Anaphylaxis, Vasovagal

Question 1

Anaphylaxis

-overview of what it is, what causes it

Answer 1

Severe, life-threatening allergic reaction

Chemical cascade causes the body to go into shock

Type I (IgE) reaction

Occurs from seconds to minutes

Second reaction directly after first = biphasic anaphylaxis (pt seems fine after 1st incident, suddenly really bad again)

Question 2

Anaphylaxis signs/symp

• general app/vitals
• dermatology
• ocular
• cardiovascular

Answer 2

Restless, anxious

Erythema, urticaria, cutaneous injection/pruritis, warmth, angioemema

Conj injection, pruritis, ecchymosis

Hypotension, weak/rapid pulse

Question 3

Anaphylaxis signs/symp

• respiratory
• GI
• neuro
• other

Answer 3

Congestion, coryza, rhinorrhea, sneezing, throat tightness, wheezing, hoarseness, dyspnea

Nausea, vomiting, diarrhea, bloating, cramps, dysphagia

Dizziness, HA, blurred vision, syncope, seizure, depressed consciousness, agitation, combative, altered mental status

Metallic taste, feeling of impending doom

Question 4

Anaphylaxis

• causes
• risk factors

Answer 4

Food, meds, venom, material, activity

Previous anaphylaxis, allergies/asthma, heart disease, mastocytosis (accum of specific WBCs)

Question 5

Anaphylaxis

-ddx (6)

Answer 5

Vasovagal
Hereditary angiodema
Malignant carcinoid syndrome
Medullary thyroid carcinoma
Pheochromocytoma
Systemic mastocytosis

Question 6

Anaphylaxis

-testing (4)

Answer 6

Serum tryptase
-confirm dx

Urinary 24h histamine
-dx recurrent

Urinary 24h 5-hydroxyindoleacetic acid level
-rule out malignant carcinoid syndrome

In vitro IgE tests
-determine cause

Question 7

Anaphylaxis

-non-pharm management

Answer 7

Airway: ventilator, intubation, mask

High-flow O2

Cardiac/pulse monitoring

IV access

Fluid resuscitation with isotonic crystalloid soln

Supine position, legs elevated

Question 8

Anaphylaxis

-pharm management

Answer 8

Adrenergic agonists
-epinephrine

Antihistamines
-diphenhydramine, hydroxyzine

H2 receptor antagonists
-cimetadine, ranitidine, famotidine

Bronchodilation
-albuterol

Corticosteroids
-methylprednisolone, prednisone

Positive inotropic agents
-glucagon

Vasopressors
-dopamine

Question 9

Anaphylaxis

-surgical management

Answer 9

Cricothyrotomy

Catheter jet ventilation

Question 10

Anaphylaxis

-in-office management

Answer 10

Call 911

Use an epipen

Lie pt down, elevate legs to avoid seizure

Administer albuterol, then O2

Check pulse, breathing, perform CPR if needed

Question 11

Vasovagal syncope
-overview
—aka
—response controlled by
—cascade

Answer 11

Aka neurocardiogenic syncope or reflex syncope

Vagus nerve (CNX, PNS)

Certain triggers induce extreme stress and lead to syncope: triggers -> bradycardia/hypotension/hyperhidrosis -> reduced blood to brain -> syncope

Question 12

Vasovagal syncope signs/symp

• general app/vitals
• dermatology
• ocular
• cardiovascular

Answer 12

Jerky, abnormal movements

Pale skin, feeling of warmth, cold/clammy sweat

Dilated pupils

Hypotension, weak/slow pulse

Question 13

Vasovagal syncope signs/symp

• respiratory
• GI
• neuro

Answer 13

Yawning

Nausea, vomiting

Dizziness, tunnel vision, lightheaded, blurred vision, syncope

Question 14

Vasovagal syncope

• causes
• risk factors

Answer 14

Triggers

• excessive standing
• heat exposure
• seeing blood or needles
• having blood drawn
• fear of injury
• straining
• tonometry
• bright lights

Risks: being around triggers

Question 15

Vasovagal syncope

-ddx (9)

Answer 15

-Anaphylaxis
– Cardiac syncope (unknown cause of syncope have a 30% increase in death vs vasovagal
have no increased risk of death) 
– Hemorrhage 
– Pulmonary embolism 
– Carotid sinus hypersensitivity 
– Orthostasis 
– Medications 
– Metabolic 
– Seizure

Question 16

Vasovagal syncope

-testing (6)

Answer 16

-Electrocardiogram
– Echocardiogram
– Exercise stress test
– Blood tests (looking for anemia)
– Neurological studies
– Tilt table (done after heart problems are r/o)

Question 17

Vasovagal syncope

-non-pharm management

Answer 17

Foot exercises
Compression stockings
Incr salt intake
Incr fluid intake

Question 18

Vasovagal syncope

-pharm management

Answer 18

Beta-blockers – Atenolol
-counteracts the increase in serum epinephrine that occurs before syncope

Mineralocorticoids
– Fludrocortisone acetate
-treats hypotension

SSRIs
– Fluoxetine
-5HT inhibits sympathetic neural outflow while increasing adrenal sympathetic stimulation

Vasoconstrictors – Disopyramide
-decrease cardiac contractility and manages heart rate

Question 19

Vasovagal syncope

-surgical management

Answer 19

Electrical pacemaker

Question 20

Vasovagal syncope

-in-office management

Answer 20

Try to catch pt before they fall
Lie pt down with legs elevated
Check pulse/breathing
Administer smelling salt