Emergency - Anaphylaxis and Angioedema Flashcards
What are the 3 key features of anaphylaxis?
- sudden onset and rapid progression of symptoms
- life-threatening airway and/or breathing and/or circulation problems
- skin and/or mucosal changes (flushing, urticaria, angioedema)
You are on duty in Emergency department (ED) and a nurse informed you that a patient, Mr Robert Jobbs, has presented to ED complaining of feeling tight chested. After a SBAR handover, you found out that Mr Jobbs is an American tourist on holiday in the UK. He had just started eating a meal and experienced the sensations he gets when he’s eaten something containing peanuts. He has a known peanut allergy.
You carry out an ABCDE assessment and note the following:
A - Clear
B - RR 18 min-1, audible wheeze, talking full sentences, SpO2, 98% on air
C - P 90 min-1, BP 110/60 mmHg, CRT < 2 s
D - Alert, anxious, tingling in lips, itchy skin
E - No rash or swelling visible. Nil of note
Is this presentation suggestive of anaphylaxis?
No - this presentation is consistent with a type 1 hypersensitivity reaction and at the moment, there are none of the 3 key features of anaphylaxis.
Taking this information into account, you should admit Mr Jobbs for close observation. Antihistamines are prescribed to be taken if required.
You are on duty in Emergency department (ED) and a nurse informed you that a patient, Mr Robert Jobbs, has presented to ED complaining of feeling tight chested. After a SBAR handover, you found out that Mr Jobbs is an American tourist on holiday in the UK. He had just started eating a meal and experienced the sensations he gets when he’s eaten something containing peanuts. He has a known peanut allergy.
You carry out an ABCDE assessment and note the following:
A - Clear
B - RR 18 min-1, audible wheeze, talking full sentences, SpO2, 98% on air
C - P 90 min-1, BP 110/60 mmHg, CRT < 2 s
D - Alert, anxious, tingling in lips, itchy skin
E - No rash or swelling visible. Nil of note
5 mins after this assessment, you have been called back to Mr Jobbs urgently because he developed SOB. What is the most appropriate treatment at this stage?
Call for help, administer IM adrenaline
Repeat A-E assessment - 15L oxygen via non-rebreather, 500ml 0.9% sodium chloride
(Mr Jobbs is at risk of airway compromise. Early treatment with adrenaline and expert help for airway management is vital)
A patient presents with rapid onset hypotension associated with skin/mucosal changes. You suspect anaphylaxis so you call for help, administer IM adrenaline and complete an A-E assessment. You have given the patient oxygen, bronchodilators and IV fluids as per the A-E assessment.
Which second-line drugs will you now prescrobe?
antihistamine - IV chlorphenamine 10mg
steroid - IV hydrocortisone 200mg
With regards to anaphylaxis: Which of the following statements are true?
- Should only be treated with IV adrenaline
- Is a life-threatening generalised or systemic hypersensitivity reaction
- Can be associated with skin changes only
- IV antihistamine and steroids should be considered as first line treatment
The only true statement is that anaphylaxis is a severe life-threatening generalised or systemic hypersensitivity reaction.
Skin changes alone do not signify anaphylaxis. For treatment, IM adrenaline is the best method for most rescuers and, although useful, antihistamines and steroids are second line drugs for the treatment of anaphylaxis.
Differential diagnosis of Anaphylaxis?
- Acute exacerbation of asthma/COPD
- Shock - cardiogenic shock, hypovolaemic shock, obstructive shock, distributive shock
- Panic attack
What skin/mucosal changes are you likely to see in anaphylaxis?
urticaria, pruritus
angioedema - – deep swelling involving dermis and subcutaneous tissues (swelling of tongue and lips
Pathophysiology of anaphylaxis?
- Sensitised individual exposed to specific antigen
- Common antigens: insect bites/stings, food (nuts, sesame seeds, shellfish, dairy) medications (penicillin, contrast media, NSAIDs, ACEi)
- IgE —> antigen —> mast cell and basophils activated —> histamine release
Describe the management of anaphylaxis.
ABCDE approach
GET HELP
Remove trigger
High flow oxygen
Administer IM 0.5ml of 1:1000 adrenaline (0.5mg) (repeat after 5min if no better)
If hypotensive, lie flat and IV fluid resuscitation
IV chlorphenamine 10mg (anti-histamine)
IV hydrocortisone 200mg
Treat bronchospasm with nebulised salbutamol
Treat laryngeal oedema with nebulised adrenaline
What’s the difference between anaphylaxis and angioedema?
Angioedema – deep swelling involving dermis and subcutaneous tissues (swelling of tongue and lips)
Anaphylaxis – bronchospasm, facial and laryngeal oedema, hypotension
What test can be used to confirm diagnosis of anaphylaxis after resuscitation?
serum mast cell tryptase (ensure to record time taken)