DR MAHAM BUSHRA

35-year-old lady is brought to the emergency

department by ambulance after collapsing at home.
She had been prescribed amoxicillin for sinusitis.
O/E: BP 70/30,HR 140, R/R 40/min & Oxygen sats
76% @ room air.
Patient is obtunded with peripheral cyanosis,
tongue swelling, stridor,wheezing & laboured
breathing.Her skin is cool and clammy with large
urticarial lesions.
What is the diagnosis?
What are the next steps?
What treatments should be instituted?
• Anaphylaxis is a an acute, life-threatening
systemic allergic reaction characterized by
circulatory collapse, bronchospasm, laryngeal
stridor often with angioedema and urticaria.
• Occurs after exposure to allergen to which
the patient had been sensitized previously.
• Anaphylactic shock is due to inappropriate
vasodilatation with endothelial disruption &
capillary leak.
• Early recognition is important because death
can occur within minutes to hours after first
symptom appears.
 DIAGNOSTIC CRITERIA
• Acute onset (min to hours) with reaction of the
skin &/or mucosal tissue in addition to
respiratory symptoms & hypotension
• Two or more of the following occuring
rapidly(min to hours) after exposure to
allergen: involvement of skin-mucosal tissue,
respiratory symptoms, hypotension or GI
symptoms.
• Hypotension occuring rapidly after exposure to
known allergen for the patient
PATHOPHYSIOLOGY
 ETIOLOGY
• IgE Mediated • Non IgE Mediated
* Foods * Drugs (aspirin &
(peanuts,eggs,fish,soy NSAIDS,Opiates)
products) * Radiocontrast media
* Insect stings *Exercise
(bee & wasp sting) * Cold
* IV Anaesthetics * Idiopathic in 20%
(suxamethonium)
* Penicillin & other
antibiotics
* Latex
 CLINICAL MANIFESTATIONS
• SKIN: Itching, erythema, urticaria, angioedema
• RESPIRATORY: Sneezing, runny nose, coughing,
wheezing, swollen larynx, hoarseness, stridor,
cyanosis
• GIT: Nausea, vomiting, diarrhea, abdominal pain
• EYES: Itching, tears
• CVS: Hypotension, fainting, pallor, tachycardia,
arrthymias, cardiac arrest, collapse
• Biphasic & protracted presentation in some
patients
 DIFFERENTIAL DIAGNOSIS
• Vasovagal syncope (hypotension)
• Cardiac arrhythmia(hypotension)
• Status asthmaticus (respiratory distress)
• Idiopathic angioedema (laryngeal obstruction)
• Carcinoid syndrome(generalized flushing)
 INVESTIGATIONS
• Serum tryptase: peak 60-90 min & persist for
6 hour
• Plasma histamine: rise within 5-10 min &
remain elevated for 30-60 min
 MANAGEMENT
• I/M EPINEPHRINE IS THE
TREATMENT OF CHOICE
FOR ANAPHYLAXIS OF
ANY SEVERITY
Give 0.2-0.3 ml (1:1000)
in antero-lateral aspect of
thigh as soon as possible.
 STEPS OF MANAGEMENT
Prevent further contact with allergen & raise
feet to restore circulation

Ensure airway patency

Give high flow oxygen & intubate if respiratory
obstruction imminent

Give adrenaline IM 0.5mg (0.5ml of 1:1000)

Repeat after every 5 min, if needed as guided by BP, pulse & respiratory
function, until better
 Secure IV acess
Give chlorphenramine 10mg IV & Solu cortef 200mg IV

Give IV fluids (0.9% saline; no role of colloids )500ml over 15 mins

If wheeze, treat for asthma(may require ventilatory support)

If still hypotensive, admit to ICU

consider IV epinephrine (as SLOW I/V infusion)

 FURTHER MANAGEMENT
• Admit to ward. Monitor ECG
• Measure serum tryptase 1-6 hr after
suspected anaphylaxis
• Continue chlorphenramine 4mg/6hr PO if
itching
 OBSERVATION
• Symptoms may recur in some patients within
1 to 8 hours (Biphasic response)
• Patients who remain symptom free for 4 hours
after treatment can be discharged unless
having severe reactions or other problems,
which require longer periods of observation.
 Special Consideration
• Patients who are taking beta blockers have
increased incidence and severity of
anaphylaxis & can develop a paradoxical
response to epinephrine; consider glucagon as
well as ipratropium for them.
• Vasopressin can be used to reduce the dose of
epinephrine required; has no benefit on
mortality
RISK FACTORS FOR FATAL ANAPHYLAXIS

• Poorly controlled asthma

• Allergy to nuts, shell fish, drugs and insect
bites
• Adolescence
• Delay to administer epinephrine or emergency
response services
• Pre-existing cardiac or respiratory conditions
 PREVENTION
REFER TO AN ALLERGIST
Skin testing
Challenge testing
Educate the patient on
avoidance of the identified
allergen & teach about self
injection of epinephrine with
‘Epipen 0.3mg’ to prevent fatal
attack in future
‘Medic alert’ bracelet
 PATIENT & FAMILY EDUCATION
• Know when & how to use the device
• Carry the device at all times
• Seek medical care immediately after use
• Wear an alert bracelet/necklace
 Reference(s)
Davidson’s principles and practice of medicine
Ed:23rd
Oxford handbook of clinical medicine Ed: 10th