Anaphylaxis

Question 1

What is anaphylaxis?

Answer 1

Anaphylaxis is a life-threatening medical emergency. It is caused by a severe type 1 hypersensitivity reaction. Immunoglobulin E (IgE) stimulates mast cells to rapidly release histamine and other pro-inflammatory chemicals. This is called mast cell degranulation. This causes a rapid onset of symptoms, with airway, breathing and/or circulation compromise.

The key feature that differentiates anaphylaxis from a non-anaphylactic allergic reaction is compromise of the airway, breathing or circulation.

Question 2

How does anaphylaxis present?

Answer 2

Patients present with a history of exposure to an allergen (although it can be idiopathic). There will be rapid onset of allergic symptoms:

Urticaria
Itching
Angio-oedema, with swelling around lips and eyes
Abdominal pain
Additional symptoms that indicate anaphylaxis are:

Shortness of breath
Wheeze
Swelling of the larynx, causing stridor
Tachycardia
Lightheadedness
Collapse

Question 3

Management of anaphylaxis?

Answer 3

Anaphylaxis requires immediate medical attention and management. It should be managed by an experienced paediatrician. Call for help early. Refer to the resuscitation guidelines for full management guidelines.

Initial assessment of acutely unwell child is with an ABCDE approach, assessing and treating:

A – Airway: Secure the airway
B – Breathing: Provide oxygen if required. Salbutamol can help with wheezing.
C – Circulation: Provide an IV bolus of fluids
D – Disability: Lie the patient flat to improve cerebral perfusion
E – Exposure: Look for flushing, urticaria and angio-oedema
Once a diagnosis of anaphylaxis is established, there are three medications given to treat the reaction:

Intramuscular adrenalin, repeated after 5 minutes if required
Antihistamines, such as oral chlorphenamine or cetirizine
Steroids, usually intravenous hydrocortisone

Question 4

Treatment after anaphylaxis?

Answer 4

All children should have a period of assessment and observation after an anaphylactic reaction, as biphasic reactions can occur, meaning they can have a second anaphylactic reaction after successful treatment of the first. Children should be admitted to the paediatric unit for observation.

Anaphylaxis can be confirmed by measuring the serum mast cell tryptase within 6 hours of the event. Tryptase is released during mast cell degranulation and stays in the blood for 6 hours before gradually disappearing.

Education and follow-up of the family and child is essential. They need to be educated about allergy, how to avoid allergens and how to spot the signs of anaphylaxis. Parents should be trained in basic life support. Specialist referral should be made in all children with anaphylaxis for diagnosis, education, follow up and training in how to use an adrenalin auto-injector.

TOM TIP: Remember to measure mast cell tryptase within 6 hours of an anaphylactic reaction. This is a common exam question and also something that will impress senior colleagues if it is part of your management plan when managing children with anaphylaxis.

Question 5

Indications for adrenalin auto injector?

Answer 5

Epipen, Jext and Emerade are trade names for adrenalin auto-injector devices.

They are given to all children and adolescents with anaphylactic reactions. They may also be considered in children with generalised allergic reactions (without anaphylaxis) with certain risk factors:

Asthma requiring inhaled steroids
Poor access to medical treatment (e.g. rural locations)
Adolescents, who are at higher risk
Nut or insect sting allergies are higher risk
Significant co-morbidities, such as cardiovascular disease

Question 6

How to use an adrenalin auto injector?

Answer 6

The first step is to confirm the diagnosis of anaphylaxis.

Prepare the device by removing the safety cap on the non-needle end. There is a blue cap on EpiPen and a yellow cap on Jext.

Grip the device in a fist with the needle end pointing downwards. The needle end is orange on EpiPen and black on Jext. Do not put your thumb over the end, because if the device is upside down you will inject your thumb with adrenalin and could risk losing it.

Administer the injection by firmly jabbing the device into the outer portion of the mid thigh until the device clicks. This can be done through clothing. EpiPen advise holding it in place for 3 seconds and Jext advise 10 seconds before removing the device.

Remove the device and gently massage the area for 10 seconds.

Phone an emergency ambulance. A second dose may be given (with a new pen) after 5 minutes if required.

TOM TIP: You may be asked to show a parent or child how to use an adrenalin auto-injector, either in exams or in clinical practice. It is worth familiarising yourself with a Jext and EpiPen device. The drug companies often provide dummy devices that are usually lying around the paediatric wards. Check the draws and shelves in the doctors office and ask a friendly senior nurse. They are useful to help you get familiar with the device and practice explaining to your peers.