Anaphylactic Shock

Anaphylaxis is an acute fatal or potentially fatal hypersensitivity

reaction.
Symptoms include
airway obstruction
generalized skin reactions, particularly flushing, itching, urticaria,
angioedema
cardiovascular symptoms including hypotension
gastrointestinal symptoms
These symptoms result from the action of mast cell mediators,
especially histamine and lipid mediators such as leukotrienes
and platelet activating factor on shock tissue.

Anaphylaxis and Anaphylactoid Reactions: Diagnosis and Management. http://www.ncbi.nlm.nih.gov/pubmed/11862283

 Based on the associated mechanism, anaphylaxis can be
classified into immunologic, nonimmunologic, or idiopathic

For example, immunologic causes of anaphylaxis are those

mediated by IgE antibodies acting through the FcR I (foods,
insect venom, and beta-lactam antibiotics).

Chapter 24: Anaphylaxis. http://www.ncbi.nlm.nih.gov/pubmed/22794697

 Non-IgE immunologic anaphylaxis is mediated without
presence of antiallergen IgE antibodies or via FcR I activation
(radiographic contrast material). Nonimmunologic anaphylaxis
involves mast cell mediator release such as occurs with
exercise, cold temperature exposure, or from medications
such as opioids or vancomycin.
Idiopathic anaphylaxis involves mast cell activation (acutely
elevated urine histamine or serum tryptase) and activated
lymphocytes.

Chapter 24: Anaphylaxis. http://www.ncbi.nlm.nih.gov/pubmed/22794697

Mast cell mediator release can be triggered by both IgE and non--
IgE-mediated factors. Therefore, anaphylaxis may be termed
anaphylaxis (IgE mediated) or anaphylactoid (non--IgE mediated).

Anaphylaxis and Anaphylactoid Reactions: Diagnosis and Management. http://www.ncbi.nlm.nih.gov/pubmed/11862283

For the initial emergency management a differentiation between

IgE-mediated and IgE-independent anaphylactoid reactions is not
required.

[Anaphylactic shock] http://www.ncbi.nlm.nih.gov/pubmed/10726327

http://www.aafp.org/afp/2003/1001/p1325.html
 Anaphylaxis occurs in 30/100,000 population/year (mortality 1-2%) and is
caused by
foods (35%),

drugs/ biologicals (25%),

insect stings (15%),

exercise (5%) or

idiopathic (20%)

Onset of anaphylaxis to stings or allergen injections is usually rapid:

70% begin in < 20 minutes

90% in < 40 minutes.

Patterns of anaphylaxis: acute and late phase features of allergic reactions. http://www.ncbi.nlm.nih.gov/pubmed/15025394
 Rule of 2's : reactions usually begin within 2 minutes to 2
hours after injection, infusion, ingestion, contact, or
inhalation.
Fatalities can be from asphyxiation from laryngeal or
oropharyngeal swelling, collapse from hypotensive shock,
cardiac arrest, or acute severe bronchoconstriction causing
respiratory failure and arrest.

Chapter 24: Anaphylaxis. http://www.ncbi.nlm.nih.gov/pubmed/22794697

The severity of anaphylactic/anaphylactoid reactions is graded
from stages 0 to IV in order to guide the management of this
disease, stage III corresponding to anaphylactic shock.
Severe anaphylactic reactions may take a progressive course
despite adequate therapy; even in the case of an initial
favourable response to treatment measures life-threatening
symptoms may recur; there may be late-phase reactions 6 to 12
hours after the initial reaction.

[Anaphylactic shock] http://www.ncbi.nlm.nih.gov/pubmed/10726327

Protocol for Treatment of Anaphylaxis

Diagnose the presence or likely presence of anaphylaxis.

Place patient in recumbent position and elevate lower extremities.
Monitor vital signs frequently (every two to five minutes) and stay with the patient.
Administer epinephrine 1:1,000 (weight-based) (adults: 0.01 mL per kg, up to a
maximum of 0.2 to 0.5 mL every 10 to 15 minutes as needed; children: 0.01 mL per
kg, up to a maximum dose of 0.2 to 0.5 mL) by SC or IM route and, if necessary,
repeat every 15 minutes, up to two doses).
Administer oxygen, usually 8 to 10 L per minute; lower concentrations may be
appropriate for patients with chronic obstructive pulmonary disease.
Maintain airway with an oropharyngeal airway device.
Administer the antihistamine diphenhydramine (Benadryl, adults: 25 to 50 mg;
children: 1 to 2 mg per kg), usually given parenterally.
If anaphylaxis is caused by an injection, administer aqueous epinephrine, 0.15 to 0.3
mL, into injection site to inhibit further absorption of the injected substance.

If hypotension is present, or bronchospasm persists in an ambulatory setting,

transfer to hospital emergency department in an ambulance is appropriate.
Treat hypotension with IV fluids or colloid replacement, and consider use of a
vasopressor such as dopamine (Inotropic)
Treat bronchospasm, preferably with a beta II agonist given intermittently or
continuously; consider the use of aminophylline, 5.6 mg per kg, as an IV loading
dose, given over 20 minutes, or to maintain a blood level of 8 to 15 mcg per mL.
Give hydrocortisone, 5 mg per kg, or approximately 250 mg intravenously
(prednisone, 20 mg orally, can be given in mild cases). The rationale is to
reduce the risk of recurring or protracted anaphylaxis. These doses can be
repeated every six hours, as required.
In refractory cases not responding to epinephrine because a beta-adrenergic
blocker is complicating management, glucagon, 1 mg intravenously as a bolus,
may be useful. A continuous infusion of glucagon, 1 to 5 mg per hour, may be
given if required.
In patients receiving a beta-adrenergic blocker who do not respond to
epinephrine, glucagon, IV fluids, and other therapy, a risk/benefit assessment
rarely may include the use of isoproterenol (Isuprel, a beta agonist with no
alpha-agonist properties). Although isoproterenol may be able to overcome
depression of myocardial contractility caused by beta blockers, it also may
aggravate hypotension by inducing peripheral vasodilation and may induce
cardiac arrhythmias and myocardial necrosis. If a decision is made to
administer isoproterenol intravenously, the proper dose is 1 mg in 500 mL D5W
titrated at 0.1 mg per kg per minute; this can be doubled every 15 minutes.
Adults should be given approximately 50 percent of this dose initially. Cardiac
monitoring is necessary and isoproterenol should be given cautiously when the
heart rate exceeds 150 to 189 beats per minute.
 Diseases that Mimic Anaphylaxis
Angioedema is a condition similar to anaphylaxis. In angioedema,
there are recurring episodes of painless swelling that may involve
the lips, face (especially around the eyes) tongue, upper airway or
anywhere in the body.
In many cases no cause for these symptoms can be identified and the
attacks stop happening after a few weeks or months.
When attacks are persistent, the most common identifiable cause is a
side-effect of ACE inhibitors, which are prescribed to treat blood pressure
problems.
According to research, this treatment causes occasional attacks of
angioedema in about 1 person in 300 who takes it (Makani et al, 2012). As
the attacks may not start for several months after the treatment has
begun, this possibility may be overlooked.

The Anaphylaxis Campaign 2014

 Diseases that Mimic Anaphylaxis
Hereditary angioedema is a rare, inherited, non-allergic form
of angioedema. In addition to external swelling, there may
also be stomach cramps, abdominal pain, nausea and
diarrhoea. The episodes may follow localised injury such as
dental work. The angioedema (swelling) tends to be painful
and slow in onset. This disorder can be differentiated from
non-inherited angioedema and anaphylaxis by blood test
findings and the lack of other symptoms of anaphylaxis.

The Anaphylaxis Campaign 2014

 Diseases that Mimic Anaphylaxis
Histamine poisoning: Histamine can sometimes be present in
spoiled fish (especially tuna and mackerel) and can cause a
condition not unlike allergy called scombroid poisoning.
Unlike an allergy, this usually affects everyone who has eaten
the offending food, although some people might be more
susceptible than others.

The Anaphylaxis Campaign 2014

 Diseases that Mimic Anaphylaxis
Mastocytosis: This is a rare condition caused by too many
mast cells gathering in the tissues of the body. These are the
cells that release histamine and other chemicals involved in
allergic reactions, causing symptoms such as a skin rash, itchy
skin and anaphylaxis. If you have this condition, its important
that your doctor identifies mastocytosis as the cause of your
symptoms.

The Anaphylaxis Campaign 2014