This is a Test

1

• This is a Test
• It is ONLY a Test

2

• A 16 y/o girl just passed out after receiving her
  penicillin shot for strep throat (doesnt
  swallow pills). Which of the following will be
  most useful to know in treating her
• A Her Blood Pressure
• B Her Glucose level
• C Her Heart Rate
• D Your Heart Rate

3

• Which of the following is the safest and most
  efficient route to administer epinephrine in an
  allergy emergency
• A IV
• B Sub Q
• C IM
• D PR

4

• Which of the following potential allergens do not
  generally cross-react
• A. COX-2 inhibitors Ibuprofen
• B. Filberts Pecans
• C. Peanuts Tofurky
• D. Lobster Shrimp

5

• A first year PEM fellow attending conference
  developed a sudden onset of urticaria, lip
  swelling and DIB. The etiology is most likely a
  reaction to
• A smelling someone elses lunch
• B a spider bite
• C another billing talk by Dr Linzer

6

• When advising parents/patients on how to
  administer an epi-pen you should tell them to
• A. hold it against the triceps and squeeze the
  trigger
• B. stab it into the anterior thigh
• C. hold it against the lateral thigh and push

7

• Which is NOT a clinical presentation of
  anaphylaxis
• A. Vomiting and Diarrhea
• B. Syncope
• C. Altered Mental Status
• D. Itchy Tongue

8

• In counseling a 50kg 15 year old after a severe
  episode of anaphylaxis to a bee sting your best
  advice is that if they get stung again they first
  should take
• A. (2) 25mg diphenhydramine capsules PO
• B. (5) tsp diphenhydramine elixer PO
• C. .5mg epinephrine SQ
• D. 60mg prednisone PO

9

• Which of the following treatments has been shown
  to decrease the incidence of biphasic reactions
• A. Corticosteroids
• B. Epinephrine
• C. Diphenhydramine
• D. Ranitidine

10
ANAPHYLAXIS

• Michael Greenwald, MD

Pediatric Emergency Medicine Emory
University Childrens Healthcare of Atlanta _at_
Egleston
11
Objectives

• Recognize patients with, or at risk for,
  anaphylactic reaction
• Understand the immunologic basis for anaphylactic
  reactions
• Know the interventions appropriate for
  anaphylactic reactions
• Know the appropriate medical follow-up

12
Historical Background

• ana- backward phylaxis- protection
• Portier and Richet reactions in dogs exposed to
  sea anenome toxin
• First documented case Egyptian pharoah 2640 B.C.
  dies after wasp sting

13
Defining Anaphylaxis

• Acute
• Systemic
• Allergic (i.e. requires prior exposure)

14
Special Features of Anaphylaxis

• Spectrum of severity
• Variety of manifestations
• Uniphasic, biphasic or protracted

15
Epidemiology

• Top triggers then
• penicillin
• insect venom
• food

• Top triggers now
• Latex (27)
• Food (25)
• Drugs (16)
• Venoms (15)

16
Anaphylaxis Epidemiology

• 84,000 cases/year in US
• 1 fatal
• Kids gt adults
• Food Allergy
• under 4 y/o 6-8
• After 10 y/o 2
• 29,000 cases food induced anaphylaxis/year
• 2000 hospitalizations
• 150 deaths high association with asthma,
  peanut/tree nut allergy
• Peanuts are 1 and increasing in Western nations

17
Hypersensitivity review Gell and Coombs
Classification

• Type I - Anaphylactic
• Type II - Cytotoxic
• Type III - Immune Complex
• Type IV - Delayed Type

18
Type I - Anaphylactic

• Immediate Exposure to reaction lt 30minutes
• Late Phase Exposure to reaction 2-12 hours
• Exposure to reaction lt30minutes
• Effector cell IgE
• Antigen pollens, foods, drugs, venoms
• Mediators histamine, leukotrienes
• Manifestations anaphylaxis, allergic rhinitis,
  allergic asthma, urticaria

19
Type II - Cytotoxic

• Exposure to reaction variable (minutes to hours)
• Effector cell IgG, IgM
• Target Red blood cells, Lung tissue
• Mediators Complement
• Examples Immune hemolytic anemia, Rh hemolytic
  disease, Goodpasture syndrome

20
Type III - Immune Complexes

• Exposure to reaction 6 - 21 days
• Effector cell Antigen with Antibody
• Target Vascular endothelium
• Mediators Complement, Anaphylatoxin
• Symptoms fever, urticaria, arthralgia,
  arthritis, lymphadenopathy
• Examples Serum sickness, PSGN

21
Type IV - Delayed Type

• Exposure to reaction 24-48 hours
• Effector cell Lymphocytes
• Antigen Chemicals, Mycobacterium tuberculosis
• Mediators Lymphokines
• Examples Contact dermatitis, Tuberculin skin
  reactions

22
Anaphylaxis and Her Cousin

• Anaphylaxis
• IgE mediated
• IgG - immune complex mediated
• Anaphylactoid
• direct stimulation of mast cells and basophils
• unknown mechanism

23
IgE - mediated Anaphylaxis

• Prior exposure required
• Allergen-IgE binding induces release of
  mediators
• histamine
• prostaglandins
• platelet activating factor
• tryptase

24
IgG -immune complex mediated

• complement activated by immune complexes or
  other agents
• Tissue antigens - RBC, WBC, Plts
• Serum proteins - Immunoglobulin, cryoprecipitin
• anaphylatoxins C3a, C5a

25
Anaphylactoid Direct stimulation

• direct stimulation of mast cells and basophils
• unknown mechanism - suspect high osmolarity
• examples radiocontrast media (not assoc w/
  iodine, shellfish allergy), mannitol, opiates,
  curare, dextran, chemotherapeutic agents

26
Unexplained Anaphylaxis

• Unknown mechanism
• ASA and other NSAIDS
• preservatives
• exercise
• mastocytosis
• cholinergic urticaria with anaphylaxis
• progesterone catamenial anaphylaxis

27
Unexplained Anaphylaxis

• Idiopathic anaphylaxis unknown trigger
• up to 37 of all reactions
• clinically indistinguishable from other forms
• particularly stressful to patients

28
Epidemiology

• Patients at risk
• Does atopic history matter?
• Who gets the worst reactions?
• Latex

29
Allergens

• Drugs
• Foods
• Venoms
• Latex

30
Defining Drug Reactions

• Predictable Drug Reactions
• 80 of all adverse effects
• dose dependent
• related to known pharmacological effect
• Unpredictable Drug reactions
• not dose dependent
• occurs in susceptible individuals
• unrelated to known pharmacological effect

31
Drugs

• Antimicrobials
• Penicillin 2 potential groups of allergens
• Major determinant Benzyl penicilloyl
• Minor determinants penicillin, penicilloate,
  penilloate, penicilloylamine
• Cephalosporins
• Sulfonamides

32
Drugs

• NSAIDS
• bronchospasm in 2-10 of asthmatics
• unknown mechanism IgE and mast cells not involved

33
Drugs

• Macromolecules
• protamine
• insulin
• IVIG
• 2 recognized mechanisms
• IgA deficiency high risk
• slow infusion and pretreat

34
Drugs

• Chemotherapeutic agents L-Asparaginase
• Vaccinations MMR?
• Immunotherapy
• 17 fatalities reported 1985-1989 (10 million
  shots given annually)
• precautions for medical facility
• observe 20 minute
• medications and airway support available

35
Drugs

• Radiocontrast media
• mast cell degranulation from anaphlatoxins of
  complement cascade
• older agents Hypaque, Renigrafin
• mild reaction in 5, severe - 1/1000,
  death - 1/10-40,000 exposures
• risk factors
• atopic/asthma history
• adult

36
Foods

• Tree nuts 1 Americans (3 million) allergic
• Legumes 25-35 also allergic to tree nuts
• Shellfish
• Fish
• Milk
• Eggs
• Food additives sulfites

37
Foods That May Contain Peanut Oil

• Arachis oil (peanut oil)
• Baked Goods and mixes
• Biscuits, cookies, pastries
• Candy
• Cereals
• Chocolate
• Emulsifiers, flavorings
• Ethnic foods African, Chinese, Mexican, Thai,
  Vietnamese

• Ice Cream
• Margarine
• Milk formula
• Satay Sauce (thai sauce)
• Soft drinks
• Soups
• Sunflower seeds
• Vegetable fats and oils

38
Venoms/Antivenins

• 5 major stinging insects in the US
• honeybees
• wasps
• yellow jackets
• hornets
• fire ants
• Rabies and snake antivenin

39
Latex

• incidence low, except for risk groups
• gt1000 episodes and 15 deaths attributed
• surgical and dental procedures highest risk
• RAST testing available

40
Exercise-induced

• Variety of forms of exercise
• not heat alone
• not associated with atopy/asthma
• strong genetic predisposition
• ? histamine and parasympathetic tone, ?
  sympathetic tone

41
Exercise-induced

• 4 phases
• Prodrome fatigue, warmth, pruritis erythema
• Early urticaria, angioedema
• Fully established (30- 4 hours) stridor,
  choking, N/V/D, syncope, hypotension
• Late fatigue, warmth, headache, lasts up to 72
  hours

42
Exercise-induced

• Diagnosis may resemble asthma or cholinergic
  urticaria
• very unpredictable some associated with foods
• Management
• recognize early signs and rest
• avoid hot, humid weather
• exercise with a partner

43
Symptoms

• Manifestations in the shock organs
• skin, respiratory tract, gastrointestinal tract,
  cardiovascular system
• Why there?
• rich in mast cells
• sensitive to effects of mast cell mediators
• exposure to high concentrations of antigen

44
Skin

• Early signs
• Flushing, feeling warm
• Erythema
• Pruritis
• Urticaria
• Angioedema
• Pallor

45
Respiratory

• Upper airway
• Nose eyes pruritis and watery discharge,
  sneezing
• Lips tongue swelling and pruritis
• Larynx epiglottis edema with hoarseness,
  dysphonia to asphyxia
• Bronchi bronchospasm with wheezing, decreased
  aeration, to apnea, asphyxia

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Gastrointestinal

• not only with food triggers
• crampy abdominal pain, nausea, vomiting, watery
  diarrhea, gastointestinal bleeding, fecal
  incontinence

50
Cardiovascular

• Intravascular volume depletion
• Direct effects on the heart
• arrythmias
• reduced contractility
• reduced coronary blood flow
• Early dizziness and confusion
• May progress to syncope, seizures, loss of
  consciousness shock, cardiac arrest

51
Other symptoms of anaphylaxis

• Neurologic HA, Mental Status changes
• Uterine contraction
• Urinary incontinence
• Anxiety, Feeling of impending doom

52
Natural history of anaphylactic reactions

• Onset of reaction after exposure seconds to
  several hours. Depends on
• patients sensitivity
• dose of allergen
• route of entry
• Biphasic reactions (1 28 hrs)
• 5-23 in adults 6 in kids
• Food, venom, medication induced anaphylaxis
• Second reaction may be worse

53
Making the correct diagnosis

• May look just like
• Asthma exacerbation
• Croup or foreign body aspiration
• Cardiogenic syncope
• food poisoning or gastroenteritis

54
Vasovagal vs. Anaphylaxis

• Vasovagal
• pallor
• diaphoresis
• bradycardia or NSR
• Anaphylaxis
• tachycardia
• flushing
• urticaria/pruritis/ bronchospasm

55
Differential Diagnosis

• Related Diseases
• Serum Sickness
• Systemic Mastosytosis
• Urticaria Pigmentosa
• Unique presentations
• MI, PE, CVA, Seizure, asphyxia, hypoglycemia

56
Making the correct diagnosis

• Detailed history as close to the event as
  possible
• All foods in prior 6-12 hours
• Consider all ingredients
• Look for likely suspects e.g. legumes
• Write it and keep it
• Prick skin tests Best Screening test
• high false positives very low false negatives
• may require food challenge

57
Less common lab tests

• histamine vs. tryptase level
• transient
• Tryptase NOT elevated in food-induced anaphylaxis
• RAST measures specific IgE,
• less sensitive than skin prick
• Useful in pt.s who cant d/c antihistamines or
  w/skin condition
• Coombs test - Type II
• complement levels - Type III
• patch testing - Type IV

58
Treatment

• Prevention, education and observation
• Early intervention
• Medications
• Managing a difficult airway

59
Early intervention epinephrine

• Injection Kits Epipen, Ana-kit, Anaguard
• When to give?
• How to administer?
• location SC vs IM, site of stinger
• dosing
• Inhaled epinephrine
• Precautions Beta-blockers and Tricyclics

60
Medical adjuncts

• Antihistamines
• Use in all cases
• H1 blockers route and type
• H2 blockers
• Steroids
• Use in all significant cases
• PO (liquid), IM or IV 2mg/kg (max 60 mg?)
• Prevents delayed reactions
• Bronchodilators aminophylline

61
Supportive treatment and airway issues

• Hypotension may not respond to epinephrine
• Aggressive use of IVF Trendelenberg,
  vasopressors if necessary
• MAST trousers, glucagon and naloxone also
  reported helpful
• Laryngeal edema and angioedema of the face pose
  critical airway challenges

62
Prevention

• Food allergies
• Avoid entire food group if sensitive to one
  member (unless proven safe)
• Canned fish (heated) may be tolerated if tested
  under controlled setting
• Beware baked goods
• Learn ingredients, pseudonyms and synonyms
• Drug allergies
• desensitization a temporary measure
• premedicate and observe closely

63
Prevention, education and observation

• Venom allergies
• Dont entice the insects sights and smells
• Who gets venom immunotherapy?
• Educate all caretakers
• 4 hour observation/ hospital observation if not
  resolving rapidly

64

• Which of the following is the safest and most
  efficient route to administer epinephrine in an
  allergy emergency
• A IV
• B Sub Q
• C IM
• D PR

65
Syncope after shot

• A 16 y/o girl just passed out after receiving her
  penicillin shot for strep throat (doesnt
  swallow pills). Which of the following will be
  most useful to know in treating her
• A Her Blood Pressure
• B Her Glucose level
• C Her Heart Rate
• D Your Heart Rate

66

• A first year PEM fellow attending conference
  developed a sudden onset of urticaria, lip
  swelling and DIB. The etiology is most likely a
  reaction to
• A smelling someone elses lunch
• B a spider bite
• C another billing talk by Dr Linzer

67
Allergen Families

• Which of the following potential allergens do not
  generally cross-react
• A. COX-2 inhibitors Ibuprofen
• B. Filberts Pecans
• C. Peanuts Tofurky
• D. Lobster Shrimp

68
Using the Epi-Pen

• When advising parents/patients on how to
  administer an epipen you should tell them to
• A. hold it against the triceps and squeeze the
  trigger
• B. stab it into the anterior thigh
• C. hold it against the lateral thigh and push

69
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70
Presentations of Anaphylaxis

• Which is NOT a clinical presentation of
  anaphylaxis
• A. Vomiting and Diarrhea
• B. Syncope
• C. Altered Mental Status
• D. Itchy Tongue
• E. None of the above

71
First line therapy

• In counseling a 50kg 15 year old after a severe
  episode of anaphylaxis to a bee sting your best
  advice is that if they get stung again they first
  should take
• A. (2) 25mg diphenhydramine capsules PO
• B. (5) tsp diphenhydramine elixer PO
• C. .5mg epinephrine SQ
• D. 60mg prednisone PO

72

• Which of the following treatments has been shown
  to decrease the incidence of biphasic reactions
• A. Corticosteroids
• B. Epinephrine
• C. Diphenhydramine
• D. Ranitidine

73
Summary

• Various mechanisms and presentations
• May resemble common illnesses
• Early recognition and treatment
• Prevention is critical