Anaphylaxis: Difference between revisions
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==Background==
==Background==
===Definition===
*Type I [[Hypersensitivity Reaction|hypersensitivity reaction]] that is either severe in nature or having two or more organ systems  involved.
Anaphylaxis is highly likely when ANY ONE of the following criteria is fulfilled<ref>Brown SGA, Mullins RJ and Gold MS. '''Anaphylaxis: diagnosis and management,''' ''MJA'' 2006; 185: 283–289  </ref><ref>Lieberman P et al. '''The diagnosis and management of anaphyalxis: An updated practice parameter,''' ''J Allergy Clin Immunol'' 2005;115;3:S483-S523 </ref>
*Clinically [[Anaphylaxis]] and its treatment is virtually identical whether it is the traditional IgE dependent anaphylaxis reaction (vast majority), or the IgE independent ''anaphylactoid'' reaction
 
*Precipitants
'''Criterion 1 (90% of patients)'''
**Food (most common)
*Acute onset of an illness involving the skin, mucosal tissue, or both AND at least one of the following:
**Medications
**Respiratory Compromise
**Insect stings
**Reduced blood pressure or associated symptoms ([[Syncope]], [[Dizziness]])
**Latex
 
**Aerobic exercise
'''Criterion 2 (10-20% of pts)'''
**Idiopathic (rare)
*TWO OR MORE of the following that that occur rapidly after exposure to a LIKELY allergen for that patient
**Involvement of the skin-mucosal tissue (hives, swollen lips-tongue-uvula)
**Respiratory compromise
**[[Reduced BP|Hypotension]] or associated symptoms
**Persistent gastrointestinal symptoms: ([[Vomiting|vomiting]], [[Diarrhea|diarrhea]], crampy [[Abd Pain|abdominal pain]])
 
'''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
 
===Expected Course===
====Uniphasic (80-90%)====
*Symptoms peak within 30 minutes to 1 hour after onset, resolve within 30 minutes to 1 hour of receiving treatment<ref>Ewan PW. '''ABC of allergies – Anaphylaxis,''' ''BMJ'' 1998; 316: 1442-1445 </ref>
====Biphasic (10-20%)====
''Biphasic reactions are rare and can occur anywhere from 10 minutes up to six days after an initial reaction.''<ref> Milne K. Biphasic Allergic Reactions: Observation, Treatment Guidelines http://www.acepnow.com/article/biphasic-allergic-reactions-observation-treatment-guidelines/</ref>
*Uniphasic response, followed by asymptomatic period of hour or more, then return of symptoms
*The second phase does not necessarily resemble the first!
*More likely with a severe initial presentation, hypotension, and recurrent epinephrine dosing requirements in the emergency department<ref>Ellis AK, Day JH: Incidence and characteristics of biphasic anaphylaxis: A prospective evaluation of 103 patients. Ann Allergy Asthma Immunology. 2007; 98:64-69</ref>
*Little evidence to support the use of discharge steroids to prevent a biphasic reaction
*0.4% of patients with anaphylaxis had a rebound event while in the ED<ref name="biphasic"/>


==Clinical Features==
==Clinical Features==
[[File:Hives2010.jpg|thumbnail|Raised [[urticaria]]]]
[[File:Hives2010.jpg|thumbnail|Raised [[urticaria]]]]
[[File:Angioedema2013.jpg|thumbnail|[[Angioedema]] of tongue]]
[[File:Angioedema2013.jpg|thumbnail|[[Angioedema]] of tongue]]
[[File:Angioedema2010.jpg|thumb|Angioedema of face.]]
*Cutaneous symptoms (90%)
*Cutaneous symptoms (90%)
**[[Hives]]
**[[Hives]]
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*Cardiovascular symptoms (35%)
*Cardiovascular symptoms (35%)
**[[Hypotension]]
**[[Hypotension]]
===Expected Course===
====Uniphasic (80-90%)====
*Symptoms peak within 30 minutes to 1 hour after onset, resolve within 30 minutes to 1 hour of receiving treatment<ref>Ewan PW. '''ABC of allergies – Anaphylaxis,''' ''BMJ'' 1998; 316: 1442-1445 </ref>
====Biphasic (10-20%)====
''Biphasic reactions are rare and can occur anywhere from 10 minutes up to six days after an initial reaction.''<ref> Milne K. Biphasic Allergic Reactions: Observation, Treatment Guidelines http://www.acepnow.com/article/biphasic-allergic-reactions-observation-treatment-guidelines/</ref>
*Uniphasic response, followed by asymptomatic period of hour or more, then return of symptoms
*The second phase does not necessarily resemble the first!
*More likely with a severe initial presentation, hypotension, and recurrent epinephrine dosing requirements in the emergency department<ref>Ellis AK, Day JH: Incidence and characteristics of biphasic anaphylaxis: A prospective evaluation of 103 patients. Ann Allergy Asthma Immunology. 2007; 98:64-69</ref>
*Little evidence to support the use of discharge steroids to prevent a biphasic reaction
*0.4% of patients with anaphylaxis had a rebound event while in the ED<ref name="biphasic"/>


==Differential Diagnosis==
==Differential Diagnosis==
{{Template:Acute Allergic DDX}}
{{Acute Allergic DDX}}
{{Shock DDX}}
{{Erythematous rash DDX}}
 
==Evaluation==
''[[Anaphylaxis]] is highly likely when ANY ONE of the following criteria is fulfilled''<ref>Brown SGA, Mullins RJ and Gold MS. '''Anaphylaxis: diagnosis and management,''' ''MJA'' 2006; 185: 283–289  </ref><ref>Lieberman P et al. '''The diagnosis and management of anaphyalxis: An updated practice parameter,''' ''J Allergy Clin Immunol'' 2005;115;3:S483-S523 </ref>
 
===Criterion 1 (90% of patients)===
*Acute onset of an illness involving the skin, mucosal tissue, or both AND at least one of the following:
**Respiratory Compromise
**Reduced blood pressure or associated symptoms ([[Syncope]], [[Dizziness]])
 
===Criterion 2 (10-20% of patients)===
*TWO OR MORE of the following that occur rapidly after exposure to a LIKELY allergen for that patient
**Involvement of the skin-mucosal tissue (hives, swollen lips-tongue-uvula)
**Respiratory compromise
**[[Reduced BP|Hypotension]] or associated symptoms
**Persistent gastrointestinal symptoms: ([[Vomiting|vomiting]], [[Diarrhea|diarrhea]], crampy [[Abd Pain|abdominal pain]])


{{Shock DDX}}
===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


==Management==
==Management==
#'''[[Epinephrine]]'''
*'''[[Epinephrine]]'''
#*1:1000 '''IM''' 0.3 - 0.5mg (0.3 - 0.5mL) every 5 - 15 minutes<ref>Dhami S. et al. Management of anaphylaxis: a systematic review. Allergy. 69 (2014) 168–175. http://onlinelibrary.wiley.com/store/10.1111/all.12318/asset/all12318.pdf?v=1&t=hrspdbpk&s=8067bfd5903c7ffebf4a274f062a71633ebe0507</ref><ref>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</ref>
**1:1000 '''IM''' 0.3 - 0.5mg (0.3 - 0.5mL) every 5 - 15 minutes<ref>Dhami S. et al. Management of anaphylaxis: a systematic review. Allergy. 69 (2014) 168–175. http://onlinelibrary.wiley.com/store/10.1111/all.12318/asset/all12318.pdf?v=1&t=hrspdbpk&s=8067bfd5903c7ffebf4a274f062a71633ebe0507</ref><ref>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</ref>
#**Give as soon as possible
**Give as soon as possible
#**Always IM initially <ref>Simons FER, Gu X, Simons KJ. '''Epinephrine absorption in adults: Intramuscular versus subcutaneous injection,''' ''J Allergy Clin Immunol'' 2001;108:871-3 </ref>
**Always IM initially <ref>Simons FER, Gu X, Simons KJ. '''[[Epinephrine]]absorption in adults: Intramuscular versus subcutaneous injection,''' ''J Allergy Clin Immunol'' 2001;108:871-3 </ref>
#**If response to IM is inadequate: give epinephrine infusion 1:10,000 2 - 10 µg/min
**If response to IM is inadequate: give epinephrine infusion 1:10,000 2 - 10 µg/min
#**'''How to make a quick epi drip:''' ''Take your code-cart epi (it doesn't matter if it's 1:1,000 or 1:10,000) and inject 1mg into a liter bag of NS.  Final concentration is 1mcg/ml.  Run at 1cc/min and titrate to effect''.
**'''How to make a quick epinephrine drip:''' ''Take your code-cart epinephrine (it does not matter if it is 1:1,000 or 1:10,000) and inject 1mg into a liter bag of NS.  Final concentration is 1mcg/ml.  Run at 1cc/min and titrate to effect''.
#*Pediatric: [[Epinephrine]] '''1:1000 0.01 mg/kg (max 0.5mg) IM''' every 5 to 15 minutes
*Pediatric: [[Epinephrine]] '''1:1000 0.01mg/kg (max 0.5mg) IM''' every 5 to 15 minutes
#**IV infusion: 0.05 - 1 mcg/kg/min
**IV infusion: 0.05 - 1 mcg/kg/min
#'''Supplemental oxygen'''
*'''Supplemental oxygen'''
#*''Consider [[Intubation|endotracheal intubation]] if airway edema present''
**''Consider [[Intubation|endotracheal intubation]] if airway edema present''
#'''Normal saline bolus'''
*'''Normal saline bolus'''
#*If unresponsive to [[epinephrine]] assume distributive [[Shock|shock]] and give 1 - 2 liters of normal saline
**If unresponsive to [[epinephrine]] assume distributive [[Shock|shock]] and give 1 - 2 liters of normal saline
#'''Also consider'''
*'''Also consider'''
##[[Albuterol]]
**[[Albuterol]] for bronchospasm resistant to IM epinephrine
##*for bronchospasm resistant to IM epinephrine
**[[Antihistamines]] (for symptom control AFTER hemodynamically stable)
##[[Antihistamines]] (for symptom control AFTER hemodynamically stable)
***[[Diphenhydramine]]: 25 to 50mg IV (1mg/kg in children)
##*[[Diphenhydramine]]: 25 to 50 mg IV
***[[Ranitidine]]: 50mg IV (0.5mg/kg in children) (has been found to improve urticaria but not angioedema at 2 hours<ref>Lin, RY et al. Improved Outcomes in Patients With Acute  Allergic Syndromes Who Are Treated With  Combined H1 and H2 Antagonists. Annals of Emergency Medicine. 36:5 NOVEMBER 2000.</ref>)
##*[[Ranitidine]]: 50 mg IV (has been found to improve urticaria but not angioedema at 2 hours<ref>Lin, RY et al. Improved Outcomes in Patients With Acute  Allergic Syndromes Who Are Treated With  Combined H1 and H2 Antagonists. Annals of Emergency Medicine. 36:5 NOVEMBER 2000.</ref>)
***AVOID promethazine as this can worsen hypotension
##Glucocorticoid
**Glucocorticoid
##*MAY blunt biphasic reaction although little evidence to support usage<ref>Choo KJ, Simons E, Sheikh A: Glucocorticoids for the treatment of anaphylaxis: Cochrane systematic review. Allergy 2010; 65:1205-1211.</ref>
***MAY blunt biphasic reaction although little evidence to support usage<ref>Choo KJ, Simons E, Sheikh A: Glucocorticoids for the treatment of anaphylaxis: Cochrane systematic review. Allergy 2010; 65:1205-1211.</ref>
##*[[Methylprednisolone]]: 125 mg IV (2mg/kg in children)
***[[Methylprednisolone]]: 125mg IV (2mg/kg in children)
##*[[Dexamethasone]]: 10mg IV or PO (0.6mg/kg in children)
***[[Dexamethasone]]: 10mg IV or PO (0.6mg/kg in children)
##[[Glucagon]]
**[[Glucagon]]
##*1 - 5mg IV over 5 minutes followed by infusion of 5 - 15 µg/min<ref>Campbell RL, et al. Emergency department diagnosis and treatment of anaphylaxis: a practice parameter. Ann Allergy Asthma Immunol. 2014; 113:599e608.</ref>
***1 - 5mg IV over 5 minutes followed by infusion of 5 - 15 µg/min<ref>Campbell RL, et al. Emergency department diagnosis and treatment of anaphylaxis: a practice parameter. Ann Allergy Asthma Immunol. 2014; 113:599e608.</ref>
##*If taking beta-blocker AND unresponsive to [[Epi|epinephrine]]
***If taking beta-blocker AND unresponsive to [[Epi|epinephrine]]
##Consider adding additional pressor support if persistent hypotension present
**Consider adding additional pressor support if persistent hypotension present
##*For example: '''vasopressin 2-8 units''' for persistent refractory shock (case series only)<ref>Schummer et al. The Pivotal Role of Vasopressin in Refractory Anaphylactic Shock. Anesthesia & Analgesia: August 2008 - Volume 107 - Issue 2 - pp 620-624.</ref><ref>Dünser et al. Treatment of Anaphylactic Shock: Where Is the Evidence? Anesthesia & Analgesia: August 2008 - Volume 107 - Issue 2 - pp 359-361</ref>
***For example: '''[[vasopressin]]''' 2-8 units for persistent refractory shock (case series only)<ref>Schummer et al. The Pivotal Role of Vasopressin in Refractory Anaphylactic Shock. Anesthesia & Analgesia: August 2008 - Volume 107 - Issue 2 - pp 620-624.</ref><ref>Dünser et al. Treatment of Anaphylactic Shock: Where Is the Evidence? Anesthesia & Analgesia: August 2008 - Volume 107 - Issue 2 - pp 359-361</ref>
***[[Norepinephrine]] 0.05 to 0.5 mcg/kg per minute


==Disposition==
==Disposition==
===Admit===
===Admit===
*Severe and moderate presentations especially if symptoms did not respond promptly to epinephrine or required repeat dosing
*Severe and moderate presentations especially if symptoms did not respond promptly to epinephrine or required repeat dosing
*Labs that may be requested by allergist/admitting team if uncertain diagnosis
**Histamine level - serum elevation 30-60 min following anaphylaxis, window easily missed
**Tryptase - peaks at 2-4 hrs, remains elevated 6-12 hrs


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


==References==
==References==

Revision as of 18:27, 23 August 2019

Background

  • Type I hypersensitivity reaction that is either severe in nature or having two or more organ systems involved.
  • Clinically Anaphylaxis and its treatment is virtually identical whether it is the traditional IgE dependent anaphylaxis reaction (vast majority), or the IgE independent anaphylactoid reaction
  • Precipitants
    • Food (most common)
    • Medications
    • Insect stings
    • Latex
    • Aerobic exercise
    • Idiopathic (rare)

Clinical Features

Raised urticaria
Angioedema of tongue
Angioedema of face.

Expected Course

Uniphasic (80-90%)

  • Symptoms peak within 30 minutes to 1 hour after onset, resolve within 30 minutes to 1 hour of receiving treatment[1]

Biphasic (10-20%)

Biphasic reactions are rare and can occur anywhere from 10 minutes up to six days after an initial reaction.[2]

  • Uniphasic response, followed by asymptomatic period of hour or more, then return of symptoms
  • The second phase does not necessarily resemble the first!
  • More likely with a severe initial presentation, hypotension, and recurrent epinephrine dosing requirements in the emergency department[3]
  • Little evidence to support the use of discharge steroids to prevent a biphasic reaction
  • 0.4% of patients with anaphylaxis had a rebound event while in the ED[4]

Differential Diagnosis

Acute allergic reaction

Shock

Erythematous rash

Evaluation

Anaphylaxis is highly likely when ANY ONE of the following criteria is fulfilled[5][6]

Criterion 1 (90% of patients)

  • Acute onset of an illness involving the skin, mucosal tissue, or both AND at least one of the following:
    • Respiratory Compromise
    • Reduced blood pressure or associated symptoms (Syncope, Dizziness)

Criterion 2 (10-20% of patients)

  • TWO OR MORE of the following that occur rapidly after exposure to a LIKELY allergen for that patient
    • Involvement of the skin-mucosal tissue (hives, swollen lips-tongue-uvula)
    • Respiratory compromise
    • Hypotension or associated symptoms
    • Persistent gastrointestinal symptoms: (vomiting, diarrhea, crampy abdominal pain)

Criterion 3

  • 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

Management

  • Epinephrine
    • 1:1000 IM 0.3 - 0.5mg (0.3 - 0.5mL) every 5 - 15 minutes[7][8]
    • Give as soon as possible
    • Always IM initially [9]
    • If response to IM is inadequate: give epinephrine infusion 1:10,000 2 - 10 µg/min
    • How to make a quick epinephrine drip: Take your code-cart epinephrine (it does not matter if it is 1:1,000 or 1:10,000) and inject 1mg into a liter bag of NS. Final concentration is 1mcg/ml. Run at 1cc/min and titrate to effect.
  • Pediatric: Epinephrine 1:1000 0.01mg/kg (max 0.5mg) IM every 5 to 15 minutes
    • IV infusion: 0.05 - 1 mcg/kg/min
  • Supplemental oxygen
  • Normal saline bolus
    • If unresponsive to epinephrine assume distributive shock and give 1 - 2 liters of normal saline
  • Also consider
    • Albuterol for bronchospasm resistant to IM epinephrine
    • Antihistamines (for symptom control AFTER hemodynamically stable)
      • Diphenhydramine: 25 to 50mg IV (1mg/kg in children)
      • Ranitidine: 50mg IV (0.5mg/kg in children) (has been found to improve urticaria but not angioedema at 2 hours[10])
      • AVOID promethazine as this can worsen hypotension
    • Glucocorticoid
      • MAY blunt biphasic reaction although little evidence to support usage[11]
      • Methylprednisolone: 125mg IV (2mg/kg in children)
      • Dexamethasone: 10mg IV or PO (0.6mg/kg in children)
    • Glucagon
      • 1 - 5mg IV over 5 minutes followed by infusion of 5 - 15 µg/min[12]
      • If taking beta-blocker AND unresponsive to epinephrine
    • Consider adding additional pressor support if persistent hypotension present

Disposition

Admit

  • Severe and moderate presentations especially if symptoms did not respond promptly to epinephrine or required repeat dosing
  • Labs that may be requested by allergist/admitting team if uncertain diagnosis
    • Histamine level - serum elevation 30-60 min following anaphylaxis, window easily missed
    • Tryptase - peaks at 2-4 hrs, remains elevated 6-12 hrs

Discharge

  • Symptom-free for at least 4 hours and mild initial presentation
  • Send home with an epinephrine autoinjector! (Epi-Pen)
  • Up to 6% of the people with anaphylaxis have a repeat ED visit for anaphylaxis within 7 days[4]

See Also

References

  1. ↑ Ewan PW. ABC of allergies – Anaphylaxis, BMJ 1998; 316: 1442-1445
  2. ↑ Milne K. Biphasic Allergic Reactions: Observation, Treatment Guidelines http://www.acepnow.com/article/biphasic-allergic-reactions-observation-treatment-guidelines/
  3. ↑ Ellis AK, Day JH: Incidence and characteristics of biphasic anaphylaxis: A prospective evaluation of 103 patients. Ann Allergy Asthma Immunology. 2007; 98:64-69
  4. ↑ 4.0 4.1 Grunau BE et al. Incidence of Clinically Important Biphasic Reactions in Emergency Department Patients With Allergic Reactions or Anaphylaxis. Ann Emerg Med. 2013 Nov 13
  5. ↑ Brown SGA, Mullins RJ and Gold MS. Anaphylaxis: diagnosis and management, MJA 2006; 185: 283–289
  6. ↑ Lieberman P et al. The diagnosis and management of anaphyalxis: An updated practice parameter, J Allergy Clin Immunol 2005;115;3:S483-S523
  7. ↑ Dhami S. et al. Management of anaphylaxis: a systematic review. Allergy. 69 (2014) 168–175. http://onlinelibrary.wiley.com/store/10.1111/all.12318/asset/all12318.pdf?v=1&t=hrspdbpk&s=8067bfd5903c7ffebf4a274f062a71633ebe0507
  8. ↑ 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
  9. ↑ Simons FER, Gu X, Simons KJ. Epinephrineabsorption in adults: Intramuscular versus subcutaneous injection, J Allergy Clin Immunol 2001;108:871-3
  10. ↑ Lin, RY et al. Improved Outcomes in Patients With Acute Allergic Syndromes Who Are Treated With Combined H1 and H2 Antagonists. Annals of Emergency Medicine. 36:5 NOVEMBER 2000.
  11. ↑ Choo KJ, Simons E, Sheikh A: Glucocorticoids for the treatment of anaphylaxis: Cochrane systematic review. Allergy 2010; 65:1205-1211.
  12. ↑ Campbell RL, et al. Emergency department diagnosis and treatment of anaphylaxis: a practice parameter. Ann Allergy Asthma Immunol. 2014; 113:599e608.
  13. ↑ Schummer et al. The Pivotal Role of Vasopressin in Refractory Anaphylactic Shock. Anesthesia & Analgesia: August 2008 - Volume 107 - Issue 2 - pp 620-624.
  14. ↑ Dünser et al. Treatment of Anaphylactic Shock: Where Is the Evidence? Anesthesia & Analgesia: August 2008 - Volume 107 - Issue 2 - pp 359-361
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