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

2. Anaphylaxis: Rapid recognition and treatment

3. Minutes to cardiac arrest
Fatal anaphylaxis
Minutes to cardiac arrest
Median
Range
55 iatrogenic 5
1 – 80
37 food 30
6 – 360
32 venom 15
4 – 120
Pumphrey RSH, Clinical and experimental allergy, 2000

4. Anaphylaxis: Rapid recognition and treatment

5. Underrecognized, undertreated Most important dg marker is trigger
recognition
Underrecognized, undertreated
Most important dg marker is trigger
Over 40 symptoms and signs described
cutaneuos
>80%
respiratory
up to 70%
gastrointestinal
up to 40%
cardiovascular
up 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
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 None Before arrest After arrest
55 iatrogenic 6 9 40
37 food 13 8 16
32 venom 29 4
Pumphrey RSH, Clinical and experimental allergy, 2000

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

14. Treatment Removal of the causing agent Epinephrine Oxygen
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