1. Foundations of Interprofessional Collaboration (FIPC): An Introduction to TeamSTEPPS® LEVEL 3 Overview of Clinical Management of Anaphylaxis for Medicine Students

2. Anaphylaxis Definition
“A serious allergic reaction that is rapid in onset and may cause death.”
Anaphylaxis is a serious allergic reaction that is rapid in onset and can be fatal. Although it is relatively rare, it can occur anywhere to anyone so we all need to be ready. The good news is that it is usually treatable when it is diagnosed in time. Timely diagnosis can be tricky, though, as the time between exposure and death is usually less than 60 minutes. When patients die from anaphylaxis, it is usually because the treatment, epinephrine, wasn’t given soon enough.
National Institute of Allergy and Infectious Disease and the Food Allergy and Anaphylaxis Network

3. Anaphylaxis Pathogenesis
EXPOSURE
IMMUNE REACTION
Anaphylaxis can be triggered by many types of antigens including foods (such as nuts, shellfish, dairy products, and eggs); medications (from prescription medications, such as antibiotics, as well as over-the-counter medications); venoms (such as from bites and stings); and latex. Adult anaphylaxis most commonly results from medication and venom triggers, whereas children are more likely to experience anaphylaxis due to food allergens.
The exposure leads to degranulation of mast cells throughout the body. The products released such as histamine and tryptase lead to symptoms including findings in the skin, such as…, the respiratory tract such as shortness of breath and wheezing, the cardiovascular system, including hypotension and the GI system in the form of N/V/d.
SYMPTOMS

4. DIAGNOSIS Acute onset of illness (minutes to hours) with:
The is a WIDE range of patient presentations with anaphylaxis. Most of the time, if you look for Skin/Mucosa findings AND either respiratory or cardiovascular findings, you’ll catch it. The catch is that 20% of the time, there are no skin symptoms and respiratory and CV symptoms are much less common. So, this is a very rare condition that we must always be on the look out for because it can lead to death in minutes. Our patient today with anaphylaxis will have the classic symptoms of skin/mucosa findings and either respiratory or CV symptoms.

5. Consider second line medications:
Identify an Event Lead
(Assigns roles and monitors situation)
Assess & Communicate with Patient
(Physical exam, keep informed, obtain history, monitor vital signs & overall status)
Consider second line medications:
Methylprednisolone 1 mg/kg
H1 antihistamine: Diphenhydramine 25 mg IV
H2 antihistamines: Cimetidine 4 mg/kg IV
Identify patient with possible anaphylaxis
Review Patient Chart for relevant History
(Other possible diagnoses? Possible causes of anaphylaxis?)
Identify & remove trigger
Epinephrine 0.3 mg IM
(Can repeat in 5-15 minutes)
Once these emergent actions are taken, there are several other components to treatment that may be helpful for your patient. We want to emphasize, that although these may be helpful to the patient over the next few hours, they do not replace and shouldn’t delay the administration of epinephrine.
Fluid bolus – start or double check that fluid bolus has been started. 1 L isotonic fluid with a pressure bag.
Steroids take 4-6 hrs to work and may be helpful in preventing a second phase of anaphylaxsis hours later mg/kg methylprednisonlone) [Of note, There is no strong evidence that supports the use of steroids in the management of anaphylaxis}
Inhaled B agonist: Albuterol: 2.5 mg in 3 mL of saline and repeated as necessary
Antihistamines help treat symptoms, particularly urticaria. H1 antagonist (diphenhydramine) mg IM or slow IV. H2 antihistamines (cimetidine) 4 mg/kg IV.
It is important to identify the trigger in order to make sure the exposure is stopped…and also to prevent further exposure.
Given the unpredictable ways a patient can present with anaphylaxis, there is ofter uncertainty in diagnosis. Tryptase is one of the mediators released in anaphylaxis and will be elevated for 1-2 hours after the exposure. It takes ~2 weeks to get the result, so doesn’t help with management in the short term, but can be very helpful determining later if in fact the patient did have anaphylaxis and if there were therefore exposures that need to be identified.
With animations:
So, today, once you identify that your patient likely has anaphylaxis, the goal is to work as a team to stabilize the patient. Since each of the emergent actions needs to happen immediately, we suggest you take a moment to huddle and assign roles.
Once these emergent actions are taken, and the patient stabilizes, we suggest you call a second huddle to re-assess patient status and plan the next steps in the treatment.
Consider alternative diagnoses and additional testing
(consider confirmatory testing (tryptase))
Fluid Bolus
Start Oxygen and Bronchodilator
(Albuterol 2.5 mg in 3 mL of saline)
Anaphylaxis Practice Parameter; Annals of Allergy Asthma & Immunology; 2015; 115:

6. Diagnosis Clinical history Supportive labs
Plausible time frame and exposure history. Review all new medications!
Supportive labs
Histamine studies
Plasma histamine- Peak 5-10 minutes, decline within 60 minutes
24 hour urine histamine
Total serum or plasma tryptase
Within 3 hours
Correlates best with hypotension
Can be normal with food anaphylaxis

7. Treatment1 Epinephrine Mechanism of action:
Autoinjectors (IM) or intravenous (IV)
Mechanism of action:
α1 adrenergic vasoconstrictors - decreases mucosal edema, prevents hypotension, increased cardiac output,
β1 adrenergic – increased force and and rate of cardiac contractions
β2 - bronchodilation, decreased release of mediators from mast cells and basophils
Delay in use increases risk of death and delayed anaphylaxis

8. Treatment Antihistamines (H1 and H2) Leukotriene inhibitors
ie diphenhydramine and ranitidine
No H2 if food allergy- delay food absorption
Leukotriene inhibitors
Bronchodilators – ie nebulized albuterol
Steroids – ie methylprednisolone
Protracted or biphasic anaphylaxis
Cochran analysis – no trial evidence in support of use of steroids…but everyone still uses them10

9. Role of Physician in Rapid Response Team
Collect information (or provide input for team leader) related to diagnosis of current acute issue.
Ongoing assessment of the patient.
Working with other members of the team, develop and implement treatment plan.
Provide mutual support to other members of the team as needed.