AnaphylaxisDr. Jen LeppardEmergency Physician, TOH

LMCC Objectives

History and Physical of allergic reaction pts

Investigations to identify allergens

Manage urticaria and anaphylaxis in ED

Determine urticaria with systemic diseases

CDMQ: What can cause allergic reactions? (5)

Urticaria: triggers

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Drugs (Antibiotics especially)Food allergensInsectsPhysical stressors (cold, exercise)Respiratory allergy (Pollen)

(Quick) Pathophysiology

LMCC Objectives

History and Physical of allergic reaction pts

Investigations to identify allergens

Manage urticaria and anaphylaxis in ED

Determine urticaria with systemic diseases

History and Physical

• HPI of ingestion/exposure• Detective work• Allergic and atopic history• Symptoms and physical

exam based on systems involved

What systems are involved?

Systems Involved

Blood Vessels

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Blood Vessels

Photo credit: kiwinky, Flickr commons

© anaphylaxisweb

© anaphylaxisweb

Soft tissues

50% has angioedema (lips/face/upper airway)

If airway/tongue -> potential airway obstruction

Lungs

GI tract

LMCC Objectives

History and Physical of allergic reaction pts

Investigations to identify allergens

Manage urticaria and anaphylaxis in ED

Determine urticaria with systemic diseases

Investigations for allergic reaction/anaphylaxis in ED

No Labs

Maybe skin testing later

LMCC Objectives

History and Physical of allergic reaction pts

Investigations to identify allergens

Manage urticaria and anaphylaxis in ED

Determine urticaria with systemic diseases

Definition of anaphylaxis

MCQ 5: Who does not have anaphylaxis?

A. Ate peanut butter. Swollen lips and wheezing. VS normal.

B. Shrimp fest at Red Lobsters. Vomiting and tight throat. VS normal.

C. Stung by bee. Low BP.D. Flu shot. Hives. VS normal. E. Hay fever, swollen throat, low BP.

Anaphylaxis Definition

> 2 systems: 1. Airway2. CVS (BP)3. GI4. Skin

OR

Just BP

CDMQ: Management steps of patient with swollen tongue, hives, BP 80/50, O2 85% (6)

swollen tongue, hives, BP 80/50, O2 85%

ABCsAirway:

Epinephrine 0.3cc 1:1000 IM Intubate if needed

(indications?)

Breathing: Bronchodilators (Ventolin) if

wheezy Supplemental O2

Bronchodilators

Epinephrine

swollen tongue, hives, BP 80/50, O2 85%

Circulation IV NS 1-2L bolus (Epi 0.3cc of 1:1000 IM) (Epi infusion)

Fluids (+ epi)

swollen tongue, hives, BP 80/50, O2 85%

Other Medications H1 Blocker: Benadryl 50mg

IV or 50mg PO H2 Blocker: Ranitidine

50mg IV or 150mg PO

Steroids: Solumedrol 125mg IV or Prednisone 50mg PO

Iv fluid 1-2 L bolus (1)Drugs (3)

Antihistamines (H1- Benadryl, H2- Ranitidine)Steroids: Prednisone or Solu-Medrol

Antihistamines

H1: Benadryl (Diphenhydramine)H2: Ranitidine

Other Drugs to Consider

Glucagon: if on beta blockers, and refractory hypotension

Nebulized racemic epi: for upper airway edema

Discharge instructions

Allergy testing outpatient

Carry Epi-Pen at all times

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Discharge meds

Epi Pen Steroid (Prednisone PO)

2nd phase reaction (6-72 hours)

Continue Antihistamines

LMCC Objectives

History and Physical of allergic reaction pts

Investigations to identify allergens

Manage urticaria and anaphylaxis in ED

Determine urticaria with systemic diseases

Urticaria- vasodilation- leaky vessels

Acute or Chronic

Typically IgE mediated hypersensitvity

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Systemic illness -> urticariaSerum sickness

Viral/bacterial infections

Vasculitis

Photo credit: mrmason.ca

Systemic illness: serum sickness

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Systemic illness: serum sickness

Fever, rash, arthralgia, GI, malaiseRelated to drugs (eg. septra, cefprozil)

Photo credit: Dermatolog Information System

Systemic urticaria: Viral/Bacterial infection

Photo credit: Dermatology image atlas

Systemic urticaria: Vasculitis

Associated with

SLE, Sjogrens, LeukemiaDrugs

Systemic unwell: Arthralgia, fever, abdo pain, lymphadenopathy

LMCC Objectives

History and Physical of allergic reaction pts

Determine urticaria with systemic diseases

Investigations to identify allergens

Manage urticaria and anaphylaxis in ED