Transcript Anaphylaxis - Komal Boyal, R2

Family Medicine 99 topics presentation
By: Komal Boyal R2
January 7, 2016
 19 year old woman with a past history of seasonal allergic
rhinitis presented to her family doctor’s office for routine
injection of allergen immunotherapy. Never had a problem
with her injections. She received her injection and after
waiting in the office for 15 minutes afterwards, left without
problems. 5 minutes later, developed itching palms, then
SOB with sensation of throat swelling. Returned to office:
flushed, sweating, moderate distress.
Various combinations of over 40 different signs/symptoms:
 Respiratory (70 %)
 Lower airway: cough, wheeze-bronchospasm, dyspnea, hypoxemia, chest tightness
 Laryngeal: stridor, hoarseness, dysphonia, itching/tightness in throat
 Nose: itching, congestion, rhinorrhea, sneezing
 Cardiovasular (45%)
 hypotension, syncope, collapse, hypotonia, incontinence
 Skin (90%)
 generalized hives, pruritis, flushing, angioedema – swollen lips/tongue/uvula, hair
standing on end – pilor erection
 Gastrointentestinal (45%)
 crampy abdominal pain, nausea, vomiting, diarrhea, dysphagia
 Neurologic
 Other: Uterine Cramps
1. Acute onset of an illness
(minutes to several hours)
with involvement of the skin,
mucosal tissue, or both
2. TWO or MORE of following
that occurs rapidly (minutes to
several hours) after exposure to
LIKELY allergen for that patient:
3. Reduced BP after exposure to
KNOWN allergen for that patient
(minutes to several hours)
a) Involvement Skin/Mucosal
tissue
b) Respiratory Compromise
c) Reduced BP or associated
symptoms
d) Persistent GI symptoms
a) Infants and Children – low SBP
(age specific) or greater than
30% decrease in BP
b) Adults – SBP less 90 or greater
than 30% decrease
AND atleast ONE of the
following:
a) Respiratory compromise
b) Reduced BP or associated
symptoms (syncope, collapse)
 What is low systolic BP?
 1 month to 1 year – less than 70
 1 year to 10 years – 70 + (2 x age in years)
 10 to 18 – less than 90
 Diagnostic Criteria same, but some key notes that make diagnosis difficult:
-sometimes first manifestation of sensitization to allergen, so caregivers may not
realize
-subjective symptoms cannot be described
-many signs/symptoms are nonspecific: regurgitation or spitting up after eating,
flushing, hoarseness/dysphonia after crying spell, loss of sphincter control)
-may manifest as sudden onset lethargy/hypotonia, abrupt cessation of
activity/play, clinging to caregiver
-study of 605 children presenting to emerg with food related anaphylaxis (by-far
most common cause in children), MOST were < 2 yrs, and MOST presented with
hives and vomiting
 Mild/Self limiting vs Severe/Progressive
Compensatory Physiologic Response (endogenous production of epinephrine,
endothelin, angiotensin II, others)
 In Series of 164 fatalities from anaphylaxis, median time from onset to
cardiac/respiratory arrest:
 5 minutes in Iatrogenic Anaphylaxis
15 minutes in stinging insect venom anaphylaxis
30 minutes in food induced anaphylaxis
 Protracted Anaphylaxis – lasts for hours, days or even weeks in severe cases
 Biphasic Anaphylaxis – recurrence of anaphylaxis without additional exposure
When?
Usually 1-8 hours
Evidence shows: Up to 38 hours (mean 10
hours)
How common?
4.5-23% of all ages
11% of children
How Severe?
-1/3 more severe
-1/3 as severe
-1/3 less severe
 Acute systemic reaction:
 Involving IgE dependent mechanisms (most common)
 Involving other immunologic mechanisms (former- anaphylactoid)
 Occuring independently of any immunologic process due to direct release of
histamine/mediators from mast cells/basophils
 No obvious trigger/mechanism
**ACUTE MANAGEMENT SAME NO MATTER WHAT MECHANISM**
Anaphylactoid
 IgE Mediated MOST COMMON Triggers:
- Insect stings
-opiates
-NSAIDS
-Radiocontrast Dyes
- Medications
- Latex
- Peanuts
- Tree nuts (walnuts, pistachios, pecans, cashews, almonds,
hazelnuts)
- Shellfish and fish
Direct Release
Histamine/Mediators
-Exercise Induced Anaphylaxis
-Cold induced
-UV light
- Milk
- Egg
- Wheat
No Trigger
-Idiopathic anaphylaxis
 The highest incidence in individuals aged 0 to 19 years. Food is the most common
cause of anaphylaxis in children, adolescents and young adults.
 In middle-aged and older adults, medications and insect venom are the most
common causes.
 1. In all patients always inquire about any allergy and clearly document in the
chart. Re-evaluate this periodically.
 2. Clarify the manifestations of a reaction in order to diagnose a true allergic
reaction (ie. Do not misdiagnose viral rash as antibiotic allergy or medication
intolerance as true allergy)
Co-morbidities – Risk factors for poor outcomes from anaphylaxis
Asthma
Cardiovascular disease
Delay in giving Epinephrine
Medications – block response to treatment and compensatory physiologic response
Beta-blockers - Role for Glucagon for patients taking B-Blockers
Alpha-blockers
ACE/ARB
In Emerg Study – using anti-HTN meds in aggregrate associated with increased organ
system involvement and hospital admission in anaphylaxis patients
Anaphylaxis is CLINICAL DIAGNOSIS
Blood tests can be used to support, but negative test cannot refute clinical diagnosis
Need to draw soon after symptom onset
 Serum or Plasma total tryptase (15 minutes to 3 hours)
 Insect stings, medications, hypotension more reliable
 If still elevated 24 or more hours later: REFER allergist ?systemic mastcytosis
 Plasma histamine (15 minutes to 60 minutes) – not as practical
 Potential Future Tests
 GOAL: rapid, sensitive, specific lab test or panel of tests that helps clinicians to
confirm the diagnosis of anaphylaxis in real time
 Common Differential: Asthma, Acute generalized urticarial, acute angioedema, syncope, panic
attack, aspiration foreign body, caustic ingestion (children), CV events (MI, PE), Neurologic
events (seizure CVA)
 Postprandial Syndromes “restaurant syndromes”(Scombroidosis, pollen food allergy syndrome,
MSG, Sulfites, food poisoning)
 Excessive production of Endogenous histamine (mast cell activation syndrome, aka mastocytosis,
basophilic leukemia)
 Flush Syndromes (perimenopause, carcinoid syndrome, autonomic epilepsy, medullary
carcinoma of the thyroid)
 Other non-organic disease (vocal cord dysfunction, hyperventilation, psychosomatic episode)
 Shock (hypovolemic, cardiogenic, septic, distributive)
 Other (non allergicangioedema, ACE angioedema, systemic capillary leak syndrome, red man
syndrome (vancomycin), pheochromocytoma (paradoxical response)
NO ABSOLUTE CONTRAINDICTATIONS TO GIVING EPINEPHRINE
GIVE if known or even SUSPECTED ANAPHYLAXIS
EPINEPHRINE and ABC ASAP
1. REMOVE INCITING AGENT IF POSSIBLE
2. CALL FOR HELP
3. IM EPINEPHRINE – prognosis related to Time to Epi – several case series evidence
4. POSITION: SUPINE WITH LE ELEVATED
5. SUPPLEMENTAL O2
6. VOLUME RESUSCITATION WITH IV FLUIDS
7. IV epinephrine IF no response to above
8. Adjunctive agents (H1, H2 blockers, Steroids, Bronchodilators)
 Maximize perfusion to vital organs
 Pregnant patients: position in LEFT lateral
recumbent position
 Prevent Empty Ventricle Syndrome – severe
hypotension causing inadequate cardiac
filling and PEA (H’s and T’s) – DEATH
imminent in seconds
 IF vomiting/resp distress and cannot tolerate
recumbent position, place in position of
comfort with leg elevated
 MASSIVE fluid shifts could occur
 Due to increased vascular permeability
 Up to 35% transfer of intravascular fluids into extravascular space within minutes
 Hypotension not responding promptly and completely to injected Epi should be
assumed to have IV volume depletion
 Large volume fluid resuscitation with normal saline may be needed
 Epinephrine 1: 1000 (1mg/ml) : IM mid-lateral thigh, Q 5- 15 minutes PRN
 ADULTS: 0.3-0.5 ml
 CHILDREN: 0.01 mg/kg (up to 0.3 ml) – for large children (>50 kg) max is 0.5 ml
BEST option based on available evidence and observation
 Decreases mediator release of mast cells (B2 agonist effect), prevents or reverses
airflow obstruction (upper and lower) (B2 agonist effect), prevents or reverses CV
collapse ( A1 agonist effects)
IF NO RESPONSE TO IM epi and aggressive fluid resusications:
 IV epinephrine by SLOW IV – preferably by clinicians trained/experience giving
pressors and can titrate rate based on response. IV dose needs to be diluted from IM
dose
 Furthermore should be given via Central line infusion as Epi is vesicant (blistering
agent – can cause chemical skin/mucosal burns)
ADVERSE EFFECTS OF EPI: RARE and
especially after overdose
 Angina, MI, ventricular arrhythmias,
Pulmonary edema, sudden sharp increase
in BP, intracranial hemorrhage
 IV bolus injection or Rapid IV infusion
 Accidental IV Injection of 1 mg/ml (1: 1000)
solution instead of diluting Epi to IV dose
(1: 10000)
 Subgroup of higher risk patients – CV
disease, taking MAO/TCA/stimulant drugs,
uncontrolled hyperthyroid/HTN etc
 BENEFIT>RISK
 Only available in:
 0.15 mg (Epi Pen Jr or Allerject 0.15) – children less
than 25 kg
 and 0.3 mg (Epi pen or Allerject 0.3) – children more
than 25 kg and adults
-ALLERJECT recall, health Canada
HOW MUCH EPI?
-most patients will only need 1, especially if given
promptly
-if more needed: typically 1, RARELY 2 additional doses
Retrospective studies: 2nd dose needed 12-36 % of cases
Patient should carry 2 epi-pens – TEACH HOW TO USE
 CSACI Statement on Allerject Recall:
“As you are likely aware, Sanofi Canada has voluntarily recalled all lots
of Allerject epinephrine auto injector devices, due to concerns about
potentially inaccurate dosing. This recall includes all Allerject devices
that have been dispensed in Canada (both 0.15 mg and 0.3 mg
strengths). Plans are in place for patients to exchange their Allerject
devices for replacement EpiPen devices at their local pharmacy, at no
cost to the patient. No prescription is needed to make this exchange.
Due to the large demand and limited EpiPen supply, it may take some
time for this exchange to be completed. Pfizer Canada, the distributor
of EpiPen, is working to increase EpiPen supply quickly. In the
meantime, while families are waiting for their EpiPen replacement
device, they should not hesitate to use their Allerject in the event of
anaphylaxis, following the directions they have been previously given
by their physician.”
 For patients on Beta Blockers – GLUCAGON 1 mg IM
 Refractory to Epinephrine – Refractory hypotension and bradycardia
 Glucagon as inotropic and chronotropic effects Not mediated through Beta
receptors
 DOSE: can be repeated or followed by infusion
 Adults – 1-5 mg IV over 5 minutes
 Children – 20 – 30 mcgs/kg to max 1 mg IV over 5 minutes
Rapid glucagon can cause vomiting, protect the airway (placement in lateral)
 NONE of these treatments to be used as initial treatment or sole treatment
HI Antihistamines
-most commonly administered medication in treatment of anaphylaxis
-only effective for skin manifestations (hives, itch) – NOT RESP/CARDIO
-over reliance
-onset of action of cetirizine/Benadryl: 30-40 minutes
-In Emerg: consider diphenhydramine 25 – 50 mg IV for adults or diphenhydramine
1 mg/kg (max 40 mg) IV for children < 40 kg. Give PO if tolerating.
 H2 Antihistamines
-because blocking 2 histamine receptors is better than 1!
-H2 with H1 antihistamine for additional skin reaction relief
-no randomized controlled trials to support use in anaphylaxis OR EVEN for
urticarial
-In EMERG: ranitidine – 50 mg (adults) or 12.5 – 50 mg (children 1mg/kg) diluted in
5% dextrose. Give 20 ml injected over 5 minutes. Or PO Ranitidine 150 mg.
Watch for hypotension (antihistamines infused rapidly can drop BP)
 Bronchodilators
-bronchospasm not responsive to epinephrine
-no relief of mucosal edema in upper airway or shock (need Alpha agonist)
 Glucocorticoids
-onset takes several hours, NOT for initial signs/symptoms
-rational: to prevent biphasic or protracted anaphylaxis
-EVIDENCE: systematic review 2012 – failed to find any randomized controlled trials that
confirmed this
-IN EMERG: methylprednisolone IV or prednisone PO
-can be stopped after 1-2 days w/o taper
-all biphasic reactions reported to date within 72 hours
 H1 antagonist: Cetirizine 10mg po daily or benadryl
50mg po daily x 3 days
 H2 antagonist ranitidine 150mg po daily x 3 days
 Corticosteroid: prednisone 50mg po daily x 5 days
FROM CSACI 2014 guideline
 Observation Period
-for biphasic reaction
-no consensus for optimal period
-suggested minimum 4-8 hours if resolved promptly/completely or longer if risk for
severe anaphylaxis (asthma, history of biphasic or history of protracted)
-admitted for observation otherwise
 Disposition Meds
 Remain with someone who can supervise for 48 hours
Anaphyaxis Emergency Action Plan
Outlining how to identify symptoms, when to give Epi, How much
Return for immediate reassessment if symptoms occur or epipen
used
Epinephrine auto-injector – preferably leave hospital with injector vs
Rx
Teach how to self administer
Medic Alert Bracelet
Counselling and Education
Resources for Anaphylaxis for your patients:
1. Food Allergy and Anaphylaxis Network :
www.foodallergy.org/anaphylaxis.html
2. Anaphylaxis Canada:
www.anaphylaxis.org
3. Canadian Society of Allergy and Clinical
Immunology: http://csaci.medical.org
Children – educate and equip (with epipen) child, teachers and
caretakers
Epi pen for house, car, school, daycare (epipen x 4)
Referral to Allergist – for clarification of allergen if unknown
(blood/skin tests), AVOID Allergen, possible
immunotherapy/desensitization if indicated
 LIST 4 features that would constitute a diagnosis of anaphylaxis:
1.
2.
3.
4.
 LIST 3 of the most common causes of anaphylaxis:
1.
2.
3.
 What dose of Epi should be given?
 How many percent of patients have biphasic reaction?
 After acute management of anaphylaxis, how should she be managed?
1.
2.
3.
4.
BONUS: FOOD with known cross sensitivity to latex?
 Up To Date
 Diagnosis and Management of Anaphylaxis – CMAJ Aug 19 2003, 169 (4), by Anna
K. Ellis, James H. Day
 Anaphylaxis. Journal Allergy and Clinical Immunology 2010; 125: S161
 http://www.nasn.org/portals/0/Anaphylaxis/web/faq.html
 http://www.iainfoctr.com/anaphylaxis/ana-causes.php
 http://store.mcguff.com/products/3346.aspx
 http://www.jacionline.org/article/S0091-6749(12)01042-1/abstract - Anaphylaxis
during pregnancy
 http://www.csaci.ca/pdf/2015_March_Anaphylaxis_in_Schools_&_Other_Settings,_
3rd_Edition.pdf