Anaphylaxis: Rapid recognition and treatment Miha Mežnar MD Medical intensive care unit General hospital Celje, Slovenia

Anaphylaxis: Rapid recognition and treatment

Minutes to cardiac arrest Fatal anaphylaxis Minutes to cardiac arrest Median Range 55 iatrogenic 5 1 – 80 37 food 30 6 – 360 32 venom 15 4 – 120 Pumphrey RSH, Clinical and experimental allergy, 2000

Anaphylaxis: Rapid recognition and treatment

Underrecognized, undertreated Most important dg marker is trigger recognition Underrecognized, undertreated Most important dg marker is trigger Over 40 symptoms and signs described cutaneuos >80% respiratory up to 70% gastrointestinal up to 40% cardiovascular up to 35%

Diagnostic criteria Criterion 1: acute onset (minutes – hours) involving skin and/or mucosa + at least one: Respiratory compromise Reduced blood pressure Criterion 2: At least 2 of the following, minutes – hours after exposure TO A LIKELY ALLERGEN FOR THAT PATIENT: Skin/mucosal involvement Gastrointestinal symptoms Criterion 3: Reduced blood pressure minutes – hours after exposure TO A KNOWN ALLERGEN FOR THAT PATIENT J Allergy Clin Immunol, 2006

Potentional pitfalls in recognition of anaphylaxis Absent / missed skin symptoms Non-specific signs of hypotension (confusion, collapse, incontinence...) Certain conditions (surgery) DD – asthma exacerbation Lab tets to support Dg (tryptase)

Anaphylaxis: Rapid recognition and treatment

Fatal anaphylaxis: risk factors Concomitant asthma No epinephrine Non effective epinephrine Upright posture Other cardiopulmonary disease

Fatal anaphylaxis: risk factors Concomitant asthma No epinephrine Non effective epinephrine Upright posture Other cardiopulmonary disease

Fatal anaphylaxis First adrenaline None Before arrest After arrest 55 iatrogenic 6 9 40 37 food 13 8 16 32 venom 29 4 Pumphrey RSH, Clinical and experimental allergy, 2000

Adrenaline Review of literature: Sheikh A, Allergy 2009 Database search Embase 223 Medline 92 Lilacs 13 Cochrane 10 CINAHL 5 BIOSIS 14 Web of science 25 Excluded: all 382 Included: 0 Sheikh A, Allergy 2009

Treatment Removal of the causing agent Epinephrine Oxygen 0.3 – 0.5 mg (0.01mg/kg) i.m. (vastus lateralis), repeat 5 – 15 minutes i.v. – titrate the dose Oxygen Intubate, if stridor or arrest Trendelenburg position i. v. Fluids (cristalloids vs. colloids?) Steroides, antihistamines, inhaled beta agonists, glucagon of secondary (and questionable) importance