Anaphylaxis

Question 1

What is the treatment of choice for anaphylaxis of all severities?

Answer 1

Epinephrine

Question 2

When should epinephrine be given in anaphylaxis?

Answer 2

Even to mild cases! It is important to give early to prevent progression.

Question 3

What is the dosing for the auto injector of epinephrine and frequency?

Answer 3

< 10kg should get weight based if possible, but if deteriorating then just give the 0.1mg dose or the 0.15 auto-injector will do
Kids < 25 kg get the 0.15mg dose
> 25kg get 0.3mg dose
>50kg give 0.5mg if possible, or just the 0.3mg dose if faster
Give in the thigh every 5–15 minutes or more frequently if needed!

Question 4

What is the weight-based dosing for epinephrine?

Answer 4

0.01mg/kg with max of 0.5mg per dose

This is for any age

Question 5

When is Epi given IM vs IV?

Answer 5

IM is preferred when not in shock, or severe distress

Progress to Epi drip if not responding to IM administration

Question 6

What are the danger signs in anaphylaxis?

Answer 6

Rapid progression
Respiratory symptoms: wheezing, difficulty breathing increased WOB, stridor, persistent cough, cyanosis
Vomiting
Abdominal Pain
Hypotension
Cardiac dysrhythmia
Chest pain
Collapse

Question 7

What is the next step if patient is not responding to first dose of IM epi?

Answer 7

Give more epi! Titrate up to desired effect! Give it IV if you have to!!! Epi, Epi, Epi!!!

Question 8

What is the starting dose for Epi drip?

Answer 8

0.1mcg/kg/min titrated to blood pressure, heart rate, oxygenation

Question 9

When could glucagon be given in anaphylaxis?

Answer 9

To patients hypotensive, on beta blockers, and not responding to epi

Question 10

What is the dose of glucagon and what is the side effect?

Answer 10

1–5mg for initial dose over 5 minutes with a drip added if needed
Causes vomiting if given too fast

Question 11

Weight of patient is not known, what is usual dose range for starting epi drip?

Answer 11

2–10 mcg/min

Question 12

Pt presents in anaphylaxis, what are the first steps?

Answer 12

Manage airway early as this is likely to deteriorate
Simultaneously give epinephrine!
Start fluids
Use albuterol for breathing difficulty
Place in recumbent position with feet up
Give oxygen
Manage BP

Question 13

What are the adjunctive therapies?

Answer 13

Glucocorticoid

H1 and H2 blockers

Question 14

Why is IM epi preferred over IV?

Answer 14

Usually faster administration and less cardiac complications and less hypertension and arrhythmias making it safer overall

Question 15

When giving epinephrine, what should be done in obese patients?

Answer 15

Use a longer needle and do your best to access the muscle in the thigh through the overlying adipose tissue. Put it deep.

Question 16

How is IV bolus of epi dosed and given and to whom?

Answer 16

IV bolus should be avoided for everyone when possible as errors in dosing lead to more severe adverse effects.
Give 50–100mcg slowly over 1–3 minutes and repeated only after 3 or more minutes of monitoring
Give only to adults, and avoid in kids.

Question 17

Which of the drugs used in anaphylaxis are life saving?

Answer 17

Only epinephrine. None of the other drugs should be used alone.

Question 18

Reduced mortality is associated with early administration of what drug?

Answer 18

Epinephrine!

Question 19

What is the role of H1 blockers?

Answer 19

Only the control of itching and hives
It has no role in reversing or preventing airway obstruction or treating hypotension
It should not be given until after Epinephrine

Question 20

What are the options and benefits of each H1 blocker?

Answer 20

Cetirizine: less sedating, comes in oral and IV, duration approaches 24 hours
Benadryl: commonly used but sedating, repeat every 4–6 hours

Question 21

What is the dosing for Cetirizine?

Answer 21

> 12 years: 10mg IV/PO
6–11 years: 5–10mg
6mo–5y: 2.5mg

Question 22

What is the dosing for benadryl?

Answer 22

> 50kg: 25–50mg Q4–6 hours, max 400mg in 24 hrs

<50kg: 1mg/kg up to 50, max of 5mg/kg or 200mg in 24 hours

Question 23

What is the role of H2 blockers?

Answer 23

Might help with hives, but there is no data supporting its use

Question 24

What is the difference is effect in the airways between epi and beta agonists?

Answer 24

Epi relieves the tissue edema and treats shock whereas bronchodilators only treat the bronchospasm
Bronchodilators are adjunctive therapies only and cannot replace epi and should only be given when epi is not effective

Question 25

How long should anaphylaxis patients be monitored?

Answer 25

Until all symptoms have resolved

Question 26

How do antihistamines and steroids affect biphasic anaphylactic reactions?

Answer 26

They do not have any effect on preventing a “rebound”

Epinephrine remains the mainstay of treatment

Question 27

What is the role of steroids in anaphylaxis?

Answer 27

They do not need to be routinely given
Might consider in kids with refractory bronchospasm and underlying asthma and when they are staying in the hospital
Treatment for 1–2 days is good and a taper or prolonged course is not needed

Question 28

What are the basic criteria to diagnose anaphylaxis?

Answer 28

Rapid onset
Affects skin or mucosa
Respiratory compromise
BP decreases (or signs of decreased perfusion, including syncope)
Abdominal complaints
Exposure to potential or known allergen