Anaphylaxis - epidemiology,management perspective in india

covers anaphylaxis and its management

1. Dr. Kanika Bhardwaj Designation 1 Attending Consultant, Emergency department 2 Joint secretary, Society Emergency medicine of India(SEMI),Punjab 3 Academic director for SEMI,CCT-EM Institute Affiliation 1 Fortis Hospital, Sector 62,Mohali,Punjab Area of Interest 1 Trauma, Acute critical care, Stroke,Toxicology,EMS effectiveness 2 Medico legal ethics, ER administration and medical quality Achievements 1 International and national publications 2 Trained in POCUS and e-FAST ASSOCIATION OF EMERGENCY MEDICINE EDUCATORS CONFERENCE 2024 AEMECON2024, PGIMER, Chandigarh 15 th -17 th March 2024

2. CORE MANAGEMENT OF ANAPHYLAXIS DR. KANIKA BHARDWAJ Attending Consultant,EM (Fortis Hospital,Mohali) Joint Secretary, SEMI Punjab

3. A 15 yr old boy presents to the emergency looking like this: He was having his dinner. Stung by an unknown insect. Developed hives over his face,chest and abdomen Took OTC antihistamine Felt lightheaded and nauseated B.P 100/60 HR 110 spo2 93% RR 28 WHAT TO DO????

4. CLINICAL CRITERIA FOR ANAPHYLAXIS ACUTE URTICARIA,generalised itching or flushing, angioedema associated with at least one of the following: Respiratory distress or Hypotension or associated symptom of organ dysfunction eg. hypotonia,syncope,incontinence GI cramps or vomitings ANAPHYLAXIS represents the most dramatic and severe form of TYPE I hypersensitivity

5. ALLERGIC REACTION VS ANAPHYLAXIS Allergic reaction - is localised, treated by antihistamines Anaphylaxis - multisystem issue which may cause collapse of circulatory and/or respiratory systems. Requires epinephrine as defense.

6. PATHOPHYSIOLOGY

7. COMMON CAUSES HYMENOPTERA STINGS OTHER INSECT BITES DRUGS(NSAIDs,ANTIBIOTICS,SALICYLATES, CONTRAST MEDIA, virtually any drug) LATEX BLOOD PRODUCTS FOOD(SHELLFISH,SOY,NUTS,EGG,MILK,WHEAT)

8. CLINICAL FEATURES Classically involves: Pruritus ,flushing,urticaria ‘Lump in the throat’ Chest heaviness Lightheadedness Hoarseness of voice Breathlessness s yncope **one half of anaphylactic fatalities occur within the hour**

9. DIAGNOSIS Easy to make, if history clear for exposure followed by multisystem involvement Blood investigations are of little value in the ED DDs include- vasovagal reaction,seizures,epiglottitis,foreign body airway obstruction,hereditary angioedema ,acute asthma etc. ANAPHYLAXIS WILL LEAD TO DEATH IF LEFT UNTREATED

10. MANAGEMENT FIRST LINE THERAPY Always ABC IV Access, oxygen administration , cardiac monitoring,IV fluids DECONTAMINATION If identified should be attempted specially in Bee stings Gastric lavage in case of foodborne is not recommended

11. EPINEPHRINE Treatment of choice Mixed 𝛂1 and 𝛃 receptor agonist 𝛂1 receptor activation reduces mucosal oedema and treats hypotension 𝛃 receptor stimulation provides bronchodilation and limits further mediator release Administered IM 0.3-0.5 mg of 1:1000 dilution (adult) 0.01mg/kg of 1:1000 dilution (paediatric) Wait for 3-5 min before second dose EPIPEN/EPIPEN JUNIOR prefilled syringes not readily available in India IV infusion to be started if refractory for multiple IM doses

12. IV FLUIDS Hypotension in anaphylaxis is generally the result of distributive shock hence the need of fluid resuscitation Isotonic crytalloid solution Bolus about 1-2 L (adult) 10-20ml/kg bolus (paediatric)

13. SECOND LINE THERAPY CORTICOSTEROIDS ANTIHISTAMINES VASOPRESSORS GLUCAGON

14. DISPOSITION AND FOLLOW UP With apt initial treatment admission to hospital is rare, only required for 1% to 4% of all cases All unstable patients should be admitted to the ICU All patients should be observed in ED for at least 4 hours Discharge planning should include: Identification of inciting allergen Prescription of a antihistamine and/or corticosteroid Referral to an allergist Education

15. REFERENCES Tintinalli’s textbook of emergency medicine ASCIA guidelines for anaphylaxis pubmed.NCBI Researchgate

16. THANKS