4311679-anaphylaxis in clinical phar.ppt

anaphylaxis in detail

1. ANAPHYLAXIS

2. ANAPHYLAXIS
The first documented case of anaphylaxis
was in 2641 B.C., when Pharaoh Menes of
Egypt died from a Wasp sting.
 
While the first fatal reaction to peanuts was
described by a Canadian researcher Dr
Evans in 1988.
Allergy to venom from wasp stings can
cause anaphylaxis as can allergy to latex
and drugs such as penicillin and aspirin.
Bee sting allergy is less common in the UK.

3. ANAPHYLAXIS
The most common cause of anaphylaxis
in the community is from eating a food to
which you are allergic such as nuts,
peanuts, eggs, mammalian milk, soya,
wheat, fish and shellfish.
  These 8 foods
account for 90% of cases of food induced
anaphylaxis.
  Peanuts and tree nuts (such
as Brazil nuts, Hazelnuts, Almonds and
Walnuts) are the foods most likely to
provoke a reaction.

4. ANAPHYLAXIS
Some people may develop anaphylaxis
after eating certain foods such as celery,
shrimps, wheat, apple, hazelnut, squid
and chicken and then exercising shortly
after ingesting the food – triggering
Exercise Induced Anaphylaxis.

5. SYSTEMIC ANAPHYLAXIS
*Most extreme over-reaction of immune system
*Caused by allergens which reach bloodstream
*Venomous insect stings
*IV and IM drugs
*PO drugs (rapid absorption and high
bioavailability)

6. Anaphylaxis- IgE-mediated
Antibiotics and other medications
Penicillins, β-lactams, tetracyclines, sulfas,
vaccines, immunotherapy
Foreign proteins
Latex, hymenoptera venoms, heterologous sera,
protamine,
Foods
Shellfish, peanuts, and tree nuts
Exercise induced

9. SYSTEMIC ANAPHYLAXIS
*Mechanism is widespread activation of mast cells
throughout body resulting in
*Vascular permeability (circulatory collapse /
anaphylactic shock)
*Constriction of smooth muscles
*Death by constriction of airways and swelling of
epiglottis

12. ANAPHYLAXIS
 Signs within 5 to 30 min (very rarely hours)
 Recurrent (biphasic) anaphylaxis – occurs 8-10h after the
initial attack
Persistent anaphylaxis – can last for up to 32h

13. SIGNS AND SYMPTOMS OF
SYSTEMIC ANAPHYLAXIS
Signs/Symptoms :
*Skin and soft tissue
*Flushing, pruritis, urticaria and angioedema
*Cardiovascular :
*Syncope, tachycardia or no pulse, hypotension, cardiac arrhythmias
*Nervous
*Apprehension, convulsions , headache, unconsciousness
*Gastrointestinal
*Vomiting, diarrhea, abdominal cramps, nausea,
*Respiratory
*Wheezing, dyspnoe, bronchospasm

14. Anaphylaxis
Skin signs:
- erythema, urticaria, pruritis,

15. Anaphylaxis
Skin signs:
- pruritis, angioedema

16. ANAPHYLAXIS
The most common symptoms were urticaria and
angioedema, occurring in 88% of patients. The next most
common manifestations were respiratory symptoms, such
as upper airway edema, dyspnoe and wheezing.
Cardiovascular symptoms of dizziness, syncope, and
hypotension, were less common, but it is important to
remember that cardiovascular collapse may occur abruptly,
without the prior development of skin or respiratory
manifestations.
Other symptoms of rhinitis, headache, substernal pain, and
pruritus without rash were less commonly observed.

17. Most Common Clinical Manifestations of
Anaphylaxis
Symptom… How often?
Urticaria /Angioedema 88%
Upper airway oedema 56%
Dyspnoe / bronchospasm 50%
Flushing 51%
Cardiovascular collapse “Anaphylactic shock” 30%
GI 30%

18. ANAPHYLAXIS TREATMENT

Prevention- avoid the allergen
People with asthma and/or allergy have the risk
of anaphylaxis, especially those with un-
controlled asthma and/or severe allergy risk.
These people should consult to an allergy
specialist. When the anaphylaxis trigger has
been identified by allergy testing, you must
avoid the allergen very carefully.

19. TREATMENT OF SYSTEMIC ANAPHYLAXIS
*Epinephrine is drug of choice
*Sympathicomimetic drug acting on
*Alpha receptors of vascular endothelium
*Beta receptors of bronchial smooth muscles
*Administered by I.M. injection into antero - lateral
thigh
*Do not inject into buttock
*Do not inject I.V.
*Cerebral hemorrhage
*Epinephrine Auto-Injector (EpiPen)
*Adult (0.3 mg) and pediatric (0.15)

20. How to Give Epinephrine?

21. How
to Give Epinephrine?
In the muscle….
Which Muscle?
Lateral
Thigh

22. How to Give Epinephrine?

23. EpiPen

/EpiPen

Jr:
Directions for Use

24. EpiPen

/EpiPen

Jr:
Directions for Use

25. EpiPen

/EpiPen

Jr:
Directions for Use

26. Use of Epi Pen….
No contraindications in anaphylaxis !!!
Failure or delay associated with
fatalities
I. M. may produce more rapid, higher
peak levels vs S. C.
Must be available at all times

27. ADMINISTRATION OF
intramuscular ADRENALINE
Intramuscular injection of epinephrine into
the tigh – more effective than injection into
the arm or subcutaneous administration

28. When to Repeat Epinephrine?
• Practice Parameter Update - US
– Repeat every 5 minutes as needed to control
symptoms and blood pressure
– Some guidelines suggest liberalizing the
frequency if deemed necessary – no absolute
contraindication for epinephrine
• UK Consensus Panel on emergency Guidelines and
International consensus guidelines for emergency
cardiovascular care
– May judiciously be repeated as often as every 5
minutes

29. Who Should Get Epinephrine?
Everyone with rapid progression of symptoms
 Laryngeal edema
 Bronchospasm
 Severe GI symptoms
 Hypotension
 Highest fatality rates when epinephrine is
delayed
 Age is not a limiting factor

30. Anaphylaxis Treatment –First Line
ESTABLISH AIRWAY and supplemental O2
• I.V. fluids
• Pulmonary symptoms: Albuterol by
nebulization or MDI
• Deterioration of pulmonary symptoms :
Racemic epinephrine by nebulization;
Consider intubation or tracheostomy

31. After The Epi –Second Line Therapy For
Everyone
Antihistamines: H1 + H2 blockers
 Diphenhydramine 25-50 mg IV/IM/PO
1 mg/kg PO/ IM/ IV (kids)
 Ranitidine •50 mg IV…….. 4 mg/kg PO
up to 300 mg
1.5 mg/kg IM/IV up to 50 mg (kids)

32. What About Non-Sedating H-1
blockers?
 Cetirazine (Zyrtec) 10 mg po q day
 Loratidine (Claritin) 10 mg po q day
 Desloratadine (Clarinex) 5 mg po q day
 Fexofenadine (Allegra)180 mg po q day
Only available in oral form, long record
of efficacy with urticaria

33. Other Second Line Considerations
Inhaled beta-agonists - if wheezing
Corticosteroids
– 1-2 mg/kg prednisone PO
– 1-2 mg/kg methylpredisolone IV (max 250 mg)
 Not helpful acutely
 ? Prevent recurrent anaphylaxis
 Glucagon ( if beta blocked) 1-5 mg slow IV, 1-
5 ug/min

34. Treatment of Anaphylaxis…
Observe for a minimum 8-12 hours
Rebound or persitant symptoms
Repeat epinephrine, repeat antihistamine ± H
2

blocker

36. This is a simple instruction of injecting EpiPen:
Pull the seal cover.
Put the black tip on your upper thigh (no need to undress
the patient, unless the fabrics is too thick).
Strongly press the EpiPen into your thigh until you feel the
injection done.
Hold the EpiPen for 10 seconds.
Release the EpiPen while slowly massage the injected
area.
Call for medical help/ambulance.
If the symptoms have not reduced after 30 minutes while
you are waiting for medical help, give the second injection.

38. Anaphylaxis Fatalities
Estimated 500–1000 deaths annually
1% risk
Risk factors:
Failure to administer epinephrine immediately
Peanut, Soy & tree nut allergy (foods in general)
Beta blocker, ACEI therapy
Asthma
Cardiac disease
Rapid IV allergen
Atopic dermatitis (eczema)
 Miller RL. Epidemiology of anaphylaxis. Presented at: Anaphylaxis: Safely Managing Your Patients at Risk for Severe Allergic
Reactions. Postgraduate Institute for Medicine; October 8, 1999; Washington, DC.Bocher BS. Anaphylaxis. N Engl J Med
1991:324:1785–1790

39. Food-induced Anaphylaxis:
Incidence
35%–55% of anaphylaxis is caused by food allergy
6%–8% of children have food allergy
1%–2% of adults have food allergy
Incidence is increasing
Accidental food exposures are common and unpredictable
Kemp SF, et al. Anaphylaxis. A review of 266 cases. Arch Intern Med 1995; 155:1749–54.
Pumphrey RSH, et al. The clinical spectrum of anaphylaxis in northwest England. Clin Exp Allergy
1996; 26:1364–1370.
Bock SA. Prospective appraisal of complaints of adverse reactions to foods in children during the
first 3 years of life. Pediatrics 1987;79:683–688.

40. Food-induced Anaphylaxis:
Common Symptoms
Oropharynx: Oral pruritus, swelling of lips and tongue,
throat tightening
GI: Crampy abdominal pain, nausea, vomiting, diarrhea
Cutaneous: Urticaria, angioedema
Respiratory: Shortness of breath, stridor, cough, wheezing

41. Food-induced Anaphylaxis:
Fatal Reactions
Fatal reactions are on the rise
~150 deaths per year ( in US )
Usually caused by a known allergy
Patients at risk:
Peanut and tree nut allergy
Asthma
Prior anaphylaxis
Failure to treat promptly epinephrine
Many cases exhibit biphasic reaction
Anaphylaxis Committee, AAAAI. Anaphylaxis. Teaching Slides. 2000.

42. Venom-induced Anaphylaxis:
Incidence
0.5%–5% (13 million) Americans are
sensitive to one or more insect venoms
Incidence is underestimated
Incidence increasing due
Incidence rising due to more outdoor activities
At least 40–100 deaths per year

43. Venom-induced Anaphylaxis:
Common Culprits
Hymenoptera
Bees
Wasps
Hornets

44. Hymenoptera

45. Venom-induced Reactions:
Common Symptoms
Normal: Local pain, erythema, mild swelling
Large local: Extended swelling, erythema
Anaphylaxis: Usual onset within 15–20
minutes
Cutaneous: urticaria, flushing, angioedema
Respiratory: dyspnoe, stridor
Cardiovascular: hypotension, dizziness, loss of
consciousness
30%–60% of patients will experience a
systemic reaction with subsequent stings

46. Venom-induced Anaphylaxis:
Prevention
Risk Management
Keep EpiPen

or EpiPen

Jr on hand at all times
Educate and train on EpiPen

use
Develop emergency action plan
Wear a MedicAlert

bracelet
Consult an allergist to determine need for venom
immunotherapy

47. Venom-induced Anaphylaxis:
Immunotherapy
Medical criteria
Venom immunotherapy is medically indicated in
any adult with a history of a systemic reaction to
an insect sting, and in children who have had life-
threatening sting reactions.
Positive venom skin test & sIgE
97% effective
Can be discontinued in most after 3–5 years;

48. Exercise-Induced Anaphylaxis
First reported in 1979
Mechanism of action is unclear
Predisposing factors:
ASA ,
Food, including: shell fish, cheese, dense
fruits, snails.
Triggered by almost any physical
exertion
Most common in very athletic children

49. Exercise-Induced Anaphylaxis
Four Phases
Prodromal phase is characterized by fatigue,
warmth, pruritus, and cutaneous erythema
The early phase: urticarial eruption that
progresses from giant hives may include
angioedema of the face, palms, and soles.
Fully established phase: hypotension, syncope,
loss of consciousness, choking, stridor, nausea,
and vomiting ( 30 minutes to 4 hours.)
Late or postexertional phase, Prolonged
urticaria and headache persisting for 24-74
hours.

50. NON-IgE ANAPHYLAXIS
Drugs
 Opiates
 NSAIDs
 ACE inhibitors
Foods
 Strawberries
 Fish e.g. Tuna (Scrombotoxin)

51. Diagnosing Anaphylaxis
Based on clinical presentation, exposure
Cutaneous, respiratory symptoms most
common
Some cases may be difficult to diagnose
Vasovagal syncope
Systemic mastocytosis

52. Diagnosing Anaphylaxis
Careful history to identify possible causes
Can be confirmed by serum tryptase
Specific for mast cell degranulation
Remains elevated for up to 6-12 hours
Serum histamine - rises w/in 5 minutes, returns to baseline after 30-60
minutes
Other labs to rule out other diagnoses
Refer to allergist for specific testing

53. Diagnosing Anaphylaxis
Skin tests/RAST
Foods
Insect venoms
Drugs
Challenge tests
Foods
NSAIDs
Exercise
Allergists can identify specific causes by:

54. Anaphylaxis summary…
 Signs and Symptoms of
Anaphylaxis:
Urticaria, itching, hives
Rash
Rhinitis
Bronchospasm
Laryngeal Edema
Syncope
Cardiac Arrest
Treatment:
Basic Life Support:
○Airway
○Breathing
○Circulation
Epinephrine  0.3-0.5 ml of
1:1000 IM  Repeat of no
response
Oxygen
Diphenhydramine
(antihistamine) 50ml IM
Corticosteroids
Intubation or cricothyrotomy

55. Can I Predict Severe Anaphylaxis?
Risk Factors
Male
Consistent antigen administration
Shorter time elapsed since last reaction < 1 year
 Asthma

56. Meet M. J.
 A 13 y/o girl with a bee sting to hand
one hour ago
Symptoms: swelling, erythema and pain
Treatment and advice?

57. Treatment and Advice
Clean area, ice for comfort
 Remove stinger
 Anti-histamines
? Topical intermediate potency
corticosteroid cream (triamciniline 0.1%)
 ? Systemic steroids
 Education/Plan
 Referral to allergist
 EpiPen