1. Anaphylaxis: Rapid recognition and treatment Miha Mežnar MD Medical intensive care unit General hospital Celje, Slovenia

2. Anaphylaxis: Rapid recognition and treatment

3. Fatal anaphylaxis Minutes to cardiac arrest MedianRange 55 iatrogenic51 – 80 37 food306 – 360 32 venom154 – 120 Pumphrey RSH, Clinical and experimental allergy, 2000

4. Anaphylaxis: Rapid recognition and treatment

5. recognition Underrecognized, undertreated Most important dg marker is trigger Over 40 symptoms and signs described cutaneuos>80% respiratoryup to 70% gastrointestinalup to 40% cardiovascularup to 35%

6. Diagnostic criteria Criterion 1 : acute onset (minutes – hours) involving skin and/or mucosa + at least one: – Respiratory compromise – Reduced blood pressure Criterion 2: At least 2 of the following, minutes – hours after exposure TO A LIKELY ALLERGEN FOR THAT PATIENT: – Skin/mucosal involvement – Respiratory compromise – Reduced blood pressure – Gastrointestinal symptoms Criterion 3: Reduced blood pressure minutes – hours after exposure TO A KNOWN ALLERGEN FOR THAT PATIENT J Allergy Clin Immunol, 2006

8. Potentional pitfalls in recognition of anaphylaxis Absent / missed skin symptoms Non-specific signs of hypotension (confusion, collapse, incontinence...) Certain conditions (surgery) DD – asthma exacerbation – Lab tets to support Dg (tryptase)

9. Anaphylaxis: Rapid recognition and treatment

10. Fatal anaphylaxis: risk factors Concomitant asthma No epinephrine Non effective epinephrine Upright posture Other cardiopulmonary disease

11. Fatal anaphylaxis: risk factors Concomitant asthma No epinephrine Non effective epinephrine Upright posture Other cardiopulmonary disease

12. Fatal anaphylaxis First adrenaline NoneBefore arrestAfter arrest 55 iatrogenic6940 37 food13816 32 venom2904 Pumphrey RSH, Clinical and experimental allergy, 2000

13. Adrenaline Review of literature: Database search Embase 223 Medline 92 Lilacs 13 Cochrane 10 CINAHL 5 BIOSIS 14 Web of science 25 Included: 0 Excluded: all 382 Sheikh A, Allergy 2009

14. Treatment Removal of the causing agent Epinephrine – 0.3 – 0.5 mg (0.01mg/kg) i.m. (vastus lateralis), repeat 5 – 15 minutes – i.v. – titrate the dose Oxygen Intubate, if stridor or arrest Trendelenburg position i. v. Fluids (cristalloids vs. colloids?) – Steroides, antihistamines, inhaled beta agonists, glucagon of secondary (and questionable) importance