Anaphylaxis CASE PRESENTATION

Content

The case & case analysis

Triggers & pathogenesis of the disease

Signs & symptoms of the disease

Potential medical problems & medical diagnostic tests

Management of the disease

Oral manifestation

How to prevent complication in the dental chair

Treatment plan modification

The Case

You have given an adult patient who needs antibiotics cover 3 g of amoxicillin orally and asked him to take a seat in a waiting room. whilst you are treating your next patient. Your receptionist rings through to tell you that the patient you have just sent to waiting room is behaving strangely and appears to be flushed making wheezing noises and his face and lips are becoming swollen.

Case Analysis

AVAILABLE INFORMATION

Adult male

Needs antibiotics cover

Given 3 g of amoxicillin orally

Then he behaved strangely and appears to be flushed making wheezing noises and his face and lips are becoming swollen

MISSING INFORMATION

The chief complaint of the patient?

Why he need antibiotic coverage?

Medical and dental history including any allergy or systemic disease?

Conditions in which Antibiotics Coverage (Amoxicillin) is Recommended prior to Dental Procedures

Allergic Reactions to AmoxicillinTrue allergic reactions to amoxicillin are mediated by the immune system and are classified into:◦ immediate (developing within 30 to 60 minutes of drug ingestion)

◦ non-immediate (beyond 1 hour of ingestion)

Immediate reactions may range in severity from eruptions limited to the skin (hives/angioedema) to reactions involving more than one organ system or hypotension ( which is anaphylaxis)

Anaphylaxis Triggers

Food such as, to peanuts, nuts, fish, shellfish and milk

Certain medications, including antibiotics such as (penicillin and its related drugs), aspirin and the intravenous (IV) contrast used in some imaging tests

Stings from bees and other insects

Latex

Exercise

The Pathophysiology of

This sudden release, results in a sudden drop

in blood pressure flushing, itching,

potentially respiratory compromise and potential death

How Anaphylaxis is diagnosed?

History: If individuals are alert and coherent, they may be able to relate a history of previous episodes of anaphylaxis. The specific history is not important at this time

Physical exam (signs and symptoms):

Tests: No immediate tests are required to establish the diagnosis. Test are done later to confirm the allergy

Diagnostic Tests

Skin prick test Placing a small amount of amoxicillin on the skin, most often on the forearm, upper

arm, or back

The diameter of the wheal is measured after 15 minutes and the reaction is considered positive when the diameter is larger and itchy comparing to the negative control

Intradermal test injection of a small amount of the amoxicillin diluted in normal saline under the surface

of the skin. After approx. 20 minutes the area is examined for a reaction at the site

Diagnostic Tests

Drug Provocation Test (graded dose challenge )Drug challenges are considered to be the gold standard in establishing a definitive

diagnosis of an allergic reaction to drugs

The starting dose for a graded challenge is usually 1/100 of the full dose, and 10-fold increasing doses are administered every 30 to 60 minutes until the full therapeutic dose is reached

Among diagnostic procedures used to confirm the presence of amoxicillin allergy, the oral challenge is considered to have the highest sensitivity

Medical Problems of Anaphylaxis

Anaphylaxis is an acute, life-threatening emergency

The most life-threatening manifestations of anaphylaxis if not treated immediately are total obstruction of the airway due to tissue swelling and circulatory collapse (shock)

Management of Anaphylaxis Immediate action◦ 1. Identify anaphylactic reaction

◦ 2. Remove allergen (if still present)

◦ 3. Activate EMS

◦ 4. Place the patient in supine position. If breathing is difficult, allow them to sit

◦ 5. assess the airway, breathing, circulation

◦ 6. Give IM injection of Epinephrine without delay

◦ 1:1000 IMI into the anteriolateral thigh, 0.3-0.5 mg , repeat every 5 minutes as needed

Why epinephrine first? It counteract the most severe symptoms of anaphylaxis (cardiovascular and

respiratory)

This parameter was developed by the Joint Task Force on Practice Parameters, representing the American Academy of Allergy, Asthma and Immunology; the American College of Allergy, Asthma and Immunology; and the Joint Council of Allergy, Asthma and Immunology. 2015 update

Management of Anaphylaxis Other intervention based on initial response

◦ Establish a patent airway and administer oxygen

◦ If required at any time, commence CPR

◦ Bronchodilators (if difficulty in breathing)

◦ H1&H2 antihistamines (until swilling diminishes)

◦ Oral steroids ( to reduce the risk of symptoms recurrence after a severe reaction)

Management of Anaphylaxis Follow-Up and Observation after Anaphylaxis

All patients discharged from the emergency department should have immediate access to epinephrine auto injectors and properly instructed on how to self-administer it in case of a subsequent episode

Biphasic anaphylaxis (recurrence rate is up to 20%)

Patients with severe anaphylactic reactions are at risk of biphasic or rebound anaphylaxis

The Most biphasic responses occur during the first 8 hours, but it might be delayed up to 72 hours

Epinephrine auto-injector Device is designed to give a predefined dose of intramuscular epinephrine

Oral Manifestation of Anaphylaxis

Rapid urticarial swilling or angioedema of the lips, tongue and soft tissues in general which may cause itching and burning.

Present 1-3 days if untreated and then will resolves spontaneously

How to Prevent Amoxicillin Anaphylaxis in the Dental Chair

Expanded and detailed medical history is important for all the patients before any dental procedures especially for patients reported with allergies Previous contact with amoxicillin

Reaction to amoxicillin

Allergic reaction to other agents

Avoid using amoxicillin and the penicillin derivatives in general if the patient is allergic to it

Always be prepare to deal with severe allergic reactions and have an emergency kit

Treatment Plan Modification

Other than avoiding the use of amoxicillin, and replacing it with cephalexin or clindamycin, no need for further modification in the treatment plan

Identify anaphylactic

reactionActivate EMS

Tell the patient to sit or lay comfortably

Assess vital signs and inject 0.3-

0.5mg epinephrine 1:1000 IM

Check for open airway, administer

oxygen

If necessary provide CPR, repeat injection of epinephrine

Take carful history, avoid amoxicillin in future appointment Summary

Tupper J, Visser S. Anaphylaxis: A review and update. Canadian Family Physician. 2010;56(10):1009-1011.

References1. Jotikasthira, Sasisakulporn, Rerkpattanapipat, Kamchaisatian, Manuyakorn, Singvijarn, &

Benjaponpitak,. (2016). Skin testing with β-lactam Antibiotics for Diagnosis of β-lactam Hypersensitivity in Children. Asian Pacific Journal Of Allergy And Immunology, 34(2), 242-247. http://dx.doi.org/10.12932/ap0750

2. Lieberman, P., Nicklas, R., Randolph, C., Oppenheimer, J., Bernstein, D., & Bernstein, J. et al. (2015). Anaphylaxis—a practice parameter update 2015. Annals Of Allergy, Asthma & Immunology, 115(5), 341-384. http://dx.doi.org/10.1016/j.anai.2015.07.019

3. Little, J., Falace, D., Miller, C., & Rhodus, N. (2013). Dental management of the medically compromised patient (8th ed.).

4. Simons, F., Ebisawa, M., Sanchez-Borges, M., Thong, B., Worm, M., & Tanno, L. et al. (2015). 2015 update of the evidence base: World Allergy Organization anaphylaxis guidelines. World Allergy Organization Journal, 8(1). http://dx.doi.org/10.1186/s40413-015-0080-1

5. Weisser, C., & Ben-Shoshan, M. (2016). Immediate and non-immediate allergic reactions to amoxicillin present a diagnostic dilemma: a case series. Journal Of Medical Case Reports, 10(1). http://dx.doi.org/10.1186/s13256-016-0801-2

Thank You

MCQsThe first line of anaphylaxis treatment is ◦ Antihistamines

◦ Corticosteroids

◦ Epinephrine

Anaphylactic reaction is mediated by

◦ IgG

◦ IgE

◦ IgM

The gold standard in establishing a definitive diagnosis of an allergic reaction to drugs

◦ Drug provocation test

◦ Skin prick test

◦ Intradermal test