ANAPHYLAXI

1
• An acute clinical syndrome characterized by
severe, life threatening, generalized type 1
hypersensitivity reaction, usually caused by
exposure to a foreign substance leading to mast
cell degranulation and release of chemical
mediators.

2
 CRITERIA
• Acute onset of an illness with involvement of the skin,
mucosal tissue, or both AND AT LEAST 1 of the following:
• a. Respiratory compromise
• b. Circulatory compromised
o Acute onset: Onset within minutes to hours
o Involvement of the skin, mucosal tissue: Includes
generalized hives or urticaria, pruritus, flushing, swollen
lips-tongue-uvula
o Respiratory compromise: Includes dyspnea, wheeze-
bronchospasm, low PEFR, stridor, hypoxemia
o Circulatory compromise: Includes low BP or associated
symptoms of end-organ dysfunction like hypotonia,
collapse, syncope, incontinence
3
 CRITERIA
• Two or more of the following that occur acutely
after exposure to a likely allergen for that patient:
• a. Involvement of the skin-mucosal tissue
• b. Respiratory compromise
• c. Circulatory compromised
• d. Persistent gastrointestinal (GI) symptoms
o GI symptoms: Crampy abdominal pain, vomiting

4
 CRITERIA
• Acutely after exposure to known allergen for that
patient, reduced BP - defined as low SBP for age
or > 30% decrease in SBP
o Low systolic blood pressure (SBP) for children is
defined as: < 60 mm Hg from birth to 1 month, <
70 mm Hg from 1 month to 1 year, < (70 mm Hg
+ [2 × age]) from 1 to 10 years, < 90 mm Hg for
11 years and above

5
 PRECIPITATING
FACTORS
• Enteral ingestion: Drugs (Antibiotics, NSAIDs,
Aspirin), Food
• Parenteral administration: Drugs (Antibiotics,
Paralytic agents, Opioids, Propofol), Insect bites
and stings, Contrast media, Vaccines, Blood
products
• Physical contact: Latex
• Others: Exercise in cases of FDEIA (Food-
dependent exercise-induced anaphylaxis)

6
DIFFERENTIAL
DIAGNOSIS

7
MANAGEMENT ALGORITHM
1. Clinical Suspect
2. Initial Management (First 1 min)
• Keep Supine Position (Sitting Position If respiratory
distress/nausea/vomiting)
• Assess Airway, Breathing, Circulation, heart rate, BP &
SpO2
• Provide O2 @ 10-15 L/min by NRBM (If respiratory
distress/shock)
• Identify and Remove the Allergic Trigger if possible
• Administer 1st Dose of IM Epinephrine @
0.01mg/kg/dose (1mg/ml of 1:1000 dilution) at
anterolateral aspect of thigh
• Can be repeated at 5 to 10 mins interval as needed
8
3. 1 to 5 min
• Respiratory Distress
• Sitting Position
• Provide High Flow O2 by HFNC and plan for
intubation
• If Stridor, 1st nebulized epinephrine @ 0.5 mL/kg
• If Wheeze, 1st nebulized salbutamol @ 0.15
mg/kg Hypotension/Poor Perfusion/Loss of
Consciousness
• Supine Position
• IV/IO Assess to be established
• 1st Bolus of NS @ 20 mL/kg by IV/IO Rapid Push
Technique
9
4. 5 to 10 min
• If No Improvement give 2nd Dose of IM
• Epinephrine
• IV/IO Assess to be Established (If not done earlier)
• Prepare for Difficult Intubation
• For Respiratory Distress
• 2nd nebulized epinephrine @ 0.5 mL/kg for Stridor
• 2nd nebulized salbutamol @ 0.15 mg/kg for
Wheeze
• Hypotension/Poor Perfusion/Loss of Consciousness
• 2nd Bolus of NS @ 20ml/kg by IV/IO Rapid Push
Technique
• Prepare for IV Epinephrine Alert Pediatric ICU/
Tertiary Care Centre
10
5. 10 to 20 min
• If no Improvement give 3rd Dose of IM
Epinephrine
• For Respiratory Distress:
• 3rd nebulized epinephrine @ 0.5 mL/kg for
Stridor; 3rd nebulized salbutamol @ 0.15 mg/kg
for Wheeze
• Proceed for Intubation
• Hypotension/Poor Perfusion/Loss of
Consciousness:
• Start giving IV Epinephrine @ 0.05 mcg/ kg/min
with titrate by 0.02 mcg/kg/min up to effect
11
• Transfer to Pediatric ICU/ Tertiary Care Centre
• If still no Improvement  Suspect Refractory
Anaphylaxis
• Start IV Norepinephrine Infusion (persistent
hypotension) @ 0.05 mcg/kg/min with titrate by
0.02mcg/kg/min up to effect (Max: 2 mcg/kg/min)
• IV Glucagon Bolus (persistent
anaphylaxis/patients on beta blockers) @ 20–30
mcg/kg/dose(Max: 1 mg) over 5 mins followed by
5 to15 mcg/min titrated till achievement of clinical
effects

12
MONITORING & FOLLOW
UP
• Delayed Anaphylaxis: Due to biphasic reaction which
generally occurs within 1 to 72 hours (mostly within
10 hours) after initial improvement or protracted
variety which is the severe persistent anaphylactic
symptoms for 24 to 36 hours despite aggressive
treatment.
• Monitoring of vitals (BP, SpO2) along with Respiratory
Symptoms (stridor or wheeze) should be done over
minutes during first 30 mins  hourly for next 24
hours 2 hourly for next 48 hours
• Follow up of patients should be done for at least 4
hours after last IM Epinephrine injection and in severe
hospitalized cases for minimum 3 days.
13
 INDICATIONS FOR
HOSPITALIZATION
• Tachycardia, Hypotension
• Stridor, Wheeze, Tachypnoea (1 to 5 Year - ≥ 40 /
min; > 5 Year - ≥ 30 / min; >10 Year - ≥ 20 /min)
• SpO2 < 95% in Room Air
• History of Severe Protracted Anaphylaxis
• Comorbidities (asthma, arrhythmia, systemic
mastocytosis)
• Live in remote area or present late in the evening

14
HOME ACTION PLAN
• Hives with Itching is the earliest (most common)
sign though it may not happen in few cases
• EpiPen (Green colour - 0.15mg / inject; Yellow
colour - 0.3mg / inject) is ideal but due its limited
resources in India, home prepared IM Epinephrine
Inj (0.01mg / kg of 1:1000 dilution) in 1ml Syringe
over anterolateral aspect of thigh may be a
practical option.
• It can be kept for 3 months at room temperature
with protection from light. (expiry date should be
written for future reference)
• Call Your Emergency Number – 112
15
16
THANK YOU

17