 50mg • Children: 1mg/kg
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  Adjunctive Agents • Inhaledbronchodilators – Albuterol – DO NOT prevent or relieve mucosal edema in upper airway or shock
• 17.
  Adjunctive Agents • Glucocorticoids –DO NOT relieve initial symptoms – Onset several hours • To prevent biphasic or protracted reactions – Methylprednisolone 1-2mg/kg
• 18.
  Treatment Errors • Failureto administer epinephrine promptly • Overreliance on Benadryl, albuterol, steroids
• 19.
  Of patients withanaphylaxis who did not receive epi prior to EMS arrival, only 12% were given epi by EMS
• 20.
  In total, only41% of children with anaphylaxis received epi prior to arrival in ED 36% of patients with indication received epinephrine from EMS 41% Benadryl, 32% Albuterol, 14% O2, 5% IVF mean time from arrival on scene to arrival in ED 28 minutes 69% of those that occurred at school received epi from school nurse 41% of those that were with parents were given epi 100% seen by physician prior to arriving in ED received epi
• 21.
  • 5yo malewith history of asthma and peanut allergy eats a cookie and shortly after develops hives and vomits once. What is the best first medication to administer? • A. Benadryl • B. Epinephrine 1:1000 • C. Steroids • D. Albuterol • E. Epinephrine 1:10,000
• 22.
  • What isthe appropriate dose of Epinephrine for this child? • A. Epi 1:1000 IV 0.2mL • B. Epi 1:1000 IM 0.2mL • C. Epi 1:10,000 IM 2mL • D. Epi 1:10,000 IV 0.2mL • E. Epi 1:1000 IM 2mL
• 23.
  • What adjunctmedications could you consider? • A. IVF • B. Solu-Medrol • C. Albuterol • D. Benadryl • E. All of the above
• 24.
  In Summary…
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  Thanks!