Anaphylaxis

1. ANAPHYLAXIS Dr.Soma Sekhara Reddy.k Emergency Physician

2. OBJECTIVES Definition Epidemiology Pathophysiology Clinical features Management prevention

3. AGAINST PROTECTION ANA - Against PHYLAX - Guard Pharoh Menes - 2641 BC

4. DEFNITION Serious allergic reaction that is rapid in onset and may cause death. Multi organ involvement Precipitated with in minutes of exposure to a particular allergen In a sensitized patient

5. Clinical criteria for Anaphylaxis 1.Acute onset of illness with involvement of skin and/or mucosal tissue along with Resp.compromise / hypotension / associated symptoms of organ dysfunction 2.Rapid onset of 2 0r more of the following after exposure to likely allergen: Involvement of skin and/or mucosal tissue Resp.compromise Hypotension G I symptoms 3. Known allergen with hypotension

6. EPIDEMIOLOGY Food Insect stings Pharmacological agents Latex Exercise Unidentified – Idiopathic anaphylaxis

7. RISK FACTORS Low in very young and very old Dose,frequency,route Poorly controlled asthma Previous anaphylaxis

8. PATHOPHYSIOLOGY Two staged process: Sensitization Degranulation

9. SENSITIZATION

10. DEGRANULATION Re –exposure mast cell degranulates Releases several chemicals Acts on target organs Clinical syndrome of anaphylaxis

11. TARGET ORGANS Rich in mast cells Skin Eye Nose Resp tract GIT CVS

12. CHEMICAL MEDIATORS Histamine Tryptase Chymase Cathepsin G TNF Proteoglycans

13. CLINICAL MANIFESTATIONS - RS Rhinitis Pharyngeal and laryngeal edema Cough Broncospasm Dyspnea / chest tightness

14. CLINICAL MANIFESTATIONS - CVS Dysrhythmia Hypotension Cardiac arrest

15. CLINICAL MANIFESTATIONS - skin Generalized warmth and tingling Pruritis Urticaria flushing Angioedema

16. CLINICAL MANIFESTATIONS - GIT Abdominal pain / cramps Nausea Vomiting Diarrhea ? Gi bleed

17. TREATMENT FIRST LINE SECOND LINE

18. FIRST LINE THERAPY Airway Breathing Circulation IV O2 monitor

19. FIRST LINE THERAPY EPINEPHRINE Drug of choice IV/IM

20. EPINEPHRINE IV Severe upper airway obstruction Acute respiratory failure Shock Caution but not contra indicated..

21. EPINEPHRINE Dose 100 microgram (0.1 mg) bolus over 5 to 10 mins 0.1 ml of 1:1000 diluted in 10 ml NS Start infusion if there is no response (1-4 mic /min) 0.1 mic /kg/min in children Stop if chest pain or arrhythmia occurs

22. EPINEPHRINE IM LESS SEVERE SYMPTOMS Dose: 0.3 -0.5 ml of 1:1000 May be repeated every 5 to 10 mins Antero lateral thigh is preferred over deltoid

23. FIRST LINE THERAPY Decontamination

24. FIRST LINE THERAPY FLUIDS 1-2 L of NS bolus 20 ml/kg bolus in children

25. SECOND LINE THERAPY CORTICOSTEROIDS Methyl prednisolone 80 -125 mg IV (2mg/kg) Hydrocortisone 250- 500 mg IV (5 -10 mg/kg) Oral prednisolone

26. SECOND LINE THERAPY ANTI HISTAMINES H1 blocker- Diphenhydramine /CPM 25 – 50 mg IV H2 blocker - Ranitidine 50 mg IV Avoid cimetidine

27. SECOND LINE THERAPY AEROSOLISED BETA AGONISTS Salbutamol Levosalbutamol Ipratropium bromide Severe persistent cases magnesium may be used

28. SECOND LINE AGENTS GLUCAGON Reserved for patients on beta blockers and refractory to initial measures 1 mg IV every 5 minutes until hypotension resolves followed by 5 – 15 mics / min infusion. Side effects: Hypokalemia , hyperglycemia , nausea , vomiting.

29. PREVENTION Allergy history Label all loaded syringes Give drugs in distal extremity whenever possible Ensure all patients wait in ED for atleast 30 mins after any drug administration

30. PREVENTION Warning identification Avoid any known allergens Epipen Use allergy bands for all predisposed patients.

31. TAKE HOME Always ABC first Epinephrine is the drug of choice Anaphylaxis is very near to severe allergic reactions Change beta blockers Put on long term steroids if it is idiopathic anaphylaxis Educate every patient about prevention

32. Thank you