Transcript MANAGEMENT OF COMMON ALLERGIC EMERGENCIES

MANAGEMENT OF COMMON
ALLERGIC EMERGENCIES
M. SCOTT LINSCOTT, M.D.
UNIVERSITY OF UTAH SCHOOL OF MEDICINE
CASE #1
A 32 Y/O FEMALE PRESENTS WITH A HISTORY OF SEVERE
WHEEZING FOR 24 HOURS. SHE HAS HAD ASTHMA SINCE
SHE WAS 8 Y/O AND IS CURRENTLY USING FLUTICASONE
AEROSOL (AZMACORT) 220 mcg bid, ALBUTEROL MDI 180
mcg q 4 HRS AND THEODUR 200 mg BID. VS: BP 160/100,
P 130, R 30, T 36.6 C. SHE IS IN ACUTE RESPIRATORY
DISTRESS, GASPING FOR EACH BREATH, USING HER
ACCESSORY MUSCLES AND SITTING IN THE SNIFFING
POSITION. SHE IS UNABLE TO SPEAK MORE THAN 2-3
WORDS WITH EACH BREATH. BREATH SOUNDS ARE
DECREASED AND SHE HAS WHEEZING WITH PROLONGED
EXPIRATORY PHASE.
WHAT ADDITIONAL
HISTORY AND PHYSICAL
FINDINGS WOULD BE
IMPORTANT?
ADDITIONAL HISTORY, EXAM
• PREVIOUSLY STEROID DEPENDENT?
• PREVIOUS HOSPITALIZATIONS FOR
•
•
•
ASTHMA?
PREVIOUS ENDOTRACHEAL
INTUBATIONS FOR ASTHMA?
RECENT URI, OTHER INCITING
FACTORS?
PHYSICAL: PULSUS PARADOXICUS?
HOW SHOULD THIS PATIENT
BE MANAGED?
MONITORING / DIAGNOSIS?
THERAPY?
MONITORING / DIAGNOSIS
• ECG MONITOR, IV
• PULSE OXIMETER (INITIALLY ON ROOM
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•
•
•
AIR UNLESS THE PATIENT IS IN
SEVERE DISTRESS)
PEAK FLOW (PEF) / FEV1
THEOPHYLLINE LEVEL
ABG?
CHEST X-RAY?
HOW SHOULD THIS PATIENT
BE MANAGED?
MONITORING / DIAGNOSIS?
THERAPY?
THERAPY
• OXYGEN
• BETA AGONISTS
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•
•
 INHALED BETA-2 AGONISTS - MDI,
NEBULIZER, CPAP, BIPAP, ETC
 SYSTEMIC – SQ/IV EPINEPHRINE OR
TERBUTALINE
IPRATROPIUM?
CORTICOSTEROIDS - IV, ORAL, INHALED
THEOPHYLLINE? MAGNESIUM? HELIOX?
LEUKOTRIENE RECEPTOR ANTAGONISTS?
SYSTEMIC BETA AGONISTS
• UNDERUTILIZED IN PATIENTS WITH SEVERE
ACUTE ASTHMA
• INHALED BETA-2 AGONISTS ALONE MAY BE
INEFFECTIVE
• TERBUTALINE OR EPI 0.3 - 0.5 mg SQ
• SAFE IN OLDER PTS (ESPECIALLY IF NO CAD)
• IV EPINEPHRINE (0.5-1.0 mcg/min) IF NO
RESPONSE TO SQ OR INHALED BETA-2
AGONISTS
• AVOID ENDOTRACHEAL INTUBATION IF
POSSIBLE (VERY HIGH PRESSURES,
PNEUMOTHORAX)
MDI VS NEBULIZER
• EFFICACY: SIMILAR IF USE MDI WITH
•
•
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SPACER OR BREATH ACTIVATED MDI
(MULTIPLE STUDIES)
COST (DOLLARS & MAN HOURS): MUCH LESS
WITH MDI
START WITH MDI (WITH SPACER) AND IF
NOT EFFECTIVE, USE NEBULIZER
IF NEBULIZER NOT EFFECTIVE, USE CPAP OR
BIPAP (ANN EMERG MED 1995;26:552 CHEST
2003;123:1018)
DOSING OF INHALED BETA2
AGONISTS IN SEVERE ASTHMA
• USE 4 SPRAYS (360 mcg) ALBUTEROL MDI
WITH SPACER OR 6 mg ALBUTEROL (1.0 ml)
WITH 2.0 ml NS (NEBULIZER) + NEBULIZED
ATROPINE (ATROVENT) 500 mcg INITIALLY
• GIVE ALBUTEROL q 15 MINUTES OR BY
CONTINUOUS NEBULIZATION
• MOST PATIENTS WITH ACUTE SEVERE ASTHMA
DO POORLY BECAUSE THEY AREN’T GIVEN
ENOUGH BETA ADRENERGIC DRUGS!!!
SYSTEMIC CORTICOSTEROIDS:
ORAL OR PARENTERAL?
• IF ACUTE, MILD OR MODERATE: ORAL
•
•
AS EFFECTIVE AS IV IN ALL STUDIES
PLUS LESS EXPENSIVE
IF ACUTE, SEVERE (VERY ILL): NO
CONTROLLED STUDIES BUT PROBABLY
BEST TO GIVE FIRST DOSE (S) IV
DOSE: PREDNISONE 40 - 60 mg po qd,
SOLUMEDROL 1 - 2 mg/kg IV q 12-24
HOURS
SYSTEMIC CORTICOSTEROIDS:
TO TAPER OR NOT TO TAPER?
• WHY TAPER?
• IF USE FOR MORE THAN 14-21 DAYS, MAY SEE
SUPPRESSION OF HYPOTHALAMIC - PITUITARY ADRENAL AXIS AND IMMUNOSUPPRESSION
• IF USE FOR ACUTE EXACERBATIONS, MAY SEE
EXACERBATION OF ASTHMA IF DON'T TAPER (LITTLE
EVIDENCE TO SUPPORT THIS - IF OPTIMUM PEAK
EXPIRATORY FLOW (PEF) HAS BEEN ACHIEVED)
• PROBABLY NO NEED TO TAPER IF OPTIMUM
PEF IS ATTAINED BEFORE DISCONTINUING
CORTICOSTEROIDS
THEOPHYLLINE
• IN ACUTE ASTHMA – PROBABLY SHOULD NOT BE USED
AS PRIMARY THERAPY. MOST STUDIES SHOW MINIMAL
OR NO ADDITIONAL BENEFIT AND INCREASED
TOXICITY WHEN THEOPHYLLINE IS ADDED TO BETA
AGONISTS AND CORTICOSTEROIDS. HOWEVER, SOME
STUDIES DO SHOW BENEFIT IN PATIENTS REFRACTORY TO
BETA-2 AGONIST THERAPY (CHEST 2003;123:1018)
• CHRONICALLY - MAY BE EFFECTIVE IN SOME CASES,
ESP. NOCTURNAL ASTHMA AND COPD. NEW FDA
RECOMMENDED MAXIMUM LEVEL - 15 mg/ml. BECAUSE
OF ITS LOW THERAPEUTIC INDEX, PROBABLY SHOULD
NOT BE FIRST-LINE DRUG FOR CHRONIC ASTHMA
• HOWEVER, IT IS INEXPENSIVE AND THEREFORE MAY BE
THE ONLY OPTION IN SOME PATIENTS
IPRATROPIUM, HELIOX, MAGNESIUM,
LEUKOTRIENE RECEPTOR ANTAGONISTS
• ALL MAY CAUSE MINIMAL ADDITIONAL BRONCHODILATION IN
PTS WITH ACUTE ASTHMA TREATED WITH OPTIMUM BETA
ADRENERGIC DRUGS AND STEROIDS, ESP. IN MODERATE-TOSEVERE ASTHMA
• IN ACUTE ASTHMA, STUDIES EMPLOYING IPRATROPIUM
INITIALLY WITH ALBUTEROL ARE CONFLICTING IN TERMS OF
EFFICACY – MOST RECENT STUDIES WOULD INDICATE EFFICACY.
• THEOPHYLLINE, HELIOX, MAGNESIUM AND LRA SHOULD
PROBABLY BE RESERVED FOR THE SEVERE CASE WHICH IS
REFRACTORY TO BETA AGONIST, IPRATROPIUM AND
SYSTEMIC CORTICOSTEROID THERAPY
CASE #2
EMS CALLS TO INFORM YOU THAT THEY ARE
TRANSPORTING A 22 YEAR OLD MALE WHO IS COMATOSE
AND HAS A BP OF 60/40, PULSE OF 140, AND RESP OF 16.
HE WAS EATING AT A LOCAL THAI RESTAURANT WHEN HE
TOLD HIS COMPANION THAT HIS THROAT FELT TIGHT AND
THEN HE COLLAPSED. HE HAD INQUIRED OF THE WAITER
WHETHER A CERTAIN ENTRÉE CONTAINED PEANUTS
BECAUSE HE HAD A VIOLENT ALLERGY TO THEM. THE
WAITER HAD ASSURED HIM THAT THERE WERE NO
PEANUTS, PEANUT OILS, ETC. IN THIS DISH. HIS
SYMPTOMS BEGAN WITHIN 5 MINUTES OF HIS EATING
THIS ENTRÉE.
MOST LIKELY DIAGNOSIS?
WHAT WOULD YOU INSTRUCT
THE EMS PERSONNEL TO DO
FOR THIS PATIENT?
ANAPHYLACTIC SHOCK
MANAGEMENT
• AT LEAST 2 LARGE BORE (16 GUAGE OR LARGER) IVs
• CRYSTALLOID (NS) WIDE OPEN (PRESSURE INFUSION IF
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•
•
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POSSIBLE) TO DELIVER 1 LITER PER LINE IN FIRST 5-10
MINUTES. PATIENT WILL OFTEN REQUIRE 10+ LITERS IN
FIRST SEVERAL HOURS (MAJOR CAPILLARY LEAK)
EPINEPHRINE 0.05-0.1 mg IV
MONITOR BP AND PULSE
CARDIAC MONITOR
LIGHTS AND SIREN TO ED!!
CASE #3
A 35 YEAR OLD FEMALE PRESENTS WITH THE ACUTE
ONSET OF A VERY PRURITIC RASH SIX HOURS PRIOR TO
ADMISSION. SHE HAD A SIMILAR RASH TWO YEARS AGO
WHICH CLEARED UP IMMEDIATELY WITH 50 mg OF
DIPHENHYDRAMINE ORALLY. SHE TOOK
DIPHENHYDRAMINE AGAIN THIS TIME WITH SLIGHT
IMPROVEMENT IN THE ITCHING FOR TWO HOURS. THE
ITCHING AGAIN BECAME SEVERE AND THE RASH SPREAD.
SHE DENIES TAKING MEDICATIONS OR ANY NEW SOAPS,
MAKEUP, ETC. THERE IS A GENERALIZED ERUPTION OF
RAISED WHEALS WITH ERYTHEMATOUS MARGINS WHICH
THE PATIENT IS VIGOROUSLY SCRATCHING.
ADDITIONAL HISTORY?
(POTENTIALLY LIFE
THREATENING PROBLEM?)
ADDITIONAL HISTORY?
• MUST WORRY ABOUT ANGIOEDEMA (SAME
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PROCESS AS URTICARIA, BUT INVOLVING
DEEPER TISSUES)
MOST SENSITIVE QUESTION RE: LARYNGEAL
ANGIOEDEMA – ANY CHANGE IN YOUR VOICE
(HOARSENESS)?
THROAT TIGHTNESS?
STRIDOR?
LIP OR TONGUE SWELLING?
DIAGNOSIS?
MANAGEMENT?
ACUTE URTICARIA
MANAGEMENT
• DIPHENHYDRAMINE 25 mg IV
• H2 BLOCKERS IV
 RANITIDINE 50 MG IV
 FAMOTIDINE 20 mg IV
 CIMETIDINE 300 MG IV
• IF PATIENT HAS WHEEZING, HOARSENESS, THROAT
TIGHTNESS, LIP/TONGUE SWELLING: EPI 0.3 – 0.5 mg sq
• REFRACTORY: HYDROXYZINE 50 mg po, DOXEPIN 50 mg
po, SYSTEMIC STEROIDS, REFER TO DERMATOLOGIST FOR
BIOPSY TO R/O URTICARIAL VASCULITIS
H1 BLOCKERS
• OLDER (“FIRST GENERATION”):
•
DIPHENHYDRAMINE (BENADRYL),
CHLORPHENIRAMINE (CHLORTRIMETON),
CYPROHEPTADINE (PERIACTIN), HYDROXYZINE
(ATARAX, VISTARIL), PROMETHAZINE
(PHENERGAN), CLEMASTINE (TAVIST), ETC.
NEWER (“SECOND GENERATION”): LORATADINE
(CLARITIN), CETIRIZINE (ZYRTEC),
FEXOFENADINE (ALLEGRA), ASTEMIZOLE
(HISMANAL), TERFENADINE (SELDANE),
H1 BLOCKING ANTIHISTAMINES
DRUG
AS PAR UR MET ON VA COST/DAY*
DIPHENHYDR
-
+++
++
HEP
<30
-
$0.85
HYDROXYZINE
o
+++
+++
REN
<30
-
$0.90
TERFENADINE
+
+++
++
HEP
>60
+
ASTEMIZOLE
+
+++
++
HEP
>120
+
LORATADINE
+
+++
++
HEP
>60
-
$2.50
++++ +++
REN
<60
-
$2.10
HEP
>60
-
$2.40
CETIRIZINE
FEXOFENADINE
++
+
+++
++
* DAILY COST TO PATIENT OF 30 DAY PRESCRIPTION (AVERAGE
OF SMITHS, DANS, WALMART, UUMC) IN SLC, UTAH, USA SEPT 2003
SUMMARY
• ASTHMA
 IF MILD, ALBUTEROL ± IPRATROPRIUM
 IF MODERATE, ABOVE PLUS SYSTEMIC CORTICOSTEROIDS
 IF SEVERE, ABOVE PLUS SYSTEMIC BETA AGONISTS – GET CXR
AND ABGs
 EPINEPHRINE DRIP – AVOID ET INTUBATION
• ANAPHYLACTIC SHOCK
 MOST IMPORTANT IS MASSIVE IV CRYSTALLOID INFUSION
 EPINEPHRINE 0.05-0.1 mg IV
 ANTIHISTAMINES, STEROIDS?
• ACUTE URTICARIA/ANGIOEDEMA
 DIPHENHYDRAMINE 25 mg IV
 H2 BLOCKER IV
 EPI IF SUSPECT ANGIOEDEMA, ESP. OF THE LARYNX