Anaphylaxis

Introduction

 Anaphylaxis is an acute, potentially life-threatening, systemic

hypersensitivity reaction caused by the sudden release of mast cell
mediators
 Anaphylaxis is defined as a serious allergic or hypersensitivity reaction
that is usually rapid in onset and may cause death
 It can be difficult to recognize because it can mimic other conditions and
is variable in its presentation
 In industrialized countries, the estimated lifetime prevalence of
anaphylaxis from all causes is between 0.05 and 2 percent in the
general population,
DIAGNOSIS

 The diagnosis of anaphylaxis is based on clinical symptoms and

signs
 Recognition of the variable and atypical presentations of
anaphylaxis is critical to providing effective therapy in the form
of epinephrine, as well as reducing over-reliance on second-line
medications, such as antihistamines and glucocorticoids, that are
not lifesaving in anaphylaxis
 There are three diagnostic criteria for anaphylaxis
 Anaphylaxis is highly likely when any one of the following three
criteria is fulfilled.
Criterion 1

 Acute onset of an illness (minutes to several hours) involving the skin,

mucosal tissue, or both (eg, generalized hives, pruritus or flushing,
swollen lips-tongue-uvula) and at least one of the following:
1. Respiratory compromise (eg, dyspnea, wheeze/bronchospasm, stridor,
reduced peak expiratory flow, hypoxemia) Or
2. Reduced blood pressure (BP) or associated symptoms and signs of end-
organ malperfusion (eg, hypotonia [collapse], syncope, incontinence)
Note that skin symptoms and signs are present in up to 90 percent of
anaphylactic episodes. This criterion will therefore frequently be helpful in
making the diagnosis.
Criterion 2

 Two or more of the following that occur rapidly after exposure to a

likely allergen for that patient (minutes to several hours):
1. Involvement of the skin-mucosal tissue (eg, generalized hives, itch-flush,
swollen lips-tongue-uvula)
2. Respiratory compromise (eg, dyspnea, wheeze/bronchospasm, stridor,
reduced peak expiratory flow, hypoxemia)
3. Reduced BP or associated symptoms and signs of end-organ
malperfusion (eg, hypotonia [collapse], syncope, incontinence)
4. Persistent gastrointestinal symptoms and signs (eg, crampy abdominal
pain, vomiting)
Criterion 3

 Reduced BP after exposure to a known allergen for that

patient (minutes to several hours):
 Reduced BP in adults is defined as a systolic BP of less than 90 mmHg or
greater than 30 percent decrease from that person's baseline.
 In infants and children, reduced BP is defined as low systolic BP (age
specific) or greater than 30 percent decrease in systolic BP.
Low systolic BP for children is defined as:
 Less than 70 mmHg from 1 month up to 1 year
 Less than (70 mmHg + [2 x age]) from 1 to 10 years
 Less than 90 mmHg from 11 to 17 years
CONTRIBUTORY FACTORS

 Comorbidities and concurrent medications may impact the

severity of symptoms and signs and response to treatment in
patients with anaphylaxis
 Comorbidities — Asthma, cardiovascular disease, older age,
and medication as a trigger are important risk factors for a poor
outcome from anaphylaxis
 Concurrent medications —certain medications, such as beta-
adrenergic blockers, angiotensin-converting enzyme (ACE)
inhibitors, and alpha-adrenergic blockers, may increase the
likelihood of severe or fatal anaphylaxis.
LABORATORY TESTS

 Anaphylaxis is a clinical diagnosis, and treatment cannot await

laboratory confirmation
 Tryptase and histamine are released almost exclusively by mast cells
and basophils and may be transiently elevated in patients with
anaphylaxis.
 However, these results are not immediately available, and elevations of
these mediators are not universal in anaphylaxis, so measurement of
mediators is not included in the diagnostic criteria.
 Despite these limitations, the finding of elevated tryptase (serum or
plasma) or histamine (plasma) suggests that the event was anaphylaxis
and can be useful in excluding other causes of sudden severe
cardiorespiratory symptoms.
 The blood sample for tryptase should be obtained within 15 minutes to 3
hours of symptom onset

LABORATORY TESTS

 Plasma histamine – Plasma histamine levels typically peak

within 5 to 15 minutes of the onset of anaphylaxis symptoms and
then decline to baseline by 60 minutes
 Elevated plasma histamine levels correlate with anaphylaxis
symptoms and signs and are more likely to be increased than are
total serum tryptase levels
Initial assessment and management

 Attention should focus first on airway, breathing, and circulation, as well

as adequacy of mentation. The lips, tongue, and oral pharynx are
assessed for angioedema, and the patient is asked to speak their name
to assess periglottic or glottic swelling.
 Epinephrine should be injected IM into the mid-outer aspect of the
thigh . If symptoms are severe, an IV epinephrine infusion should be
prepared in case it is needed.
 Placement of the patient in the supine position with the lower
extremities elevated, unless there is prominent upper airway swelling
prompting the patient to remain upright (and often leaning forward). If
the patient is vomiting, placement of the patient semirecumbent with
lower extremities elevated may be preferable. Place pregnant patients
on their left side.
Initial assessment and management

 Supplemental oxygen.
 Volume resuscitation with IV fluids.
In normotensive adults, isotonic (ie, 0.9%) saline should be infused at a rate of
125 mL/hour to maintain venous access.
In normotensive children, isotonic saline should be infused at an appropriate
maintenance rate for weight in order to maintain venous access
 Continuous electronic monitoring of cardiopulmonary status, including
frequent measurements of blood pressure (BP), heart rate, and respiratory
rate, as well as monitoring of oxygen saturation by pulse oximetry, is required
for the duration of the episode.
Treatment

 IV access should be obtained in all cases of anaphylaxis

 Adults should receive 1 to 2 liters of normal saline at the most rapid flow
rate possible in the first minutes of treatment.
 Children should receive normal saline in boluses of 20 mL/kg, each over
5 to 10 minutes, and repeated, as needed.
 Epinephrine —is the first and most important treatment for
anaphylaxis, and it should be administered as soon as anaphylaxis is
recognized
 Delayed epinephrine injection is associated with fatalities. Epinephrine
should also be administered to patients who have symptoms or signs
consistent with impending anaphylaxis when the clinical suspicion for
anaphylaxis is high, even if formal diagnostic criteria are not met.
Treatment

 the recommended dose of epinephrine for patients of any age is

0.01 mg/kg (maximum dose of 0.5 mg) per single dose, injected
IM into the mid-outer thigh.
 The IM dose can be repeated at intervals of 5-15 min if
symptoms persist or worsen.
 If there is no response to multiple doses of epinephrine, IV
epinephrine using the 1:10,000 dilution may be needed.
 If IV access is not readily available, epinephrine can be
administered via the endotracheal or intraosseous routes.
Weight-based intramuscular epinephrine
dosing and administration for anaphylaxis in
health care settings
Treatment

 H1 antihistamines (such as diphenhydramine or cetirizine) relieve

itch and hives. These medications do not relieve upper or lower
airway obstruction, hypotension, or shock and, in standard doses, do
not inhibit mediator release from mast cells and basophils.
 Bronchodilators - For the treatment of bronchospasm not
responsive to epinephrine, inhaled bronchodilators (eg, albuterol,
salbutamol) should be administered by mouthpiece (or facemask for
those whose age or condition requires) and nebulizer/compressor, as
needed
 Glucocorticoids - these medications do not relieve the initial
symptoms and signs of anaphylaxis. They are used to prevent the
biphasic anaphylaxis.
Follow-up care

 Patients successfully treated for anaphylaxis should be discharged with

a personalized, written anaphylaxis emergency action plan, an
epinephrine autoinjector;
 written information about anaphylaxis and its treatment; and referral to
an allergist for further evaluation.
 It is important to make all efforts to confirm the cause to reduce the risk
of recurrence.
 Anaphylaxis action plans for patients of any age
Epinephrine autoinjector
This epinephrine autoinjector (EpiPen) contains 0.3
mg of epinephrine (1:1000 dilution). It is intended
for intramuscular injection into the anterolateral
thigh in the case of anaphylaxis.