1. Anaphylaxis

2. Severe Anaphylactic Reactions Manifestation Respiratory difficulty Signs of shock/hypotension Involvement of skin/mucosal tissue GI symptoms

3. Manifestations of severe anaphylaxis Respiratory Difficulty Progressive stridor, wheezing, dyspnoea Reduced PEF Hypoxaemia

4. Manifestations of severe anaphylaxis Signs of shock/Hypotension Lightheadedness, hypotonia, syncope Systolic BP 30% decrease from patient’s baseline Incontinence

5. Manifestations of severe anaphylaxis Involvement of skin/mucosal tissue Generalised hives, pruritis Pale or flushed Swollen face, lips, tongue, uvula Rhinitis

6. Manifestations of severe anaphylaxis GI symptoms Crampy abdominal pains Nausea, vomiting, diarrhoea

7. Manifestations of severe anaphylaxis Reactions may be slow, progressive, or rapidly fatal within minutes. Manifestations may be delayed, or persist > 24hrs May recur (biphasic) up to 36hrs after initial onset Generally, the shorter the interval between exposure and reaction, the more severe the reaction

8. Management of Anaphylaxis It consist of the following measures: 1. Remove or stop the precipitating agent 2. Administer drugs  Oxygen  Adrenalin  Establish Rapid IV access (crystalloid fluids)  Glucagon  Antihistamin  Corticosteroids  Inhaled beta-agonists  H2 Receptor blocker 3. Admission for observation 4. Preventing recurrence

9. Management of Anaphylaxis Airway and Oxygen Must be given as soon as possible Maintain airway patency Give high flow oxygen Use a rebreather mask Position patient in a semi-Fowler’s position (unless hypotensive) to assist breathing Pulse oxymetry if available, and monitor vital signs continuously If impending airway obstruction (angioedema), intubate or consider cricothyrotomy

10. Management of Anaphylaxis Adrenalin (1mg/ml 1:1000) Should be given IM, never SC Adults: 0.5ml Children: 0.01mg/kg 6-12 yrs:0.3ml 2-5 yrs: 0.2ml < 2 yrs: 0.1ml Repeat every 5-15 minutes if no improvement and consider IV continuous infusion at 2-10 mcg/min (0.1- 1mcg/kg/min)

11. Management of Anaphylaxis Caution on adrenalin: IV adrenalin is potentially hazardous in anaphylaxis, should only be considered if life-threatening hypotension persists despite IM adrenalin and aggressive fluid resuscitation. Dilute 1mg adrenalin in 200ml normal saline, and slowly infuse at 1ml/minute (5mcg/min) with continuous ECG monitoring

12. Management of Anaphylaxis Crystalloids These should be given if hypotensive or unresponsive to adrenalin Establish rapid IV access Rapidly infuse 1-2 liters of crystalloid (RL/NS) 20ml/kg for children Repeat IV infusion prn, as large amounts may be required

13. Management of Anaphylaxis Glucagon Adult: 1-2mg IM or slowly IV every 5min if not responsive to adrenalin, and especially if on beta-blockers Child: 20 mcg/kg (maximum 1mg) Watch out for nausea, vomiting and hyperglycaemia

14. Management of Anaphylaxis Antihistamin – H1 Blocker Promethazine (Phenergan) should be given IM or slowly IV > 12 yrs:25-50mg 6-12 yrs:12.5mg 2-5 yrs:6.25mg

15. Management of Anaphylaxis Corticosteroids Hydrocortisone/Methylprednisolone (Hydrocort/Solu-medrol) - IM or slowly IV For prevention or shortening protracted reactions Adults and Children > 12yrs: 100mg/125mg Children: 1mg/kg

16. Management of Anaphylaxis Inhaled beta-agonists (Ventolin) Nebulised salbutamol (Ventolin) 5mg (1cc) or 0.15mg/kg To be given every 15 min if bronchospasm is a measure feature or no response to given drugs, especially if the patient is on beta-blockers

17. Management of Anaphylaxis H2 receptor blockers  Ranitidine (Zantac)  Adult: 50mg IM or slowly IV (diluted in 20ml over 2min)  Child: 1mg/kg (max. 50mg) OR  Cimetidine (Tagamet)  Adult: 300mg IM or slowly IV (diluted in 20ml over 2min)  Child: 5mg/kg (max. 300mg)

18. Management of Anaphylaxis Admit for observation 8-24 hrs Recurrence may occur

19. Management of Anaphylaxis Prevention of recurrence Identify the causative agent Arrange for a “Medic Alert” bracelet Educate patient and family on the use of self-injectable adrenalin device (EpiPen). The EpiPen kit is a MUST for every patient who has had a severe reaction before.