Anaphylaxis: Racing to Diagnosis Beth Anne Fox, M.D., M.P.H. ETSU Family Physicians of Kingsport

Objectives Be able to recognize anaphylaxis Be aware of common manifestations of anaphylaxis Demonstrate team management and treatment of anaphylaxis

34 yo female presents with difficulty breathing after eating at a local seafood restaurant. She is brought by her boyfriend to be evaluated. She has a history of asthma and is allergic to PCN. She smokes about ½ ppd. She has been complaining of a “cold” for two days.

Examination She is wheezing, coughing and has a pruritic maculopapular rash over her abdomen and face VS: 98.2 108 24 121/88 Sa0₂-93% 2L/min per nasal cannula Diagnosis ? Treatment Options ?

DIFFERENTIAL DIAGNOSES Hypotension: Septic/hemorrhagic/cardiogenic Shock Vasovagal Reaction Respiratory distress (wheeze) or stridor Foreign Body Asthma/COPD Vocal Cord Dysfunction

DIFFERENTIAL DIAGNOSIS (cont.) Miscellaneous Panic Attacks Hereditary angioedema Flushing syndromes Drugs, endocrine

Anaphylaxis Clinical Diagnosis: acute life-threatening systemic reaction caused by the release of mediators from mast cells and basophils more than one organ system involved most common organ systems include skin, respiratory, cardiovascular, and gastrointestinal systems.

Clinical Criteria Acute onset with skin and mucosal involvement and one of: Respiratory involvement Reduced BP End-organ dysfunction 2 or more of the following: Skin or mucosal involvement Respiratory Persistent GI sx Low BP after exposure to possible trigger (30%)

Physiologic Effects of Mediators Increased vascular permeability Peripheral vasodilatation Coronary vasoconstriction Smooth muscle contraction Sensory nerve irritation Recruitment of inflammatory cells Vagal activation

Angioedema Urticaria Laryngeal edema Hypotension Flushing Myocardial ischemia Wheezing Nausea, vomiting, diarrhea, abdominal pain Pruritus

Common Causes Foods Drugs Venoms Immunotherapy injections Latex Radiocontrast media Exercise

Risk Factors Atopy Gender Age Route/recurrence of administration Previous reaction Economic status Season

What next? Who to call? What equipment and supplies are needed? What role can you play? What role should you play?

MEDICAL MANAGEMENT ABCs Supine/ Oxygen Remove Antigen if applicable EPINEPHRINE 1:1000 (IM) [SOR A] H1 and H2 Blockers Corticosteroids possibly for prevention of recurrent or extended event

MEDICAL MANAGEMENT EPINEPHRINE 1:1000 (IM) [SOR A] dosage: 0.2-0.5mg adults 0.01mg/kg peds (max 0.3mg) IV: 1:10,000 0.1-0.2 mg or 2-10mcg per minute (adult) 0.01mg/kg or 2 mcg/min (peds) Ranitidine 50mg or 1mg/kg up to 50mg (peds) Diphenhydramine 25-50mg or 1mg/kg up to 50mg (peds) Methylyprednisolone 125mg IV or 2mg/kg (peds)

TREATMENT (cont.) He is more SOB and now has cyanosis. What now? His BP has decreased despite being supine.

TREATMENT (cont.) IV with volume replacement (20-30ml/kg/first hour) Inhaled B2-agonists for bronchospasm Hypotension-dopamine (?); norepinephrine or phenylephrine with epinephrine; possibly vasopressin Persistent hypotension when on beta-blockers, glucagon (1-5mg, adults; 20-30mcg/kg in children to max of 1mg)

Roles and Functions Primary Functions Secondary Functions Training Knowledge Function Secondary Functions How else could you help now that you know what is needed during the emergency?

SUMMARY Anaphylaxis is a medical emergency requiring immediate recognition and intervention. Management requires a team approach. Team members have primary and secondary roles that contribute to patient safety and stabilization.

References Arnold JJ and Williams PM. Anaphylaxis: recognition and management. Am Fam Physician. 2011; 84(10): 1111-1118. Peckler BF and Becker MO. Anaphylaxis. http://www.essentialevidenceplus.com. Updated August 26, 2013. Accessed September 10, 2013. Masoodi N. Anaphylaxis. Last updated 2013 Oct 23. Dynamed. Available from http://www.DynamedMedical.com. Accessed November 15, 2013.