Emergency management of anaphylaxis in infants and children

Question 1

What is the incidence of anaphylaxis in ED?

Answer 1

1 - 4 per 1000

Question 2

How many kids with anaphylaxis have an identifiable trigger?

Answer 2

1/3

Question 3

What are the most common triggers?

Answer 3

In order:

1. food: peanuts, tree nuts, fish, milk, egg, shellfish
2. bee/wasp stings
3. medication

Question 4

What are the most common symptoms?

Answer 4

SKIN: 80 - 90% of kids have cutaneous manifestations
-pruiritis, urticaria, angioedema, flushing

RESP: 60 - 70% of kids

Question 5

What is the least frequent symptoms?

Answer 5

Cardiovascular: 10 - 30%

Syncope or incontinence

Question 6

What are the diagnostic criteria?

Answer 6

1. Unknown allergen:
   - skin
   AND
   - resp or CVS
2. 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
3. Known allergen exposure + CVS (low BP/syncope)

Question 7

What do you do first out of hospital?

Answer 7

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

Question 8

In kids less than 10 kg, is giving parents small amplues and syringes a good option?

Answer 8

No, this method has been shown to be both error and delay prone

Question 9

If you were a parent would you give IM epi to a kid with just skin findings?

Answer 9

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

Question 10

In hospital, what do you do first?

Answer 10

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

Question 11

Is IM epi and SC epi equivalent?

Answer 11

No
IM has higher peak plasma concentration, which are achieved faster
SC - causes localized vasoconstriction so worse absorption

Question 12

How much blood volume can be lost in anaphylaxis?

Answer 12

35% !

Question 13

What do you do if there are signs of poor perfusion or hypotension?

Answer 13

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

Question 14

Kid is on beta blockers, do you need to do anything special

Answer 14

If hemodynamic concerns despite fluid resuscitation and epi
Glucagon 20-30 uk/kg/bolus
Infusion 5-15ug/min

Question 15

How does epinephrine work

Answer 15

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

Question 16

How frequently can you repeat IM epi

Answer 16

decisions re repeated doses are individualized, but Q5-10 minutes

Question 17

What are the second line medications

Answer 17

1. H1 antagonist: certirizine and benedryle - decrease urticaria, pruritis and angioedema.
2. H2 antagonist: ranitidine - helps the H1
3. Steroids: no good evidence, but given.
4. Inhaled Epi and ventolin

Question 18

Does IM epi have any effect on CVS stuff

Answer 18

NOPE

Only IV epi

Question 19

How does glucagon work

Answer 19

activates adenylate cyclase independent of beta receptors

Question 20

What is the timing of a biphasic reaction and how common is it

Answer 20

1 - 72 hours
5 - 20% of patients

3 % = severe (intubation, vasopressors etc)

Question 21

Who is at higher risk of biphasic reaction

Answer 21

severe symptoms at presentation
multiple doses of epi
delayed administration of epi

Question 22

How long do you have to observe a patient

Answer 22

Minimum 6 hours because most biphasic responses are within 4-6 hours

Question 23

Who would you observe longer or admit

Answer 23

• rural environment
• multiple doses of epi
• severe symptoms at presentation (hypotension, severe resp distress)
• biphasic reaction
• Peanut allergy
• beta blockers
• asthma

Question 24

Things to consider of DC

Answer 24

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

Question 25

Which kids with a non-anaphylactic allergic reaction would you give an epi pen to

Answer 25

• 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

Question 26

What is the dose of cetirizine

Answer 26

6 m - 2 year: 2.5 mg daily
5 - 5 years: 2.5 - 5 mg daily
over 5: 5 - 10 mg daily

Question 27

What is the dose of steroids, ranitidine and benedryl

Answer 27

all 1 mg/kg/dose

Question 28

In anaphylaxis, which would you prefer: cetirizine or benedryl

Answer 28

if no vomiting, cetirizine because faster acting and non-sedating

Question 29

If there are airway concerns, would you do RSI

Answer 29

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