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anaphylaxis and drug adverse reactions Flashcards

1
Q

Serious allergic reaction, rapid in onset and may cause death

A

ANAPHYLAXIS

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2
Q

____in infants and children

A

Underdiagnose

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3
Q

Sudden release of potent biologically active mediators from

A

mast cells
basophils

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4
Q

leading to cutaneous, respiratory,
cardiovascular, gastrointestinal symptoms

A

basophils

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5
Q

allergic reaction to medications and latex

A

Hospital-related –

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6
Q

Community-related

A

– food allergy

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7
Q

important cause of food induced anaphylaxis

A

Peanut allergy –

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8
Q

pathology

A

Acute bronchial obstruction with pulmonary hyperinflation,
pulmonary edema, intra-alveolar hemorrhage, visceral
congestion, laryngeal edema, urticaria, and angioedema

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9
Q

Result of the activation of mast cells and basophils via cellhound allergen

A

specific IgE.

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10
Q

CLINICAL MANIFESTATION

A
  • Vary depending on the cause of the reaction
  • Ingested allergen (food, medication) delayed in onset – mins
    to 2 hours
  • Injected allergens (meds, sting) – GI symptoms
  • Pruritus mouth and face, sensation warmth, weakness, and
    apprehension; flushing, urticaria and angioedema, oral or
    cutaneous pruritus, tightness in the throat, dry staccato cough
    and hoarseness, periocular pruritus, nasal congestion,
    sneezing, dyspnea, deep cough, and wheezing; nausea,
    abdominal cramping, and vomiting; faintness and loss of
    consciousness in severe cases
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11
Q

Ingested allergen (food, medication) delayed in onset

A

– mins to 2 hours

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12
Q

GI symptoms

A

Injected allergens (meds, sting) –

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13
Q

clinical manifestations

A

Pruritus mouth and face, sensation warmth, weakness, and
apprehension; flushing, urticaria and angioedema, oral or
cutaneous pruritus, tightness in the throat, dry staccato cough
and hoarseness, periocular pruritus, nasal congestion,
sneezing, dyspnea, deep cough, and wheezing; nausea,
abdominal cramping, and vomiting; faintness and loss of
consciousness in severe cases

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14
Q

ANAPHYLAXIS SYMPTOMS THAT
INFANTS CANNOT DESCRIBE >GENERAL

A

Feeling of warmth, weakness, anxiety,
apprehension, impending doom

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15
Q

ANAPHYLAXIS SYMPTOMS THAT
INFANTS CANNOT DESCRIBE >SKIN/MUCUS MEMBRANES

A

Itching of lips, tongue, palate, uvula, ears,
throat, nose, eyes, etc.; mouth-tingling
or metallic taste

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16
Q

ANAPHYLAXIS SYMPTOMS THAT
INFANTS CANNOT DESCRIBE >RESPIRATORY

A

Nasal congestion, throat tightness; chest
tightness; shortness of breath

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17
Q

ANAPHYLAXIS SYMPTOMS THAT
INFANTS CANNOT DESCRIBE >GASTROINTESTINAL

A

Dysphagia, nausea, abdominal pain/
cramping

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18
Q

ANAPHYLAXIS SYMPTOMS THAT
INFANTS CANNOT DESCRIBE >CARDIOVASCULAR

A

Feeling faint, presyncope, dizziness,
confusion, blurred vision, difficulty in
hearing

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19
Q

ANAPHYLAXIS SYMPTOMS THAT
INFANTS CANNOT DESCRIBE >CENTRAL NERVOUS SYSTEM

A

Headache

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20
Q

ANAPHYLAXIS SIGNS THAT MAY BE DIFFICULT
TO INTERPRET/UNHELPFUL IN INFANTS,
AND WHY>GENERAL>

A

Nonspecific behavioral changes such as persistent crying, fussing, irritability, fright, suddenly
becoming quiet

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21
Q

ANAPHYLAXIS SIGNS THAT MAY BE DIFFICULT
TO INTERPRET/UNHELPFUL IN INFANTS,
AND WHY>SKIN/MUCUS MEMBRANES

A

Flushing (may also occur with fever, hyperthermia, or
crying spells)

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22
Q

ANAPHYLAXIS SIGNS THAT MAY BE DIFFICULT
TO INTERPRET/UNHELPFUL IN INFANTS,
AND WHY>RESPIRATORY

A

Hoarseness, dysphonia (common after a crying spell);
drooling or increased secretions (common in
infants)

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23
Q

ANAPHYLAXIS SIGNS THAT MAY BE DIFFICULT
TO INTERPRET/UNHELPFUL IN INFANTS,
AND WHY>GASTROINTESTINAL

A

Spitting up/regurgitation (common after feeds),
loose stools (normal in infants, especially if
breastfed); colicky abdominal pain

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24
Q

ANAPHYLAXIS SIGNS THAT MAY BE DIFFICULT
TO INTERPRET/UNHELPFUL IN INFANTS,
AND WHY>CARDIOVASCULAR

A

Hypotension (need appropriate-size blood pressure
cuff; low systolic blood pressure for children is
defined as <70 mm Hg from 1 mo to 1 yr, and less
than (70 mm Hg + [2 × age in yr]) from 1-10 yr;
tachycardia, defined as >140 beats/min from 3 mo
to 2 yr, inclusive; loss of bowel and bladder control
(ubiquitous in infants)

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25
ANAPHYLAXIS SIGNS THAT MAY BE DIFFICULT TO INTERPRET/UNHELPFUL IN INFANTS, AND WHY>CENTRAL NERVOUS SYSTEM
Drowsiness, somnolence (common in infants after feeds)
26
ANAPHYLAXIS SIGNS IN INFANTS>SKIN/MUCUS MEMBRANES
Rapid onset of hives (potentially difficult to discern in infants with acute atopic dermatitis; scratching and excoriations will be absent in young infants); angioedema (face, tongue, oropharynx)
27
ANAPHYLAXIS SIGNS IN INFANTS>RESPIRATORY
Rapid onset of coughing, choking, stridor, wheezing, dyspnea, apnea, cyanosis
28
ANAPHYLAXIS SIGNS IN INFANTS>GASTROINTESTINAL
Sudden, profuse vomiting
29
ANAPHYLAXIS SIGNS IN INFANTS>CARDIOVASCULAR
Weak pulse, arrhythmia, diaphoresis/ sweating, collapse/unconsciousness
30
ANAPHYLAXIS SIGNS IN INFANTS>CENTRAL NERVOUS SYSTEM
Rapid onset of unresponsiveness, lethargy, or hypotonia; seizures
31
Diagnosis of Anaphylaxis
Anaphylaxis is highly likely when any 1 of the following 3 criteria is fulfilled: 1. Acute onset of an illness (minutes to several hours) with involvement of the skin and/or mucosal tissue (e.g., generalized hives, pruritus or flushing, swollen lips/tongue/uvula) AND AT LEAST 1 OF THE FOLLOWING: a. Respiratory compromise (e.g., dyspnea, wheeze/ bronchospasm, stridor, reduced peak PEF, hypoxemia) b. Reduced BP or associated symptoms of end-organ dysfunction (e.g., hypotonia [collapse], syncope, incontinence) 2. 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 (e.g., generalized hives, itch/flush, swollen lips/tongue/uvula) b. Respiratory compromise (e.g., dyspnea, wheeze/ bronchospasm, stridor, reduced PEF, hypoxemia) c. Reduced BP or associated symptoms (e.g., hypotonia [collapse], syncope, incontinence) d. Persistent gastrointestinal symptoms (e.g., crampy abdominal pain, vomiting) 3. Reduced BP following exposure to known allergen for that patient (minutes to several hours): a. Infants and children: low systolic BP (age-specific) or >30% drop in systolic BP b. Adults: systolic BP <90 mm Hg or >30% drop from patient’s baseline
32
Acute onset of an illness (minutes to several hours) with involvement of the skin and/or mucosal tissue (e.g., generalized hives, pruritus or flushing, swollen lips/tongue/uvula) AND AT LEAST 1 OF THE FOLLOWING:
a. Respiratory compromise (e.g., dyspnea, wheeze/ bronchospasm, stridor, reduced peak PEF, hypoxemia) b. Reduced BP or associated symptoms of end-organ
33
2. 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 (e.g., generalized hives, itch/flush, swollen lips/tongue/uvula) b. Respiratory compromise (e.g., dyspnea, wheeze/ bronchospasm, stridor, reduced PEF, hypoxemia) c. Reduced BP or associated symptoms (e.g., hypotonia [collapse], syncope, incontinence) d. Persistent gastrointestinal symptoms (e.g., crampy abdominal pain, vomiting)
34
3. Reduced BP following exposure to known allergen for that patient (minutes to several hours):
a. Infants and children: low systolic BP (age-specific) or >30% drop in systolic BP b. Adults: systolic BP <90 mm Hg or >30% drop from patient’s baseline
35
TREATMENT
* Medical emergency and requires aggressive management. * IM/IV epinephrine (IM epinephrine is safer), IM/IV H1(Ranitidine) & H2(Diphenhydramine) antihistamines, O2, inhaled B2 agonist, corticosteroid * Ensure adequate airway and effective respiration, circulation, and perfusion (low bp → hydrate px, give epinephrine first)
36
* IM/IV epinephrine (which is safe)
(IM epinephrine is safer)
37
IM/IV H1
(Ranitidine)
38
IM/IV H2
(Diphenhydramine)
39
Ensure adequate airway and effective respiration, circulation, and perfusion
(low bp → hydrate px, give epinephrine first)
40
Occur when anaphylactic symptoms recur after apparent resolution
biphasic anaphylaxis
41
biphasic anaphylaxis occur when treatment is initiated late & symptoms is mild
severe
42
biphasic anaphylaxis 90% occur within
4 hours
43
Anaphylaxis preparedness>Patient presents with possible/probable acute anaphylaxis>Initial assessment supports potential anaphylaxis? e.g., non-localized urticaria after immunotherapy> no
Consider other diagnosis
44
Anaphylaxis preparedness>Patient presents with possible/probable acute anaphylaxis>Initial assessment supports potential anaphylaxis? e.g., non-localized urticaria after immunotherapy> yes
Immediate intervention * Assess airway, breathing, circulation, mentation * Inject epinephrine and reevaluate for repeat injection if necessary * Supine position (if cardiovascular involvement suspected)
45
Anaphylaxis preparedness>Patient presents with possible/probable acute anaphylaxis>Initial assessment supports potential anaphylaxis? e.g., non-localized urticaria after immunotherapy> yes> Immediate intervention> Goodclinical response?>
yes> * Observation Length and setting of observation must be individualized, * Autoinjectible epinephrine> Consultation with allergistimmunologist
46
Anaphylaxis preparedness>Patient presents with possible/probable acute anaphylaxis>Initial assessment supports potential anaphylaxis? e.g., non-localized urticaria after immunotherapy> yes> Immediate intervention> Good clinical response?
no>Subsequent emergency care that may be necessary depending on response to epinephrine: Consider: * Call 911 and request assistance * Recumbent position with elevation lower extremity * Establish airway * O2 * Repeat epinephrine injection if indicated * IV fluids if hypotensive; rapid volume expansion Consider inhaled bronchodilators if wheezing * H1 and H2 antihistamines * Corticosteroids
47
Anaphylaxis preparedness>Patient presents with possible/probable acute anaphylaxis>Initial assessment supports potential anaphylaxis? e.g., non-localized urticaria after immunotherapy> yes> Immediate intervention> Good clinical response?> Subsequent emergency care that may be necessary depending on response to epinephrine>no>
Call 911 if not already done Consider: * Epinephrine intravenous infusion * Other intravenous vasopressors * Consider glucagon
48
Cardiopulmonary arrest during anaphylaxis:
* CPR and ACLS measures * Prolonged resucitation efforts encouraged (if necessary)
49
cardiopulmonary arrest during anaphylaxis consider:
* High-dose epinephrine * Rapid volume expansion * Atropine for asystole or pulseless electrical activity * Transport to emergency dept. or ICU
50
GELL AND COOMBS CLASSIFICATION
1. Immediate hypersensitivity reaction (Type I) 2. Cytotoxic antibody reaction (Type II) 3. Immune complex reactions (Type III) 4. Delayed type hypersensitivity reaction (Type IV)
51
o Histamines and leukotrienes
Immediate hypersensitivity reaction (Type I)
52
Urticaria, bronchospasm, anaphylaxis
Immediate hypersensitivity reaction (Type I)
53
Complement
Cytotoxic antibody reaction (Type II)
54
Drug induced hemolytic anemia and thrombocytopenia
Cytotoxic antibody reaction (Type II)
55
Immune complex activating complement cascade
Immune complex reactions (Type III)
56
Immune complex activating complement cascade
Immune complex reactions (Type III)
57
Serum sickness
Immune complex reactions (Type III)
58
Appear 1-3 weeks after last dose of offending drug
Immune complex reactions (Type III)
59
Immune complex reactions (Type III) Appear ____ after last dose of offending drug
1-3 weeks
60
Drug specific T lymphocytes
Delayed type hypersensitivity reaction (Type IV)
61
Occur in topical route
Delayed type hypersensitivity reaction (Type IV)
62
o Contact dermatitis
Delayed type hypersensitivity reaction (Type IV)
63
RISK FACTORS
* Prior exposure * Previous reactions * Age (20-49 yo) * Route of administration (parenteral/topical) * Dose (high) * Dosing schedule (intermittent) * General predisposition
64
Age occur
(20-49 yo)
65
DIAGNOSIS
* Accurate medical history * Identification of the drug * Skin testing * Coombs test (direct and indirect)
66
o Most rapid and sensitive method of demonstrating the presence of IgE antibody to a specific Ag
skin testing
67
Drug induced hemolytic anemia
Coombs test (direct and indirect)
68
TREATMENT
* Desensitization * Drugs causing non-IgE related reactions * Severe non-IgE mediated hypersensitivity should not receive predisposing agents even in small amounts
69
Progressive administration of an allergen to render effector cell less effective
Desensitization
70
Reserve for patients with IgE antibodies to a particular drug for whom an alternative drug is not available or appropriate
Desensitization
71
Graded challenges done by giving drug in an incremental fashion until therapeutic dose is achieved
Drugs causing non-IgE related reactions
72
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73
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