Lecture 4 - Anaphylaxis And Rhinitis Flashcards
What is anaphylaxis?
Severe life threatening systemic hypersensitivity reaction (rapid)
Potentially life threatening airway, breathing or circulation problems
What are some symptoms of anaphylaxis?
Hives
Angiodema
Cough
Stridor
Wheeze
Breathless
Shock
Hypotension
Headache
What is the pathogenic mechanism for anaphylaxis?
Mast cells get activated (can be IgE mediated or non IgE mediated) and their mediators act
What are some upper resp symptoms of anaphylaxis?
Rhinorrhea
Sneezing
Angiodema
Stridor
What are some resp symptoms of anaphylaxis?
Cough
Wheeze
Dyspnea
Bronchoconstriction
Hypoxia
What are some skin symptoms of anaphylaxis?
Flushing
Urticaria
Angiodema
Itch
What are some conditions that often occur with anaphylaxis?
Asthma
Allergic rhinitis and eczema
Psychiatric illness
Mastocytosis
CVS disease
What are some factors that amplify anaphylaxis?
Exercise
Acute infection
Emotional stress
Dysruption of routine (travel)
Premenstrual status
What is the diagnosis criteria for anaphylaxis?
Any once of the 2 criteria:
Acute onset of an illness with simultaneous involvement of the skin, mucosal tissue or both (generalised hives, puritis, flushing
+
Resp compromise
Reduced BP or symptoms of end organ dysfunction
Severe GI symptoms
Acute hypotension, bronchospasm or laryngeal involvement
Slide 42 and further information:
Does this patient need an Epi Pen?
No difficulty breathing only urticaria and angiodema episodes
What are thee 3 main features you need to manage in anaphylaxis?
Airways
Breathing
Circulation
Slide 48:
Is this anaphylaxis?
Yes
What is the management for Acute anaphylaxis?
look for sudden onset of Airway, breathing and circulation problems (can have skin changes)
Call for help
Remove trigger
Keep patient on the floor
IM ADRENALINE
Repeat IM adrenaline after 5mins if not worked
O2
Fluids if not response
What posture should we put a patient in with anaphylaxis?
Keep patient sat or lay down
Where do you administer IM adrenaline in anaphylaxis?
Anterolateral thigh
What dose of IM do under 6yrs receive?
150mg
What dose of IM adrenaline do over 6yr olds receive in anaphylaxis?
300mg
What part of the epipen faces the sky, what part of the epipen is in the thigh?
Blue = sky
Orange = thigh
What should be done after giving an epipen?
May need further adrenaline dosing to maintain optimal dose to resolve symptoms
Adrenaline via needle/syrinnge has better pharmacokinetics
Why are IV fluids useful in anaphylaxis?
Help increase venous return
Dec stroke volume
Inc heart rate
What volume of IV fluids should be given in a child with anaphylaxis?
10ml/kg
Why type of IV solution is given as a bolus for anaphylaxis for adults ?
500ml
What is refractory anaphylaxis?
Anaphylaxis that doesn’t resolve after 2 doses of intramuscular adrenaline
How do you treat refractory anaphylaxis?
IV fluids
Start adrenaline infusion (IV)
Ensure has oxygen
Are anti-histamines and corticosteroids part of the initial emergency management for acute anaphylaxis?
Not initial emergency managemtn
Given after stabilisation
How to you manage anaphylaxis long term?
Risk assessment
Allergen avoidance
Emergency plans
What are considered avoidable causes of anaphylaxis and not reliably avoidable?
Avoidable = prescription drugs
Not avoidable = foods, stings, latex, idiopathic
What should be done if a patient presents with asthma in context with exposure to known allergen?
IM adrenaline
Can consider bronchodilators like salbutamol/ipratropium
What is the definition of rhinitis?
Inflammation of the nasal mucosa
Rhinorrhoea, nasal blockage, congestion, itchiness adn sneezing
What is rhinitis including the sinus linings called?
Rhinosinusitis
What is rhinitis called involving the conjunctivae?
Rhino-conjunctivitis
What are the different types of rhinitis?
Allergic
Infective
Non-allergic
What are the different classifications of allergic rhinitis?
Intermittent
Persistent
Mild
Moderate-severe
What is considered moderate-severe allergic rhinitis?
Sleep disturbance
Impairment of daily activities, sport, leisure’s
What is considered mild allergic rhinitis?
Normal sleep
No impairment of daily activities, sport and leisure
What condition is strongly associated withi allergic rhinitis?
Asthma
What is the pathophysiology of rhinitis?
Allergen picked up by dendritic cells and macrophages in nasal epithelial cells
MHC II to TH2
IgE made and binds to mast cells and basophils
Activating the cells
Degranulation occurs with allergen being reintroduced release of mediators
What is the pathophysiology of rhinitis?
Allergen picked up by dendritic cells and macrophages in nasal epithelial cells
MHC II to TH2
IgE made and binds to mast cells and basophils
Activating the cells
Degranulation occurs with allergen being reintroduced release of mediators
What is the pathophysiology of rhinitis?
Allergen picked up by dendritic cells and macrophages in nasal epithelial cells
MHC II to TH2
IgE made and binds to mast cells and basophils
Activating the cells
Degranulation occurs with allergen being reintroduced release of mediators
What are teh effects of some of the mediators being released in rhinitis?
Mucus oedema, mucus hypersecretion
Infiltration of inflammatory cells
Eosinophils
Basophils
Neutrophils
What are teh symptoms of rhinitis?
Sneezing
Rhinnorrhrea
Nasal obstruction
Nasal itching
Ocular symptoms
What is the process of being exposed to house dust mite allergens in rhinitis?
Allergen infiltration
Cascade of IgE overproduction by B cells
Th2 proliferation due to increased IL-6
House Dust Mite proteases cleave pulmonary surfactants causing dec lung core acne of allergens
What are some comorbidities associated with allergic rhinitis?
Asthma
Conjunctivitis
Rhinosinusitis/anosmia
Otitis media with effusion
Throat and laryngeal effects
Sleep problems
How do you diagnose allergic rhinitis?
Mroe than 2 clinal sympotms for more than an hr on most days
Sneezing
Nasal itching
Rhinorrheao
Nasal obstruction
Snoring, sleep problems
+- conjunctivitis
What are some features of a Hx for rhinitis?
Seasonal
Indoors/outdorrs location
What makes rhinitis mroe likely in Fhx?
Fhx of it
What are some clinical findings on examination for rhinitis?
Allergic salute/horizontal nasal crease
Dennie-Morgan lines
Hypertrophic, pale and boggy ITs
Clear, coloured or purulent secretions
What signs are seen on slide 14 for rhinitis?
What are some differentials for rhinitis?
Adenoidal hypertrophy
Acute/chronic sinusitis
Foreign bodies
Acute infectious rhinitis
Look at slide 15
What are some investigations done for rhinitis?
Skin prick test
ssIgE (serum specific IgE)
How is climate change affecting the prevalence of rhinitis?
More warming means more pollens likely to be spread around
What are the treatments for rhinitis?
Prevention of triggers
Saline rinses
Antihistamines
Intranasal steroids
Ipratropium bromide
Surgical intervention
Septoplasty
Turbinate reduction
What are some symptomatic therapies in allergic rhinitis?
Antihistamines (cetirizine)
Intranasal corticosteroid suppress immune cells infiltration momenta’s on furoate
Intranasal H1 antihistamines + ICS combination therapies
Leucotriene receptor antagonists
What is an example of a leukotreine receptor antagonist?
Monteleukast
How do nasal decongestants work?
Agonist at alpha 1 and alpha 2 adrenergic receptors on nasal mucosa reducing mucosal swelling
What are some nasal sprays?
Sudafed (pseudoephedrine)
Neo-synephrine (phenylephrine)
What is the problem with overuse of nasal decongestant?
Rhinitis medicamentosa
What is rhinitis medicamentosa?
How’s it treated?
Condition of rebound congestion upon withdrawal of nasal decongestants
Treated by Intranasal corticosteroid
What is the treatment pathway for allergic rhinitis?
Antihistamines
Intranasal corticosteroids
What are the mechanisms of immune tolerance with rhinitis?
Regulatory cells. Induced
Regulatory cells produce IL-10 to suppress the Type 2 inflammatory cells
Induces allergen specific immunogobin class switch
How do you take nasal drops?
Gently blow/clear nose
Tilt head forward and keep bottle upright and squeeze a fine mist and breathe in slowly then out
