Part 10.

6: Anaphylaxis

A naphylaxis is a severe, systemic allergic reaction char-

acterized by multisystem involvement, including the
skin, airway, vascular system, and gastrointestinal tract.
fatal reaction occurs within 10 to 15 minutes. Cardiovas-
cular collapse is the most common mechanism.3–5
Foods. Peanuts, tree-grown nuts, seafood, and wheat are the
Severe cases may result in complete obstruction of the foods most frequently associated with life-threatening ana-
airway, cardiovascular collapse, and death. The term classic phylaxis.6 Bronchospasm and asphyxia are the most fre-
quent mechanisms.3–5
anaphylaxis refers to hypersensitivity reactions mediated by
the subclass of antibodies immunoglobulins IgE and IgG.
Signs and Symptoms
Prior sensitization to an allergen has occurred, producing Consider anaphylaxis when responses from 2 or more body
antigen-specific immunoglobulins. Subsequent reexposure to systems (cutaneous, respiratory, cardiovascular, neurologic,
the allergen provokes the anaphylactic reaction. Many ana- or gastrointestinal) are noted; the cardiovascular and respira-
phylactic reactions, however, occur without a documented tory systems may not be involved. The shorter the interval
prior exposure. between exposure and reaction, the more likely the reaction is
Anaphylactoid or pseudoanaphylactic reactions display a to be severe. Signs and symptoms include the following:
similar clinical syndrome, but they are not immune-mediated.
Treatment for the two conditions is similar. ● Serious upper airway (laryngeal) edema, lower airway
edema (asthma), or both may develop, causing stridor and
Pathophysiology wheezing. Rhinitis is often an early sign of respiratory
The inciting allergen binds to antigen-specific IgE that has involvement.
accumulated on previously sensitized basophils and mast ● Cardiovascular collapse is the most common periarrest
cells. These cells almost immediately release a series of manifestation. Vasodilation produces a relative hypovole-
mediators, including histamines, leukotrienes, prostaglandins, mia. Increased capillary permeability contributes to further
thromboxanes, and bradykinins. When released locally and intravascular volume loss. The patient may be agitated or
systemically, these mediators cause increased mucous mem- anxious and may appear either flushed or pale. Additional
brane secretions, increased capillary permeability and leak, cardiac dysfunction may result from underlying disease or
and markedly reduced smooth muscle tone in blood vessels the development of myocardial ischemia from administra-
(vasodilation) and bronchioles. tion of epinephrine.3–5
● Gastrointestinal signs and symptoms of anaphylaxis in-
Etiology clude abdominal pain, vomiting, and diarrhea.
Any antigen capable of activating IgE can be a trigger for
anaphylaxis. In terms of etiology, researchers generally list Differential Diagnoses
the following categories of causes: pharmacologic agents, A number of disease processes produce some of the signs and
latex, stinging insects, and foods. In up to 5% of cases the symptoms of anaphylaxis. Only after the clinician eliminates
antigenic agent cannot be identified. anaphylaxis as a diagnosis should the other conditions be
considered, because failure to identify and appropriately treat
Pharmacologic agents. Antibiotics (especially parenteral anaphylaxis can be fatal.7,8
penicillins and other ␤-lactams), aspirin and nonsteroidal
anti-inflammatory drugs, and intravenous (IV) contrast ● Scombroid poisoning often develops within 30 minutes of
agents are the most frequent medications associated with eating spoiled fish, including tuna, mackerel, or dolphin
life-threatening anaphylaxis. (mahi-mahi). Typically scombroid poisoning presents with
Latex. Much attention has focused on latex-induced anaphy- urticaria, nausea, vomiting, diarrhea, and headache. It is
laxis, but it is actually quite rare.1,2 A decade-long registry treated with antihistamines.
of anaphylactic deaths in England has not registered any ● Angioedema that seems to occur in families is termed
latex-associated deaths.3,4
hereditary angioedema. This hereditary form is indistin-
Stinging insects. Fatal anaphylaxis has long been associated
with stings from hymenoptera (membrane-winged insects), guishable from the early angioedema of anaphylaxis or
including ants, bees, hornets, wasps, and yellow jackets. medication-related angioedema. Urticaria does not occur
Fatal anaphylaxis can develop when a person with IgE with hereditary angioedema, however. Angioedema is
antibodies induced by a previous sting is stung again. A treated with C1 esterase inhibitor replacement concentrate
if available. Otherwise, fresh frozen plasma may be used.
● Angiotensin-converting enzyme (ACE) inhibitors are asso-
(Circulation. 2005;000:IV-143-IV-145.) ciated with a reactive angioedema predominantly of the
© 2005 American Heart Association.
upper airway. This reaction can develop days or years after
This special supplement to Circulation is freely available at ACE inhibitor therapy is begun. The best treatment for this
http://www.circulationaha.org
form of angioedema is unclear, but aggressive early airway
DOI: 10.1161/CIRCULATIONAHA.105.166568 management is critical.9
IV-143
IV-144 Circulation December 13, 2005

● Severe, near-fatal asthma attacks can present with broncho- Antihistamines. Administer antihistamines slowly IV or IM
spasm and stridor. In general, asthma attacks do not present (eg, 25 to 50 mg of diphenhydramine).
with urticaria or angioedema. Asthma treatment is very H2 blockers. Administer H2 blockers such as cimetidine
different from treatment of anaphylaxis even though the (300 mg orally, IM, or IV).16
mechanism of immunologic hypersensitivity may be com- Inhaled ␤-adrenergic agents. Provide inhaled albuterol if
mon to both. bronchospasm is a major feature. Inhaled ipratropium may be
● In some forms of panic disorder, functional stridor devel- especially useful for treatment of bronchospasm in patients
ops as a result of forced adduction of the vocal cords. In a receiving ␤-blockers. Note that some patients treated for
panic attack there is no urticaria, angioedema, hypoxia, or near-fatal asthma actually had anaphylaxis, so they received
hypotension. repeated doses of conventional bronchodilators rather than
● Along with anaphylaxis, consider vasovagal reactions. epinephrine.17
Urticaria, angioedema, and bronchospasm are not present Corticosteroids. Infuse high-dose IV corticosteroids early
in vasovagal reactions. in the course of therapy. Beneficial effects are delayed at least
4 to 6 hours.
Interventions to Prevent Removal of venom sac. Insect envenomation by bees (but
Cardiopulmonary Arrest not wasps) may leave a venom sac attached to the victim’s
Recommendations to prevent cardiopulmonary arrest are skin. At some point during initial assessment, look at the sting
difficult to standardize because etiology, clinical presentation site, and if you see a stinger, immediately scrape it or any
(including severity and course), and organ involvement vary insect parts at the site of the sting, using the dull edge of a
widely. Few randomized trials of treatment approaches have knife.18 Avoid compressing or squeezing any insect parts near
been reported. Providers, however, must be aware that the the skin because squeezing may increase envenomation.
patient can deteriorate quickly and that urgent support of
Potential Therapies
airway, breathing, and circulation are essential. The following
therapies are commonly used and widely accepted but are ● Vasopressin. There are case reports that vasopressin may
based more on consensus than evidence: benefit severely hypotensive patients.19,20
● Atropine. Case reports suggest that when relative or severe
● Oxygen. Administer oxygen at high flow rates.
bradycardia is present, there may be a role for administra-
● Epinephrine tion of atropine.8
● Glucagon. For patients who are unresponsive to epineph-
–Absorption and subsequent achievement of maximum
plasma concentration after subcutaneous administration is rine, especially those receiving ␤-blockers, glucagon may
slower and may be significantly delayed with shock.10,11 be effective. This agent is short-acting; give 1 to 2 mg
Thus, intramuscular (IM) administration is favored. every 5 minutes IM or IV. Nausea, vomiting, and hyper-
• Administer epinephrine by IM injection early to all glycemia are common side effects.
patients with signs of a systemic reaction, especially
Observation
hypotension, airway swelling, or definite difficulty
Patients who respond to therapy require observation, but there
breathing.
is no evidence to suggest the length of observation time
• Use an IM dose of 0.3 to 0.5 mg (1:1000) repeated
needed. Symptoms may recur in some patients (up to 20%)
every 15 to 20 minutes if there is no clinical within 1 to 8 hours (biphasic response) despite an intervening
improvement. asymptomatic period. Biphasic responses have been reported
–Administer IV epinephrine if anaphylaxis appears to be to occur up to 36 hours after the initial reaction.15,16,21–24 A
severe with immediate life-threatening manifestations.12 patient who remains symptom-free for 4 hours after treatment
• Use epinephrine (1:10 000) 0.1 mg IV slowly over may be discharged.25 Severity of reaction or other problems,
5 minutes. Epinephrine may be diluted to a 1:10 000 however, may necessitate longer periods of observation.
solution before infusion.
• An IV infusion at rates of 1 to 4 ␮g/min may Airway Obstruction
prevent the need to repeat epinephrine injections Early elective intubation is recommended for patients ob-
frequently.13 served to develop hoarseness, lingual edema, stridor, or
–Close monitoring is critical because fatal overdose of oropharyngeal swelling. Patients with angioedema pose a
epinephrine has been reported.3,14 particularly worrisome problem because they are at high risk
–Patients who are taking ␤-blockers have increased inci- for rapid deterioration. Most will present with some degree of
dence and severity of anaphylaxis and can develop a labial or facial swelling. Patients with hoarseness, lingual
paradoxical response to epinephrine.15 Consider glucagon edema, and oropharyngeal swelling are at particular risk for
as well as ipratropium for these patients (see below). respiratory compromise.
Aggressive fluid resuscitation. Give isotonic crystalloid Patients can deteriorate over a brief period of time (1⁄2 to 3
(eg, normal saline) if hypotension is present and does not hours), with progressive development of stridor, dysphonia or
respond rapidly to epinephrine. A rapid infusion of 1 to aphonia, laryngeal edema, massive lingual swelling, facial
2 L or even 4 L may be needed initially. and neck swelling, and hypoxemia. This may occur when
 Part 10.6: Anaphylaxis IV-145

patients have a delayed presentation to the hospital or fail to References

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