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Urticaria, Angioedema and Anaphylaxis in the Emergency Department Back to Basics 2011 Jennifer Clow MD, CCFP (EM) With slides by: Anita Pozgay, MD, FRCPC.

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Presentation on theme: "Urticaria, Angioedema and Anaphylaxis in the Emergency Department Back to Basics 2011 Jennifer Clow MD, CCFP (EM) With slides by: Anita Pozgay, MD, FRCPC."— Presentation transcript:

1 Urticaria, Angioedema and Anaphylaxis in the Emergency Department Back to Basics 2011 Jennifer Clow MD, CCFP (EM) With slides by: Anita Pozgay, MD, FRCPC EM

2 Case One A 7 year old comes in to the ED after an possible exposure to peanut butter A 7 year old comes in to the ED after an possible exposure to peanut butter He has a severe nut allergy for which he was prescribed an EpiPen He has a severe nut allergy for which he was prescribed an EpiPen He was recently admitted to PICU for a severe asthma attack but was not intubated He was recently admitted to PICU for a severe asthma attack but was not intubated Mom gave him some oral Benadryl and he is no longer itchy but still has lip swelling Mom gave him some oral Benadryl and he is no longer itchy but still has lip swelling

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4 Case One continued He is sent for a CXR due to decreased air entry in the lower lobes He is sent for a CXR due to decreased air entry in the lower lobes While in radiology, he becomes acutely SOB and his lip becomes more swollen While in radiology, he becomes acutely SOB and his lip becomes more swollen What do you do now? What do you do now?

5 Case Two A 45 y o woman involved in a MVC needs a CT abdo after she is stabilized in the ED A 45 y o woman involved in a MVC needs a CT abdo after she is stabilized in the ED She received 2 L NS for a hypotensive episode and her BP is now 120/70 She received 2 L NS for a hypotensive episode and her BP is now 120/70 She has a positive FAST U/S She has a positive FAST U/S Although her CXR is normal she has palpable lower rib fractures & a distended abdomen Although her CXR is normal she has palpable lower rib fractures & a distended abdomen

6 Case Two continued She is given both oral and IV contrast for her CT She is given both oral and IV contrast for her CT She becomes hypotensive again! She becomes hypotensive again! What do you do now? What do you do now? There is no rash There is no rash

7 Case Three A 67 y o man is stung by an insect while gardening A 67 y o man is stung by an insect while gardening He developed pruritus, dizziness, and SOB 20 min later so he called 911 He developed pruritus, dizziness, and SOB 20 min later so he called 911 He self-treated with Benadryl po and was given another 50 mg IV by EMS due to persistent sx and rash He self-treated with Benadryl po and was given another 50 mg IV by EMS due to persistent sx and rash He is now asymptomatic and refusing transport to hospital He is now asymptomatic and refusing transport to hospital

8 Case Three: Do you transport? EMS convinced him to get “checked out” in the hospital EMS convinced him to get “checked out” in the hospital On arrival, he becomes hypotensive, and his hives reappeared, along with facial edema On arrival, he becomes hypotensive, and his hives reappeared, along with facial edema An ECG shows T wave inversion in his lateral leads An ECG shows T wave inversion in his lateral leads PHx: MI, HTN, IV contrast allergy PHx: MI, HTN, IV contrast allergy Meds: ASA, metoprolol, lisinopril Meds: ASA, metoprolol, lisinopril

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10 Allergic Reactions Generalized: anaphylaxis/anaphylactic shock Generalized: anaphylaxis/anaphylactic shock Localized: Localized: Skin – dermatitis, urticaria, angioedema Skin – dermatitis, urticaria, angioedema Respiratory – rhinorrhea, angioedema, wheezing Respiratory – rhinorrhea, angioedema, wheezing GI – food intolerance (as contrasted with food allergy) GI – food intolerance (as contrasted with food allergy)

11 Definitions Anaphylaxis: a severe systemic allergic reaction involving 2 or more systems Anaphylaxis: a severe systemic allergic reaction involving 2 or more systems * hives/angioedema NOT universally present! Anaphylactic Shock: above, plus hypotension and other signs of shock Anaphylactic Shock: above, plus hypotension and other signs of shock Allergic reactions: localized reaction, involving a single system; e.g. urticaria, angioedema, contact dermatitis, rhinoconjunctivitis Allergic reactions: localized reaction, involving a single system; e.g. urticaria, angioedema, contact dermatitis, rhinoconjunctivitis

12 Urticaria versus Angioedema Both characterized by transient, pruritic, red wheals on raised serpiginous borders Both characterized by transient, pruritic, red wheals on raised serpiginous borders urticaria due to edema of dermis urticaria due to edema of dermis angioedema due to edema of subcutaneous tissues angioedema due to edema of subcutaneous tissues

13 Urticaria

14 AKA Hives AKA Hives Raised, well-circumscribed areas of edema and erythema involving the dermis and epidermis Raised, well-circumscribed areas of edema and erythema involving the dermis and epidermis Intensely pruritic Intensely pruritic May be acute or chronic (>6 weeks) May be acute or chronic (>6 weeks) Multiple types: IgE-mediated, chemical-induced, cholinergic, cold-induced, autoimmune, etc. Multiple types: IgE-mediated, chemical-induced, cholinergic, cold-induced, autoimmune, etc.

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20 Pathophysiology Mast cells and basophils release histamine, bradykinin, leukotrienes, prostaglandins into the dermis Mast cells and basophils release histamine, bradykinin, leukotrienes, prostaglandins into the dermis Causes fluid extravasation… leads to lesion Causes fluid extravasation… leads to lesion Pruritis is due to histamine release into the dermis Pruritis is due to histamine release into the dermis Multiple triggers: IgE mediated, others Multiple triggers: IgE mediated, others

21 Causes Causes: found in 40-60% of acute urticaria, and 10-20% chronic urticaria Causes: found in 40-60% of acute urticaria, and 10-20% chronic urticaria Include: Include: Infections, pregnancy, other medical conditions Infections, pregnancy, other medical conditions Foods, drugs, latex Foods, drugs, latex Environmental factors Environmental factors Stress Stress Cold/heat, exercise Cold/heat, exercise

22 History Previous episodes/causative factors Previous episodes/causative factors Medical history, medications, allergies Medical history, medications, allergies Possible precipitants: Possible precipitants: Recent illness or travel Recent illness or travel New medications or IV contrast New medications or IV contrast Foods, pets, exposures Foods, pets, exposures Changes in perfumes, lotions, clothes Changes in perfumes, lotions, clothes Exercise, temperature extremes, stress Exercise, temperature extremes, stress

23 Physical Exam Identify and confirm urticarial diagnosis Identify and confirm urticarial diagnosis Dermographism? Dermographism? Look for precipitants/other illnesses: Look for precipitants/other illnesses: Signs of infections: e.g. URTI, fungal infection Signs of infections: e.g. URTI, fungal infection Signs of liver/thyroid disease Signs of liver/thyroid disease Angioedema, respiratory changes (edema, wheezes) Angioedema, respiratory changes (edema, wheezes) Joint examination Joint examination Ensure no signs of anaphylaxis are present Ensure no signs of anaphylaxis are present

24 Treatment H1-blockers i.e. diphenhydramine, hydroxyzine H1-blockers i.e. diphenhydramine, hydroxyzine H2-blockers i.e. ranitidine H2-blockers i.e. ranitidine Act synergistically with H1 blockers Act synergistically with H1 blockers Doxepin 10-25mg tid-qid Doxepin 10-25mg tid-qid Glucocorticoids e.g. prednisone Glucocorticoids e.g. prednisone Stabilize mast cells, stopping histamine release Stabilize mast cells, stopping histamine release Anti-inflammatory effect Anti-inflammatory effect

25 Angioedema

26 Deep, subcutaneous, submucosal edema due to increased vascular permeability Deep, subcutaneous, submucosal edema due to increased vascular permeability May be episodic and self-limited, or recurrent May be episodic and self-limited, or recurrent May involve skin, buccal mucosa/tongue, larynx or GI mucosa May involve skin, buccal mucosa/tongue, larynx or GI mucosa Usually presents with urticaria: mast-cell mediated in these cases Usually presents with urticaria: mast-cell mediated in these cases

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30 Types Hereditary C1-esterase inhibitor deficiency Hereditary C1-esterase inhibitor deficiency Acquired: autoimmune/lymphoprolif. disorders Acquired: autoimmune/lymphoprolif. disorders Drug-induced (e.g. ACEI) Drug-induced (e.g. ACEI) Urticaria-associated Urticaria-associated Idiopathic (most cases) Idiopathic (most cases) Urticaria-associated is mast-cell mediated, all others are kinin-mediated Urticaria-associated is mast-cell mediated, all others are kinin-mediated

31 History Hereditary/idiopathic/drug-induced: Hereditary/idiopathic/drug-induced: Episodic, self-limiting episodes of edema Episodic, self-limiting episodes of edema Skin swelling, tongue swelling, abdominal pain Skin swelling, tongue swelling, abdominal pain Look for triggers Look for triggers Urticaria-associated: Urticaria-associated: Look for potential triggers: drugs, allergens, food allergies, hymenoptera Look for potential triggers: drugs, allergens, food allergies, hymenoptera History of atopy History of atopy

32 Physical Exam Acute onset of well-demarcated cutaneous edema of distensible tissues Acute onset of well-demarcated cutaneous edema of distensible tissues Usually face, limbs, genitals Usually face, limbs, genitals Assess airway Assess airway Abdominal examination Abdominal examination

33 Treatment AIRWAY management AIRWAY management Intubate early if any question Intubate early if any question Mild Angioedema Mild Angioedema Remove offending agent; self-limited Remove offending agent; self-limited Severe Angioedema Severe Angioedema H1, H2 blockers, corticosteroids H1, H2 blockers, corticosteroids Epinephrine Epinephrine

34 Anaphylaxis

35 Definition Severe allergic reaction (IgE-mediated) Severe allergic reaction (IgE-mediated) Requires prior-sensitization and re-exposure Requires prior-sensitization and re-exposure Rapid in onset, may cause death Rapid in onset, may cause death Usually includes prominent dermal and systemic manifestations Usually includes prominent dermal and systemic manifestations Full syndrome involves urticaria/angioedema, respiratory manifestations +/- GI upset Full syndrome involves urticaria/angioedema, respiratory manifestations +/- GI upset Anaphylactic shock: above + hypotension Anaphylactic shock: above + hypotension

36 Anaphylactic vs. Anaphylactoid Anaphylactoid has the same clinical features as anaphylaxis but is not IgE mediated Anaphylactoid has the same clinical features as anaphylaxis but is not IgE mediated Instead it is due to direct mast cell degranulation and thus, does not require prior sensitization Instead it is due to direct mast cell degranulation and thus, does not require prior sensitization

37 Pathophysiology Sensitization occurs when IgE adheres to the mast cell Ag (allergen) Sensitization occurs when IgE adheres to the mast cell Ag (allergen) IgE specific IgE specific Degranulation of mast cell mediators

38 Pathophysiology Re-exposure leads to antigen binding, and rapid release of mediators: Re-exposure leads to antigen binding, and rapid release of mediators: Histamines, leukotrienes, prostaglandins, tryptase Histamines, leukotrienes, prostaglandins, tryptase Leads to rapid onset of: Leads to rapid onset of: Increased secretion from mucus membranes Increased secretion from mucus membranes Increased bronchial smooth muscle tone Increased bronchial smooth muscle tone Decreased vascular smooth muscle tone Decreased vascular smooth muscle tone Increased capillary permeability Increased capillary permeability

39 Epidemiology Likely under reported due to lack of recognition or self treatment in the field Likely under reported due to lack of recognition or self treatment in the field in Ontario: 4 cases/ 1 million in Ontario: 4 cases/ 1 million in Germany: 10 cases/ in Germany: 10 cases/ in Minnesota, U.S.A.: 17/19,122 visits in Minnesota, U.S.A.: 17/19,122 visits in Brisbane, Australia: 1/440 visits in Brisbane, Australia: 1/440 visits

40 Common Causative Agents Drugs: Antibiotics, ASA, NSAIDS, sulfa, opioids, IV contrast dye Drugs: Antibiotics, ASA, NSAIDS, sulfa, opioids, IV contrast dye Foods: Peanuts, Seafood, Eggs, milk Foods: Peanuts, Seafood, Eggs, milk Latex gloves Latex gloves Insect Stings Insect Stings Physical Factors: Exercise (FDEIA), Cold/Heat Physical Factors: Exercise (FDEIA), Cold/Heat

41 Clinical Features CAPILLARY LEAK urticaria urticaria angioedema angioedema laryngeal edema laryngeal edema hypotension/syncope hypotension/syncope SMOOTH MUSCLE CONTRACTION abdominal cramps nausea rhinitis conjunctivitis MUCOSAL SECRETIONS bronchospasm bronchospasm diarrhoea diarrhoea vomiting vomiting

42 DDx: Anaphylaxis MI/arrhythmia/cardiogenic shock MI/arrhythmia/cardiogenic shock Airway obstruction due to other causes: FB aspiration, asthma, COPD, epiglottitis, peri- tonsillar abscess, etc. Airway obstruction due to other causes: FB aspiration, asthma, COPD, epiglottitis, peri- tonsillar abscess, etc. Flushing syndromes (eg: carcinoid) Flushing syndromes (eg: carcinoid) Vasovagal syncope Vasovagal syncope Panic attack Panic attack Scombroid poisoning Scombroid poisoning Hereditary angioedema Hereditary angioedema

43 History Skin: pruritis, edema Skin: pruritis, edema Respiratory: upper and lower tract symptoms Respiratory: upper and lower tract symptoms Rhinorrhea, congestion, dyspnea Rhinorrhea, congestion, dyspnea GI complaints GI complaints Nausea, vomiting, diarrhea, abdominal pain Nausea, vomiting, diarrhea, abdominal pain Try to elicit causes/triggers Try to elicit causes/triggers PMHx, allergies, previous episodes PMHx, allergies, previous episodes

44 Physical Examination Vitals, ABC’s Vitals, ABC’s General appearance General appearance Skin Skin Respiratory Respiratory Cardiovascular Cardiovascular

45 Grading of Anaphylaxis Grade Skin GI tract RespCVNeuro 1 Local pruritus, hives, mild lip swelling Oral “tingling”, pruritus 2 Generalized pruritus, hives, flushing, angioedema Above plus nausea +/- emesis Nasal congestion/ sneezing Activity change 3 Any of above Any of above + repetitive vomiting Rhinorrhea, sensation of throat tightness Tachy ( > 15 bpm) Above plus anxiety 4 Any of above Any of above + diarrhea Hoarseness dysphagia, SOB, cyanosis Above + arrhythmia +/- dec BP dizziness Feeling of impending doom 5 Any of above Any above + stool incont. Any above + resp arrest Brady +/- card arrest LOC

46 Management Questions? What is the first line of therapy? What is the first line of therapy? When do you give IV vs IM epi? When do you give IV vs IM epi? Do all patients need Epinephrine; corticosteroids? Do all patients need Epinephrine; corticosteroids? What is the role of combined H1 & H2 blockers? What is the role of combined H1 & H2 blockers? Who needs to be monitored? Referred? Who needs to be monitored? Referred? Who needs an EpiPen? Who needs an EpiPen?

47 Key Management of Anaphylaxis 1 st line of therapy: AWARENESS AWARENESS RECOGNITION RECOGNITION TREAT QUICKLY TREAT QUICKLY CALL FOR BACK-UP! CALL FOR BACK-UP!

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49 Management: Adult Epi dosing Epinephrine: Epinephrine: 0.3 mg (0.3 ml) 1:1000 solution IM (NOT SC or IV) may repeat in 5 min X 1 (empirical only but safe)

50 Epi: Pediatric Dosing (0.01 ml/kg) Age (yrs)Volume ofDose (mg) 1:1000 (1mg/ml) 10.1 ml ml0.2 > 40.3 ml0.3

51 EPI cautions: Co-morbidities Thyroid disease Thyroid disease Cocaine addicts Cocaine addicts CAD on BBlockers, ACEi CAD on BBlockers, ACEi Depression using MAOIs or TCAs Depression using MAOIs or TCAs

52 Mechanisms of Epinephrine Alpha agonist effects increase peripheral resistance, raise BP, reduce vascular leakage Alpha agonist effects increase peripheral resistance, raise BP, reduce vascular leakage Beta agonist effects cause bronchodilation, positive cardiac inotropy/chronotropy (caution in CAD pts!) Beta agonist effects cause bronchodilation, positive cardiac inotropy/chronotropy (caution in CAD pts!)

53 Dangers of Epinephrine IV Only use IV Epi if patient has refractory shock not responding to fluid bolus first Only use IV Epi if patient has refractory shock not responding to fluid bolus first dose 0.1 mg (10 ml) 1:100,000 dilution over 10 minutes dose 0.1 mg (10 ml) 1:100,000 dilution over 10 minutes must be on cardiac monitor must be on cardiac monitor caution in elderly or those with CAD caution in elderly or those with CAD may cause supraventricular/ventricular dysrhythmias! may cause supraventricular/ventricular dysrhythmias!

54 Management Do all patients need Epi? Epinephrine reverses mediator release while antihistamines (H1) do not Epinephrine reverses mediator release while antihistamines (H1) do not Epinephrine should be used for all systemic signs of allergy: airway edema (includes tongue/lips), SOB, cyanosis, hypotension Epinephrine should be used for all systemic signs of allergy: airway edema (includes tongue/lips), SOB, cyanosis, hypotension

55 Management: Do all patients need Corticosteroids? Corticosteroids take 4-6 hours to work Corticosteroids take 4-6 hours to work theoretically blunt the multi-phasic reaction of anaphylaxis theoretically blunt the multi-phasic reaction of anaphylaxis the quicker the onset of anaphylaxis the worse the reaction/quicker resolution less likely to relapse the quicker the onset of anaphylaxis the worse the reaction/quicker resolution less likely to relapse Caution in IV steroids esp if given in bolus doses; case reports of anaphylaxis! Caution in IV steroids esp if given in bolus doses; case reports of anaphylaxis! Oral form preferred if possible Oral form preferred if possible

56 Histamine Classes H1 receptor: stimulates bronchial, intestinal, smooth muscle contraction, vascular permeability, coronary artery spasm H1 receptor: stimulates bronchial, intestinal, smooth muscle contraction, vascular permeability, coronary artery spasm H2 receptor: increase rate & force of ventricular & atrial contraction, gastric acid secretion, airway secretions, vascular permeability, bronchodilation, & inhibition of histamine release H2 receptor: increase rate & force of ventricular & atrial contraction, gastric acid secretion, airway secretions, vascular permeability, bronchodilation, & inhibition of histamine release

57 Management: What is the role of combined H1 & H2 Antagonists? RCT, N=91 w/ allergic syndromes RCT, N=91 w/ allergic syndromes 50 mg Benadryl (H1) & saline vs. 50 mg Benadryl & 50 mg Ranitidine (H2) IV 50 mg Benadryl (H1) & saline vs. 50 mg Benadryl & 50 mg Ranitidine (H2) IV Endpoints of resolution of urticaria, angioedema, or erythema Endpoints of resolution of urticaria, angioedema, or erythema also measured subjective improvement & vitals also measured subjective improvement & vitals Lin et al., Improved outcomes in patients with acute allergic syndromes who are tre ated with combined H1 & H2 antagonists, Annals of Emergency Medicine 36(5) 2000.

58 Histamines: Results Statistically significant diminution of angioedema and/or urticaria with addition of H2 blocker Statistically significant diminution of angioedema and/or urticaria with addition of H2 blocker study too small to determine if H2 blockers helpful in anaphylaxis (those with respiratory compromise &/or hypotension) study too small to determine if H2 blockers helpful in anaphylaxis (those with respiratory compromise &/or hypotension) also significant decrease in HR in Rx group also significant decrease in HR in Rx group

59 Back to Cases: Management Case 1

60 Case One: Peanut allergy in asthmatic A 7 year old comes in to the ED after an possible exposure to peanut butter A 7 year old comes in to the ED after an possible exposure to peanut butter He has a severe nut allergy for which he was prescribed an EpiPen He has a severe nut allergy for which he was prescribed an EpiPen He was recently admitted to PICU for a severe asthma attack but was not intubated He was recently admitted to PICU for a severe asthma attack but was not intubated Mom gave him some oral Benadryl and he is no longer itchy but still has lip swelling Mom gave him some oral Benadryl and he is no longer itchy but still has lip swelling

61 Case One continued He is sent for a CXR due to decreased air entry in the lower lobes He is sent for a CXR due to decreased air entry in the lower lobes While in radiology, he becomes acutely SOB and his lip becomes more swollen While in radiology, he becomes acutely SOB and his lip becomes more swollen What do you do now? What do you do now?

62 Case 1 Conclusion He needs IM Epi! He needs IM Epi! (He weighs 30 kg and thus 0.3 mg IM is fine.) O2, IV fluids, cardiac monitoring O2, IV fluids, cardiac monitoring Consider Ventolin neb (esp if concurrent asthma) Consider Ventolin neb (esp if concurrent asthma)

63 Case Two : MVC Management A 45 y o woman involved in a MVC needs a CT abdo after she is stabilized in the ED A 45 y o woman involved in a MVC needs a CT abdo after she is stabilized in the ED She received 2 L NS for a hypotensive episode and her BP is now 120/70, HR 100 She received 2 L NS for a hypotensive episode and her BP is now 120/70, HR 100 She has a positive FAST U/S She has a positive FAST U/S Although her CXR is normal she has palpable lower rib fractures & a distended abdomen Although her CXR is normal she has palpable lower rib fractures & a distended abdomen

64 Case Two continued She is given both oral and IV contrast for her CT She is given both oral and IV contrast for her CT She becomes hypotensive again! She becomes hypotensive again! What do you do now? What do you do now? There is no rash There is no rash

65 Case 2: Conclusion Is she in hypovolemic shock or anaphylactic? doesn’t matter b/c both require IV crystalloids! Is she in hypovolemic shock or anaphylactic? doesn’t matter b/c both require IV crystalloids! There may be no rash initially There may be no rash initially Look for airway compromise/swelling: intubate? Look for airway compromise/swelling: intubate? IV contrast reactions are anaphylactoid and so prior sensitization not necessary (thus may be no prior hx of anaphylaxis) IV contrast reactions are anaphylactoid and so prior sensitization not necessary (thus may be no prior hx of anaphylaxis) If no response to fluids give IV epi 1 st via slow infusion, except if pulseless then may give IV bolus If no response to fluids give IV epi 1 st via slow infusion, except if pulseless then may give IV bolus

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67 Case 3: Gardener Management

68 Case Three A 67 y o man is stung by an insect while gardening A 67 y o man is stung by an insect while gardening He developed pruritus, dizziness, and SOB 20 min later so he called 911 He developed pruritus, dizziness, and SOB 20 min later so he called 911 He self-treated with Benadryl po and was given another 50 mg IV by EMS due to persistent sx and rash He self-treated with Benadryl po and was given another 50 mg IV by EMS due to persistent sx and rash He is now asymptomatic and refusing transport to hospital He is now asymptomatic and refusing transport to hospital

69 Case Three: Do you transport? EMS convinced him to get “checked out” in the hospital EMS convinced him to get “checked out” in the hospital On arrival, he becomes hypotensive, and his hives reappeared, along with facial edema On arrival, he becomes hypotensive, and his hives reappeared, along with facial edema An ECG shows T wave inversion in his lateral leads An ECG shows T wave inversion in his lateral leads PHx: MI, HTN, IV contrast allergy PHx: MI, HTN, IV contrast allergy Meds: ASA, metoprolol, lisinopril Meds: ASA, metoprolol, lisinopril

70 Case 3 Management: Refractory Anaphylaxis Biphasic (multi?) reactions can occur typically after 3-4 hours but as late as 72 hours later! Biphasic (multi?) reactions can occur typically after 3-4 hours but as late as 72 hours later! Beware of the patient with increased age and co- morbidities (eg. CAD) b/c anaphylaxis can cause cardiac ischemia Beware of the patient with increased age and co- morbidities (eg. CAD) b/c anaphylaxis can cause cardiac ischemia B-Blockers & ACEi blunt the catecholamine response B-Blockers & ACEi blunt the catecholamine response

71 Management Refractory Anaphylaxis: Glucagon Glucagon: increases inotropy/chronotropy & causes smooth muscle relaxation independent of B receptors Dose: 1-5 mg in adults ( mg in kids) IV/IM Dose: 1-5 mg in adults ( mg in kids) IV/IM

72 Management: Disposition & Follow-up Inquire about possible antigen exposure Inquire about possible antigen exposure Those with systemic reactions require a prescription for and instruction on how to use a EpiPen Those with systemic reactions require a prescription for and instruction on how to use a EpiPen A Medic Alert Bracelet is useful A Medic Alert Bracelet is useful Follow-up with an allergist for skin testing should be arranged particularly if the allergen is unknown Follow-up with an allergist for skin testing should be arranged particularly if the allergen is unknown

73 EpiPen EpiPen

74 Summary Acute anaphylaxis is often poorly recognized & treated due to the protean clinical features and variation in the speed of onset Acute anaphylaxis is often poorly recognized & treated due to the protean clinical features and variation in the speed of onset a trigger is often not found a trigger is often not found Pruritis is a universal feature and should differentiate anaphylaxis from asthma Pruritis is a universal feature and should differentiate anaphylaxis from asthma Expedious treatment w/ epi is necessary & thus patient education on its use is essential Expedious treatment w/ epi is necessary & thus patient education on its use is essential

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76 Case of EIA 28 year old male, after eating spaghetti and then playing soccer 1 hr later, developed urticaria & dizziness 28 year old male, after eating spaghetti and then playing soccer 1 hr later, developed urticaria & dizziness attempted to drive to hospital but pulled over because worse attempted to drive to hospital but pulled over because worse EMS vitals: BP 80/42, HR 90, RR 24 EMS vitals: BP 80/42, HR 90, RR 24 Rx: w/ epi and 1 litre NS Rx: w/ epi and 1 litre NS In ED: BP 130/85, chest was clear and “hives” gone but skin still edematous In ED: BP 130/85, chest was clear and “hives” gone but skin still edematous

77 Exercise Induced Anaphylaxis Clinical features indistinguishable from allergen induced anaphylaxis Clinical features indistinguishable from allergen induced anaphylaxis food dependent & food independent forms (also cholinergic urticaria) food dependent & food independent forms (also cholinergic urticaria) mechanism not fully known, but thought exercise lowers threshold for mast cell degranulation esp after a food allergen triggers an IgE response mechanism not fully known, but thought exercise lowers threshold for mast cell degranulation esp after a food allergen triggers an IgE response

78 Exercise-Induced Allergic Syndromes

79 Natural History of EIA N= 365 respondents with 10 yr hx of EIA to 75 item questionaire N= 365 respondents with 10 yr hx of EIA to 75 item questionaire EIA if anaphylactic Sx with exercise but not with passive warming EIA if anaphylactic Sx with exercise but not with passive warming Shadick, Nancy A., et al. The Natural History of Exercise-Induced Anaphylaxis: Survey results from a 10-year follow-up study, J Allergy Clin Immunol 1999; 104:

80 Results of Survey frequency of attacks lesson over time frequency of attacks lesson over time a wide range of activities associated but more CV demand more likely a wide range of activities associated but more CV demand more likely 70% had atopy or family hx of it 70% had atopy or family hx of it subjects avoided attacks by not exercising in humid weather or high allergy seasons subjects avoided attacks by not exercising in humid weather or high allergy seasons no single trigger identified; most common food no single trigger identified; most common food H1 blockers/ epi were used by 30% emergently; Role of prophylaxis? H1 blockers/ epi were used by 30% emergently; Role of prophylaxis?


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