Anaphylaxis - Acute
Rahul Soman, M. Pharm
Definition
A sudden, severe, potentially life-threatening allergic reaction
Medical History
* Atopy
* Drug allergy
* Hymenoptera sting
* Food anaphylaxis
* Latex allergy
* Anaphylactoid reaction to radiocontrast media
Findings
* Dyspnea - Acute
* Hypotension
* Increased heart rate
* Stridor
* Syncope - Acute
* Wheezing
* Airway edema
* Angioedema - Acute
* Bradyarrhythmia - Acute
* Chest pain - Acute
* Palpitations - Acute
* Tachypnea
* Abdominal pain - Acute
* Anxiety
* Erythema
* Nausea and vomiting - Acute
* Pruritus - Acute
* Urticaria - Acute
Tests
Suspected allergy
* Type 1 hypersensitivity skin test: Skin test results may reveal the presence of IgE sensitivities to allergens and may suggest the cause of anaphylaxis .
Suspected allergy
* Allergen specific IgE antibody measurement: A finding of allergen specific IgE antibodies may identify the cause of an allergic reaction .
Suspected anaphylaxis .
* Serum tryptase level: A ratio of total tryptase to beta-tryptase of 10 or less indicates anaphylaxis; a ratio of 20 or greater is suggestive of systemic mastocytosis .
Suspected food allergy
* Gastrointestinal food challenge: If the history and other test findings are inconclusive in a patient with suspected food allergy, oral food challenge testing may be indicated .
Suspected anaphylaxis
* Urine N-methyl histamine measurement: Elevated urinary N-methyl histamine levels may be used to help confirm anaphylaxis and to screen for mastocytosis .
Differential Diagnosis
* Anaphylactoid reaction
* Vasovagal syncope
* Flushing
* Postprandial syncope
* Acute respiratory distress
* Hypotension, acute
* Angioedema - Acute
* Pheochromocytoma - Acute
* Systemic mast cell disease
* Disorder of nervous system
Treatment
Drug Therapy
Treatment of choice for acute anaphylaxis
EPINEPHRINE
Adults: 1:1000 (1 mg/mL) 0.2 to 0.5 mL IM or subcutaneously every 5 minutes as needed to control symptoms and increase blood pressure
Pediatrics: 0.01 mg/kg (maximum 0.3 mg) IM or subcutaneously every 5 minutes as needed to control symptoms and increase blood pressure
Treatment of bronchospasm refractory to epinephrine
Albuterol (Related toxicological information in ALBUTEROL)
Adults: 2.5 to 5 mg in 3 mL saline via nebulizer every 20 minutes for 3 doses, then give 2.5 to 10 mg mg every 1 to 4 hours as needed OR 10 to 15 mg/hour continuous nebulization
Pediatrics: 0.15 mg/kg (minimum dose 2.5 mg) every 20 minutes for 3 doses, then give 0.15 to 0.3 mg/kg up to 10 mg every 1 to 4 hours as needed OR 0.5 mg/kg/hour by continuous nebulization
Adjunctive therapy for anaphylaxis associated with urticaria-angioedema or pruritus
DIPHENHYDRAMINE HYDROCHLORIDE
Adults: 25 to 50 mg IV or orally for milder attacks
Pediatrics: 1 mg/kg (up to 50 mg) IV or orally for milder attacks
RANITIDINE HYDROCHLORIDE
Adults: 1 mg/kg IV infused over 10 to 15 minutes or diluted in 5% dextrose to a total volume of 20 mL and injected over 5 minutes
Pediatrics: 12.5 to 50 mg IV infused over 10 to 15 minutes
Adjunctive therapy for anaphylaxis associated with urticaria-angioedema or pruritus in adults
CIMETIDINE
Adults: 4 mg/kg IV administered slowly
Severe or prolonged anaphylaxis or history of idiopathic anaphylaxis and asthma
METHYLPREDNISOLONE
Adults: 1 to 2 mg/kg/day IV in divided doses every 6 hours
Self-treatment for patients with a history of anaphylaxis
EPINEPHRINE
Adults: EpiPen® or Twinject™ 0.3 mg IM (anterolateral thigh) as needed
Pediatrics (body weight 22 to 55 pounds [10 to 25 kg]): EpiPen Jr® or Twinject™ 0.15 mg IM (anterolateral thigh) as needed
Pediatrics (body weight over 55 pounds [25 kg]): EpiPen Jr® or Twinject™ 0.3 mg IM (anterolateral thigh) as needed
Procedural Therapy
Respiratory distress
* Airway management: Airway management must assume the first priority in the management of any seriously ill or injured patient .
Patients with an anaphylactic reaction and hypotension
* Intravenous fluid replacement: In anaphylactic reactions with hypotension, large volumes of crystalloid (normal saline or lactated Ringers) should be rapidly administered .
Monitoring during treatment for anaphylaxis
* Cardiac monitoring: Cardiac arrhythmias, conduction defects, and myocardial ischemia may occur during anaphylaxis and treatment with epinephrine .
Cardiac arrest
* Basic life support: Victims of cardiac arrest need immediate cardiopulmonary resuscitation, and survival improves with early defibrillation .
Cardiac arrest
* Advanced cardiac life support: Establishing a hemodynamically effective cardiac rhythm, optimizing ventilation, and maintaining and supporting circulation are the major goals of ACLS .
Non-Procedural Therapy
Anaphylaxis
* Avoidance of precipitating factors
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