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Anaphylaxis

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19 year old female with acute onset dyspnea. Dyspnea, wheezing, ... Dye / preservative allergy (rare) Specific Allergens. Dependent upon societal eating pattern ... – PowerPoint PPT presentation

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Title: Anaphylaxis


1
Anaphylaxis Acute Allergic Reactions in the
Emergency Department
  • Theodore J. Gaeta, DO, MPH
  • Sunday Clark, MPH
  • Carlos A. Camargo, Jr., MD, DrPH
  • On behalf of the MARC Investigators

www.emnet-usa.org
2
Outline
  • Case Presentation
  • Prevalence and Natural History
  • Pathophysiology
  • ED Diagnosis and Management
  • Food-related Allergic Reactions
  • Post-care Plans

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3
Case Presentation
  • 19 year old female with acute onset dyspnea
  • Dyspnea, wheezing, vomiting and generalized
    flushing
  • minutes after eating a chocolate chip cookie
  • Past medical history eczema

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Case Presentation (continued)
  • Vital signs
  • SBP 80/p, P 124, R 40, T 98.8oF (37.1oC)
  • Airway patent, diminished breath sound at the
    bases with wheezing in the upper fields
  • Weak pulses with delayed capillary refill
  • Diffuse erythematous rash observed and Medic
    Alert tag indicates peanut allergy

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Anaphylaxis
  • Multi-system syndrome resulting from mediator
    release
  • Acute onset
  • Varies from mild and self-limited to fatal
  • IgE and non-IgE mediated

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Anaphylaxis
  • Incidence
  • 21 per 100,000 person-years (95 confidence
    interval CI 17 - 25 per 100,000 person-years)1
  • 10.5 per 100,000 person-years among children (95
    CI 8.1 13.3 per 100,000 person-years)2

1Yocum et al. J Allergy Clin Immunol 1999 2Bohlke
et al. J Allergy Clin Immunol 2004
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Estimated prevalence of Generalized Allergic
Reaction
urticaria / angioedema or dyspnea or hypotension
8
Anaphylaxis - Clinical Manifestations
  • Cardiovascular
  • Tachycardia then hypotension
  • Shock 50 intravascular volume loss
  • Bradycardia (4) (transient or persistent)
  • Myocardial ischemia
  • Lower respiratory bronchoconstriction wheeze,
    cough, shortness of breath
  • Upper respiratory
  • Laryngeal/pharyngeal edema
  • Rhinitis symptoms

Fisher. Anesth Intens Care 1986
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9
Anaphylaxis - Clinical Manifestations
  • Cutaneous
  • Pruritus, urticaria, angioedema, flushing
  • Gastrointestinal
  • Nausea, emesis, cramps, diarrhea
  • Ocular
  • Pruritus, tearing, redness
  • Genitourinary
  • Urinary urgency, uterine cramps

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Anaphylaxis -Temporal Pattern
  • Uniphasic
  • Biphasic
  • Initial allergic reaction
  • Recurrence of same manifestations up to 8 hours
    later
  • Protracted
  • Up to 32 hours
  • May not be prevented by glucocorticoids

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Anaphylaxis Mediators
  • Histamine
  • H1 smooth muscle contraction vasc
    permeability
  • H2 vascular permeability
  • H1H2 vasodilatation, pruritus
  • Leukotrienes
  • Smooth muscle contraction
  • vascular permeability and dilatation
  • Nitric Oxide
  • Smooth muscle relaxation
  • vascular permeability and dilatation

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Causes of Anaphylaxis
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Causes of IgE-Mediated Anaphylaxis
  • Antibiotics and other medications
  • ?-lactams, tetracyclines, sulfas
  • Foreign proteins
  • Latex, hymenoptera venoms, heterologous sera,
    protamine, seminal plasma, chymopapain
  • Foods
  • Shellfish, peanuts, and tree nuts
  • Exercise induced

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Causes of Anaphylactoid Mediator Release
  • Complement activation
  • Iodinated dye
  • Aggregated IgG
  • IgA deficiency
  • Unknown mechanisms
  • Aspirin
  • Opiates
  • Local anesthetics

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Severity of Anaphylaxis
  • Risk Factors
  • Male
  • Consistent antigen administration
  • Shorter time elapsed since last reaction
  • Asthma

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Anaphylaxis Fatalities
  • Post Mortem Findings
  • Airway (laryngeal) and tissue (visceral) edema
  • Pulmonary hyperinflation
  • Tissue eosinophilia
  • Elevated serum tryptase
  • Myocardial injury

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Anaphylaxis Fatalities
  • Fatalities _at_ 4
  • Increased risk
  • ? blockade, severe hypotension, bradycardia,
    sustained bronchospasm, poor response to
    epinephrine
  • Adrenal insufficiency
  • Asthma
  • Coronary artery disease

Van der Klauw et al. Clin Exp Allergy 1996
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Anaphylaxis Fatalities
60
50
40
Percentage
30
20
10
0
0-9
10-19
20-29
30
Age
Bock SA et al. J Allergy Clin Immunol 2001
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19
Anaphylaxis Differential Diagnosis
  • Vasovagal syncope
  • Systemic mastocytosis
  • Scombroid (fish) poisoning
  • Other causes of shock

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Anaphylaxis Diagnosis
  • Clinical features
  • Serum tryptase
  • (measurable up to 6 hours)

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21
Anaphylaxis Treatment
  • O2 , airway maintenance IV fluids
  • Loose tourniquet? (to extremity for bee sting)
  • Epinephrine
  • 0.01 ml/kg (11000) IM q 10-20 min (max 0.3-0.5
    ml)
  • In shock, 0.5- 5 mcg/min (110,000) IV to
    maintain SBP
  • H1 H2 histamine receptor antagonists
  • Diphenhydramine, 1 mg/kg PO/ IM/ IV (max 75 mg)
  • Ranitidine
  • Adult, 4 mg/kg PO (max 300 mg), 50 mg IM/IV q 6 h
  • Child, 1.5 mg/kg IM/IV (max 50 mg)

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Treatment (continued)
  • Corticosteroids
  • 1-2 mg/kg prednisone PO (max 75 mg)
  • 2 mg/kg methylpredisolone IV (max 250 mg)
  • Not effective in protracted anaphylaxis
  • Effective in iodinated dye prophylaxis
  • Inhaled beta-agonists
  • Albuterol 2.5 mg q 15-20 min
  • Glucagon (consider if patient is on ?-blocker)

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Return to case
  • Placed on supplemental O2 and cardiac monitor
  • IV access and fluid bolus
  • Albuterol via nebulizer
  • Epinephrine 0.3 ml IM
  • Diphenhydramine 50 mg IV
  • Ranitidine 50 mg IV
  • Methylpredisolone 125 mg IV

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24
Response
  • Despite multiple doses of epinephrine and
    albuterol the patient remained in respiratory
    distress
  • Impending respiratory failure
  • Rapid sequence intubation
  • Transferred to ICU
  • Further history
  • The patients roommate presents a Medic Alert
    tag indicating peanut allergy

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25
Food-Related Allergic Reaction
  • Epidemiology
  • Fatal
  • Peanut
  • Schools
  • Exercise

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26
Fatal Food Anaphylaxis
  • Frequency (USA) 150 deaths / year
  • Risk
  • Underlying asthma
  • Delayed epinephrine
  • Symptom denial
  • Previous severe reaction
  • History known allergic food
  • Key foods peanut / tree nuts / shellfish
  • Biphasic reaction
  • Lack of cutaneous symptoms

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27
Prevalence of Food Allergy
  • Perception by public 20-25
  • Confirmed allergy (oral challenge)
  • Adults 1-2
  • Infants/Children 6-8
  • Dye / preservative allergy (rare)
  • Specific Allergens
  • Dependent upon societal eating pattern
  • Milk (infants) 2.5
  • Peanut / tree nuts in general population 1.1

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28
Diagnosis History / Physical
  • History symptoms, timing, reproducibility
  • Acute reactions vs. chronic disease
  • Diet details / symptom diary
  • Specific causal food(s)
  • Hidden ingredient(s)
  • Physical examination evaluate disease severity
  • Identify general mechanism
  • Allergy vs. intolerance
  • IgE vs. non-IgE mediated

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29
Disposition
  • Most patients with allergic reactions can be
    discharged
  • Hospitalize or observe patients with airway
    angioedema, persistent brochospasm,
    hypoperfusion, cardiac problems, on ?-blockers
  • Observe 4 to 6 hours

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30
Risk Management for Anaphylaxis
  • Education
  • Allergen avoidance
  • Written emergency action plan
  • Resources (eg, FAAN website www.foodallergy.org)
  • Prescription for self-injectable epinephrine
  • Referral to an allergy specialist

31
Anaphylaxis Operational Definition
  • Two or more organ systems
  • skin (e.g., hives)
  • respiratory (e.g., swelling of the lips, tongue,
    or throat trouble breathing or shortness of
    breath stridor, wheezing)
  • cardiovascular (e.g., hypotension, dizziness or
    fainting, altered mental status)
  • gastrointestinal (e.g., trouble swallowing,
    abdominal pain)
  • Hypotension (SBP lt100 mmHg)

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State of the ED
Objective To describe ED management of food
allergy
Methods The Multicetner Airway Research
Collaboration is a program within the Emergency
Medicine Network (www.emnet-usa.org)
Clark et al. J Allergy Clin Immunol 2004
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EMNet Sites (137 US sites)
9/22/04
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Methods (continued)
  • 21 North American EDs participated in this study
  • Chart review of randomly selected patients
    presenting to the ED over a one year period with
    physician-diagnosed food allergy
  • ICD-9 codes
  • 693.1 (dermatitis due to food)
  • 995.0 (other anaphylactic shock)
  • 995.3 (allergy, unspecified)
  • 995.60 (allergy due to unspecified food)
  • 995.61-995.69 (allergy due to specified foods)

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35
Results
  • 678 patients with physician-identified food
    allergy were randomly selected for chart review
  • 57 female, 43 white
  • Mean age, 29 18 years
  • 92 had documentation of a specific food item as
    the cause of the current reaction
  • Only 41 of patients had documentation of a
    history of allergic reaction to the specific food
    that caused the current reaction

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Specific Foods
More than one option allowed.
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Presentation and ED Course
Inhaled ?-agonists and inhaled anticholinergics
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Outcomes
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Instructions to Avoid Offending Allergen
Overall 40 (95 CI, 36-43)
Goal 100
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Self-injectable Epinephrine at Discharge
Goal 100
Overall 16 (95 CI, 14-20)
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Referred to Allergist at Discharge
Goal 100
Overall 12 (95 CI, 9-15)
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Summary
  • Although allergic reactions to food can be life
    threatening, 18 of patients came to the ED by
    ambulance and only 3 were admitted
  • A variety of foods provoked the allergic
    reaction, with crustaceans and peanuts being the
    most common triggers
  • Only 16 of patients received a prescription for
    self-injectable epinephrine when leaving the ED


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Summary (continued)
  • Similarly, only 12 were referred to an allergist
    as part of discharge instructions
  • At a minimum, there is poor documentation of
    medications prescribed at ED discharge
  • Although guidelines suggest specific approaches
    for the emergency management of food allergy,
    concordance to these guidelines appears low

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44
Take Home
  • Keys to successful management
  • Prompt recognition of the signs and symptoms of
    anaphylaxis
  • Early administration of IM epinephrine
  • Volume resuscitation
  • Comfort and familiarity with 2nd line therapies

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Take Home (continued)
  • A successful post-care plan must include
  • Education
  • Allergen avoidance
  • Written emergency action plan
  • Educational resources
    (eg, www.foodallergy.org)
  • Prescription for self-injectable epinephrine
  • Referral to an allergy specialist

www.emnet-usa.org
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