Thursday, March 11, 2010

Anaphylaxis

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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