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

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

3. 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.

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

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

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

7. 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.

8. 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%)

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

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

11. Common Causes Foods Drugs Venoms Immunotherapy injections Latex
Radiocontrast media
Exercise

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

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

14. 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

15. MEDICAL MANAGEMENT EPINEPHRINE 1:1000 (IM) [SOR A]
dosage: mg adults
0.01mg/kg peds (max 0.3mg)
IV: 1:10, 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)

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

17. 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)

18. 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?

19. 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.

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