ANAPHYLAXIS

Question 1

MANAGEMENT

Answer 1

A - STRIDOR.
Fiberoptic awake intubation preferred
Prepare for Cricothyroidotomy

B - RESPIRATORY RATE. >/ 30, 02 sats 90% on Fi02 30%. Work of breathing.
Bronchodilators PRN

C - MOTTLED APPEARANCE. GCS. Pallor. Cap Refill. Distal Pulses. Palpate Abdomen.

D - CHECK GLUCOSE. GCS, PERRLA, lateralizing signs

E - LIMIT FURTHER EXPOSURE,

INITIAL MANAGEMENT

1. EPINEPHRINE: INTRAMUSCULAR

> 50 kg: 0.5 mg IM Anteriorlateral Thigh (0.5 mL of 1:1000)

Children >30 kg 0.3 mg IM Anteriorlateral Thigh (0.3 mL of 1:1000)

Children 15-30 kg 0.15 mg IM Anteriorlateral Thigh

Children < 15 kg 0.01 mg / kg / dose (max 0.15 mg) IM Anteriorlateral Thigh

Repeat q 5 min PRN

If > 2-3 IM Epinephrine Doses or Severe Hypotension or Refractory Anaphylaxis, progress to Epinephrine Infusion

2. EPINEPHRINE: INFUSION

ANAPHYLAXIS: INFUSION

Weight-Based:
0.01-0.1 μg/kg/minute titrated by 0.01-0.05 μg/kg/minute every 2-3 minutes (1 mg / 1000 ml NS = 1 mcg / mL)

Fixed Dose:
Start at 5 mcg / min (5 mL / min) titrate to effect

OR

Bolus ONLY ADULTS 20-50 up to 100 ug (1 ml of 1:1000 Epi in 10 mL of NS) (0.1 mg/10ml) IV over 5 min to 10 min (cardiac monitoring required)

2. FLUID

ADULT DOSING:
30 mL / kg isotonic solution

Pediatric Dosing:
10 to 20 mL/kg isotonic solution

3. ANTI-HISTAMINE
   Diphenhydramine 50mg IV/PO (pediatric dose, 2 mg / kg) q 4-6 hr x 48-96 hrs (max 400mg/24hr) – this may sedate you patient

OR

Cetirizine (Reactine) 10-20mg PO q12-24hr; slow pharmacokinetics vs. rapidity of anaphylaxis

Ranitidine 50 mg IV (pediatric dose, 0.5 mg / kg) / 150 mg PO in addition may help pruritis

4. STEROIDS

ADULT DOSING:
Methylprednisolone 125 mg IV

PEDIATRIC DOSING
Methylprednisolone 2 mg / kg IV

5. BETA AGONIST
   Salbutamol 2.5 mg nebulized
6. GLUCAGON

For BetaBlockers with refractory hypotension

Adult dosing: 1-5 mg IV followed by 5-15 ug/min

Pediatric dosing: 20-30 ug/min (max 1 mg) followed by 5-15 ug / min

7. ECMO

Refractory to all treatments

Question 2

DOCUMENTATION

Answer 2

CRITERIA ONE
Acute onset of an illness (minutes to several hours) with involvement of the skin, mucosal tissue, or both (eg, generalized hives, pruritus or flushing, swollen lips-tongue-uvula)

AND AT LEAST ONE OF THE FOLLOWING:

A. Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, hypoxemia)

B. Reduced BP* or associated symptoms of end-organ dysfunction (eg, hypotonia, collapse, syncope, incontinence)

CRITERIA TWO
TWO OR MORE OF THE FOLLOWING that occur rapidly after exposure to a LIKELY allergen for that patient (minutes to several hours):
A. Involvement of the skin mucosal tissue (eg, generalized hives, itch-flush, swollen lips-tongue-uvula)
B. Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, hypoxemia)
C. Reduced BP* or associated symptoms (eg, hypotonia, collapse, syncope, incontinence)
D. Persistent gastrointestinal symptoms (eg, crampy abdominal pain, vomiting)

CRITERIA THREE
Reduced BP* after exposure to a KNOWN allergen for that patient (minutes to several hours):

A. Infants and children - Low systolic BP (age-specific)* or greater
than 30% decrease in systolic BP

B. Adults - Systolic BP of less than 90 mmHg or greater than 30% decrease from that person’s baseline

Question 3

DDx

Answer 3

Allergic (Histamine Mediated) Angioedema
Non-allergic (Bradykinin Mediated) Angioedema
Anaphylaxis
Trauma / Hematoma
Foreign Body
Peritonsilar Abscess
Retropharyngeal Abscess
Epiglotitis
Superior Vena Cava Syndrome

Question 4

PENICILLIN ALLERGY

Answer 4

FAST
0 of:

Five years since last reaction
Anaphylaxis
Severe cutaneous reaction
Treatment required

<1 % chance of allergy