Emergency management of anaphylaxis in infants and children Flashcards
What is the incidence of anaphylaxis in ED?
1 - 4 per 1000
How many kids with anaphylaxis have an identifiable trigger?
1/3
What are the most common triggers?
In order:
- food: peanuts, tree nuts, fish, milk, egg, shellfish
- bee/wasp stings
- medication
What are the most common symptoms?
SKIN: 80 - 90% of kids have cutaneous manifestations
-pruiritis, urticaria, angioedema, flushing
RESP: 60 - 70% of kids
What is the least frequent symptoms?
Cardiovascular: 10 - 30%
Syncope or incontinence
What are the diagnostic criteria?
- Unknown allergen:
- skin
AND
- resp or CVS - Known allergen exposure and 2 of the following:
- skin: angioedema, urticaria, swolen uvula/vulvu, itch
- resp: dyspnea, wheeze, stridor
- CVS: hypotension or end organ dysfunction (syncope or incontinence)
- GI: AP (crampy) or vomiting - Known allergen exposure + CVS (low BP/syncope)
What do you do first out of hospital?
IM EPI! 1:1000
10-25 kg : 0.15 mg
Over 25 kg: 0.3 mg
less than 10 kg: syringe versus 0.15 mg
In kids less than 10 kg, is giving parents small amplues and syringes a good option?
No, this method has been shown to be both error and delay prone
If you were a parent would you give IM epi to a kid with just skin findings?
YES. we err on the side of caution. In a kid with a known allergen and exposure to the same allergen, you advocate to administer epi with just skin findings
In hospital, what do you do first?
IM EPI! 1:1000 + O2 + monitor + 2xIV Access
10-25 kg : 0.15 mg
Over 25 kg: 0.3 mg
less than 10 kg: syringe versus 0.15 mg
0.01 mg/kg
Do not delay IM epi in order to establish IV
Is IM epi and SC epi equivalent?
No
IM has higher peak plasma concentration, which are achieved faster
SC - causes localized vasoconstriction so worse absorption
How much blood volume can be lost in anaphylaxis?
35% !
What do you do if there are signs of poor perfusion or hypotension?
Aggressive fluid resuscitation 20 mlékg IV NS x 2 then consideration for IV Epi 0.1 - 1.0 ug/kg/min
Place in trendelenburg or supine
Kid is on beta blockers, do you need to do anything special
If hemodynamic concerns despite fluid resuscitation and epi
Glucagon 20-30 uk/kg/bolus
Infusion 5-15ug/min
How does epinephrine work
alpha agonist: peripheral vasoconstriction, decrease angioedema and urticaria
beta 1 agonist: positive chronotropic and inotropic
beta 2 agonist: bronchodilation and reduction of inflammatory mediator release from mast cells and basophils
How frequently can you repeat IM epi
decisions re repeated doses are individualized, but Q5-10 minutes
What are the second line medications
- H1 antagonist: certirizine and benedryle - decrease urticaria, pruritis and angioedema.
- H2 antagonist: ranitidine - helps the H1
- Steroids: no good evidence, but given.
- Inhaled Epi and ventolin
Does IM epi have any effect on CVS stuff
NOPE
Only IV epi
How does glucagon work
activates adenylate cyclase independent of beta receptors
What is the timing of a biphasic reaction and how common is it
1 - 72 hours
5 - 20% of patients
3 % = severe (intubation, vasopressors etc)
Who is at higher risk of biphasic reaction
severe symptoms at presentation
multiple doses of epi
delayed administration of epi
How long do you have to observe a patient
Minimum 6 hours because most biphasic responses are within 4-6 hours
Who would you observe longer or admit
- rural environment
- multiple doses of epi
- severe symptoms at presentation (hypotension, severe resp distress)
- biphasic reaction
- Peanut allergy
- beta blockers
- asthma
Things to consider of DC
Safety for DC (ie do they need to be admitted)
Education
Epipen (give on DC in case biphasic reaction)
Advise re MedicAlert
Perscriptions: 3 days of H1 + H2 + steroids
Which kids with a non-anaphylactic allergic reaction would you give an epi pen to
- reaction to trace allergen
- repeat exposures likely
- high risk allergen: peanuts, milk, tree nuts, sea food
- generalized urticaria from insect venom
- Asthma
- beta blocker
- unclear history or allergen
- remote area
What is the dose of cetirizine
6 m - 2 year: 2.5 mg daily
5 - 5 years: 2.5 - 5 mg daily
over 5: 5 - 10 mg daily
What is the dose of steroids, ranitidine and benedryl
all 1 mg/kg/dose
In anaphylaxis, which would you prefer: cetirizine or benedryl
if no vomiting, cetirizine because faster acting and non-sedating
If there are airway concerns, would you do RSI
because you are anticipating a difficult airway, you may not do RSI. YOu do not want to get into a situation where you cannot ventilate.
You want ENT and anaesthesia for help
