Anaphylaxis

Question 1

Background

Answer 1

Severe, fatal due to laryngeal oedema

Question 2

Type of hypersensitivity

Answer 2

Type 1 IgE mediated
Anaphylaxis
- caused by drugs, blood transfusions, eggs, nuts, bee stings

Question 3

What does anaphylaxis cause? (histology)

Answer 3

Histamine release from mast cells and eosinophils

Question 4

What does anaphylaxis cause? (systemic)

Answer 4

Capillary leakage, 
oedema, 
shock, 
asphyxia, 
anaphylactoid

Question 5

Initial symptoms

Answer 5

Pruritis, erythema, urticarial,

Rhinitis (runny nose), conjunctivitis, angio-oedema

Question 6

What is pruritis?

Answer 6

Itchy skin

Question 7

What is urticarial?

Answer 7

Hives - red raised rash

Question 8

General symptoms

Answer 8

Palpitations & tachycardia,
Nausea & vomitting, Abdominal pain
Collapse and LOC (loss of consciousness)

Question 9

Airway symptoms

Answer 9

Itchy palate of external auditory meatus
Dyspnoea (difficulty breathing)
Bronchospasm (wheezing) –> oedema & stridor
Cyanosis
Circulatory collapse - reduced CRT, hyPOtension, tachycardia

Question 10

How is anyphylaxis managed?

Answer 10

ABCDE approach

Question 11

Management - Airway:

Answer 11

Obstruction, swelling?
Signs of allergen?
Call for help –> intubation
High flow O2 15L through non rebreathe mask

Question 12

Management - Breathing:

Answer 12

Auscultate

Signs of resp distress: tracheal tug, nasal flaring, intercostal recession, head bobbing

Question 13

Management - Circulation:

Answer 13

Colour, Pulse, BP, CRT
IV fluid challenge - 20mL/kg 0.9% sodium chloride in 5 mins.
Maintain fluids - 100mL/kg for 1st 10kg, 50mL/kg for next 10kg, 20mL/kg after

Question 14

Management - Disability:

Answer 14

Consciousness level

Question 15

GCS - Eye opening response

Answer 15

Spontaneous - 4
To speech - 3
To pain - 2
No response 1

Question 16

GCS - Best verbal response

Answer 16

Oriented to time, place and person -5
Confused - 4
Inappropriate words - 3
Incomprehensible sounds - 2
No response - 1

Question 17

GCS - Best motor response

Answer 17

Obeys commands - 6
Moves to localised pain - 5
Flexion withdrawal from pain - 4
Abnormal flexion (decorticate) - 3
Abnormal extensions (decerebrate) - 2
No response - 1

Question 18

GCS - total score

Answer 18

Best response - 15
Comatose client - 8 or less
Totally unresponsive - 3

Question 19

Management - Exposure:

Answer 19

Glucose

System review

Question 20

What medication is given?

Answer 20

Adrenaline (IM)
Chlorphenamine
Corticosterioids
Salbutamol (inh), Ipratropium bromide (inh), aminophylline (IV)

Question 21

Dose of adrenaline:

Answer 21

500mcg if >12
300mcg if >6
150mcg if <6

Repeated after 5 mins if no effect

Question 22

Dose of chlorphenamine

Answer 22

antihistamine after resuscitation

10mg if >12
5mg if >6
2.5mg if <6

Question 23

Dose of corticosteroids

Answer 23

Hydrocortisone IV (can take hours to take effect)

200mg if >12
100mg if >6
50mg if <6

Question 24

What home medication is used for children with a history of anaphylaxis?

Answer 24

Adrenaline pen 150mcg subcutaeous administration

Oral antihistamine

Parents should know BLS

Question 25

How is anaphylaxis monitored?

Answer 25

ABC

Question 26

Monitoring - Airways:

Answer 26

Intubation

Bag mask ventilation

Question 27

Monitoring - Breathing:

Answer 27

Maintain sats 94-98%

Question 28

Monitoring - Circulation:

Answer 28

BP:
0-1 month --> 50-60mmHg
<1 year --> >70mmHg
>1 - 10 year --> 70 + (age in years x 2) mmHg
>10 ==> minimum 90mmHg

Question 29

What happens if there is no improvement after management and monitoring?

Answer 29

Repeat fluid challenge - unless signs of overload
Measure serum mast cell tryptase ASAP, confirm diagnosis, admit patient under paeds team, discharge with info about epi pen and BLS for parents