management of anaphylaxis

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  • 1. Im all Itchy Anaphylaxis in the Pediatric ER Dr. Rebecca Starr Pediatric Emergency Medicine Fellow February 6, 2014 certifiedallergysa.com
  • 2. Objectives Discuss the most current definition of anaphylaxis Explain the causes and pathophysiology of anaphylaxis Analyze symptoms and be able to diagnose and effectively treat anaphylaxis Review biphasic anaphylactic reactions List appropriate discharge materials from the ED
  • 3. Question 1 A 5 year old M who has experienced a severe allergic reaction to shrimp in the past needs a CT scan with IV and oral contrast. What precautions should you take? A. NS bolus and diphenhydramine B. NS bolus, diphenhydramine, and prednisone C. This patient can not receive contrast D. Reassurance, there is no associated risk for a reaction between shellfish and contrast
  • 4. Question 2 You have been asked by a local school to provide recommendations about the use of self injectable epinephrine for anaphylaxis. What is the BEST response to give regarding anaphylaxis? A. A patient should not receive a second dose of epinephrine unless a physician is present B. Epinephrine reaches higher peak plasma concentrations when injected into the thigh rather than the arm C. Families should keep one epinephrine auto injector in the car in case a reaction occurs after school D. Subcutaneous injection of epinephrine is preferable to intramuscular injection
  • 5. Question 3 A 14 y/o M who has seasonal allergies and moderate persistent asthma is currently receiving allergen immunotherapy. Today in clinic he received his usual allergen injection, but after 10 minutes, he started coughing and complaining of dyspnea and throat swelling. On physical exam he exhibits moderate respiratory distress and has diffuse expiratory wheezing on auscultation. No oropharyngeal edema noted. Vitals signs include a pulse ox of 97%, BP of 130/70, and HR of 90. Of the following, the MOST appropriate next action is to administer: A. A short acting beta-2 agonist nebulization B. An oral antihistamine C. An oral corticosteroid D. Intramuscular epinephrine
  • 6. Question 4 A 10 y/o M with a history of peanut allergy presents with diffuse itching and trouble breathing after eating a friends candy bar that contained nuts during school lunch. At the nurses office the patient received IM epinephrine with his EpiPen with symptom resolution. EMS was called and the patient was brought to the local pediatric ED (about a 12 minute ride). On arrival to the ED, the patient is again complaining of itching with an urticarial rash on his chest and per EMS the patient began vomiting as they were pulling up to the ambulance bay. Arrival vitals include a pulse ox of 96%, BP of 88/67, and HR of 95. Of the following, the MOST appropriate treatment plan is: A. Intramuscular epinephrine, oral antihistamine, oral corticosteroid, and a short acting beta-2 agonist neb treatment B. Intramuscular epinephrine, IV antihistamine, IV corticosteroid, NS bolus C. Intramuscular epinephrine, IV antihistamine, IV Zantac, NS bolus D. Intramuscular epinephrine, oral antihistamine, and oral corticosteroid
  • 7. What is Anaphylaxis? Big Bang
  • 8. Anaphylaxis 411 Severe allergic reaction that can be life threatening IgE-mediated hypersensitivity reaction resulting in the release of potent chemical mediators Mast Cells Basophils Affects multiple organ systems Respiratory Cardiovascular Gastrointestinal Dermatologic Clinical Diagnosis Biphasic Reactions Russell et al.,Pediatric Emergency Care, 2010
  • 9. Clinical Definition
  • 10. History First death from anaphylaxis was documented in Egyptian hieroglyphics in 2641 BC Pharaoh Menes dying after a hornet sting Questionable and now not supported by historians
  • 11. History First described in scientific literature in 1902 by two French physiologists, Charles Richet and Paul Portier Prince Albert I of Monaco Investigating jellyfish toxins Initially coined aphylaxis with a meaning contrary to and phylaxis meaning protection Richet won the Nobel Prize in Medicine Lane et al, Pediatric Emergency Care, 2007
  • 12. Pediatric Epidemiology 10.5 per 100,000 Increasing over the past 4 decades 2:1 Male to female ratio 25% require admission 1500 deaths per year in US (adults and children) 40% had prior history of allergic reaction Only 20% of prior anaphylaxis patients had an Epipen available during repeat anaphylaxis encounter Lane et al, Pediatric Emergency Care, 2007 Russell et al.,Pediatric Emergency Care, 2010
  • 13. Pediatric Epidemiology Severity of a previous reaction does not predict the severity of a subsequent reaction Previous anaphylactic reactions = higher risk for reoccurrence Lane et al, Pediatric Emergency Care, 2007
  • 14. Causes of Anaphylaxis
  • 15. Causes of Anaphylaxis Food Leading cause of all anaphylaxis in children 50% of anaphylactic triggers Peanuts, tree nuts and shellfish are the most common Usually the most life-threatening reactions Older children Milk, soy, eggs Most common in younger children Potential to outgrow Food dyes Lane et al, Pediatric Emergency Care, 2007 Russell et al.,Pediatric Emergency Care, 2010
  • 16. Causes of Anaphylaxis Medications 24% of anaphylactic triggers Antibiotics most common- PCN and cross reaction drugs to PCN Penicillin-allergic individuals have a 4-10% risk of allergic reaction to a cephalosporin Only antibiotic that can have skin testing (for IgE mediated rxn) NSAIDs Latex- chronic patients and multiple surgeries IV contrast Propofol- sedative medication that contains eggs and soy Blood products, IVIG, etc Lane et al, Pediatric Emergency Care, 2007
  • 17. Causes of Anaphylaxis Hymenoptera envenomation 12% of anaphylactic triggers Honeybees, yellow jackets, hornets, wasps, and fire ants Life threatening reactions require venom immunotherapy 20-60% risk per sting of anaphylaxis Lane et al, Pediatric Emergency Care, 2007
  • 18. Causes of Anaphylaxis Immunizations- estimated 1.5 events per 1 million MMR and influenza are the most common Prepared using chick-derived cells AAP recommends giving MMR to children with egg sensitivity Per CDC, egg sensitivity a contraindication for influenza vaccine Unknown exposure 16% of anaphylactic triggers
  • 19. Contrast Media Anaphylactoid reaction- not IgE mediated Osmolality-hypertonicity reaction Triggers degranulation of mast cells and basophils Association of shellfish allergy and contrast media (because of iodine content) is a myth Pretreatment with prednisone and diphenhydramine is only indicated in documented history of an adverse reaction to contrast media
  • 20. Question 1 A 5 year old M who has experienced a severe allergic reaction to shrimp in the past needs a CT scan with IV and oral contrast. What precautions should you take? A. NS bolus and diphenhydramine B. NS bolus, diphenhydramine, and prednisone C. This patient can not receive contrast D. Reassurance, there is no associated risk for a reaction between shellfish and contrast
  • 21. Question 1 A 5 year old M who has experienced a severe allergic reaction to shrimp in the past needs a CT scan with IV and oral contrast. What precautions should you take? A. NS bolus and diphenhydramine B. NS bolus, diphenhydramine, and prednisone C. This patient can not receive contrast. D. Reassurance, there is no associated risk for a reaction between shellfish and contrast.
  • 22. Route of Exposure Insect stings and parenterally injected medication may have rapid onset of symptoms PO ingestions may develop over several minutes to hours Most symptoms occur within 5-30 minutes post exposure Lane et al, Pediatric Emergency Care, 2007
  • 23. Pathophysiology First time exposure to the allergen Specific IgE antibodies are formed around the allergen and bind to Fc receptors on mast cells Repeat allergen exposure and binding of the allergen to IgE antibodies causes degranulation of mast cell Massive release of chemical m