PMS 5: Allergy and Anaphylaxis Reaction

Case Presentation

History
Mr S, a 27 year old Malay gentleman presented to the emergency department complaining of bilateral periorbital edema for 1 day. The swelling occurred approximatly 2-3 hours after ingestion of a tablet medication, as he was having fever and sore throat on that day. The swelling grew bigger and was painful associated with sudden generalized headache. Known case of allergy to NSAIDs. No underlying medical illness e.g. asthma, renal failure, heart disease or hypothyroidism. Previously in 2009, he had a similar episode of bilateral periorbital swelling after ingestion of NSAID he took from a clinic in Sarawak.

 Other allergies that he know he has is towards seafood such as squid, prawn, and shellfish. However, he has never been admitted before. No lips swelling, no generalized facial swelling, no rashes, no vomiting, no shortness of breath, no altered bowel habit and no episodes of syncope. There was also no recent insect bites on the area around the eyes. No history of recent travelling Chagas disease (rural areas of Mexico, Central America, and South America.) Does not smoke or consume alcohol. Works as a teacher. No family history of asthma or allergy.

Physical Examination
On examination of the patient, the patient appeared calm, not tachypnoec and responsive sitting on a chair. He was afebrile with a temperature of 37.5 BP: 125/67 Pulse rate: 87 Respiratory rate: 18 breaths per minute.

 On examination of his face, there was marked periorbital swelling bilaterally with conjunctiva a bit injected. Other than that, there was no other swellings, no rashes, and no facial tenderness. O/e of the abdomen, there was no tenderness and no rigidity. O/e of the respiratory system, there was no ronchi. Other than that, everything was normal.

What is anaphylaxis?
A severe systemic reaction to an antigen precipitated by the abrupt release of chemical mediators in a previously desensitized patient

What Happens In Anaphylaxis?

Allergy reaction

2 pathways

ASPIRIN

Mediators and Effects

Mediators Histamine, H1 Description Found on smooth muscle, endothelium, and central nervous system tissue Effects Bronchoconstriction + bronchial smooth muscle contraction SOB separation of endothelial cells increased venous permeability runny nose and watery eyes. Vascular engorgement nasal congestion Leukotrienes Produced in the body from arachidonic acid Bronchoconstriction and increase vascular permeability. Causes vasodilation, fever, and pain.

Prostaglandins A group of lipids

C3, C4

stimulates H1 release by mast cells Warmth at area of inflammation vasodilation Histamine effects

Classic Clinical Presentation

Begins with pruritus, cutaneous flushing, and urticaria. Followed by a sense of fullness in the throat, anxiety, a sensation of chest tightness, shortness of breath, and lightheadedness. As the cascade progresses, decreased level of consciousness, respiratory distress, and circulatory collapse may ensue. In its severest form, loss of consciousness and cardiorespiratory arrest may result. A complaint of a "lump in the throat" and hoarseness heralds life-threatening laryngeal edema in a patient with symptoms of anaphylaxis.

 Respiratory:

Clinical Manifestations of Anaphylaxis

Rhinitis, pharyngeal edema, laryngeal edema, cough, bronchospasm, dyspnea

Cardiovascular:
Dysrhythmias, collapse, cardiac arrest

Skin:
Pruritus, urticaria, angioedema, flushing

GI:
Nausea, emesis, cramps, diarrhea

Eye:
Pruritus, tearing, redness

GU:
Urgency, cramps

Factors
Provoking Factor:
Foods, medications, insect stings, and allergen immunotherapy injections any agent capable of producing a sudden degranulation of mast cells or basophils A significant number of anaphylaxis cases reported have no identified cause (idiopathic anaphylaxis).

Common Causes of Anaphylaxis and Allergic Reactions

Drugs: Beta-Lactam antibiotics, Acetylsalicylic acid, Trimethoprimsulfamethoxazole, Vancomycin, NSAIDs, Virtually any drug Foods and additives: Shellfish, Soybeans, Nuts (peanuts and tree nuts), Wheat, Milk, Eggs, Seeds Others: Hymenoptera stings, Insect parts and molds, Radiographic contrast material, Vaccines, Latex

Criteria
Anaphylaxis is highly likely when any one of the three criteria listed occurs:
1. Acute onset of an illness (minutes to several hours) with involvement of the skin and/or mucosal tissue (e.g., hives/urticaria, pruritus, flushing, swollen lips, tongue, or uvula) associated with at least one of the following:
Respiratory compromise (e.g., dyspnea, wheeze, stridor, etc.) or Reduced blood pressure or Associated symptoms of organ dysfunction (e.g., hypotonia, syncope, incontinence, etc.)

2. Two or more of the following that occur rapidly after exposure to a likely allergen for that patient (minutes to several hours):
Involvement of the skin and/or mucosal tissue Respiratory compromise Reduced blood pressure or associated symptoms Persistent GI symptoms (e.g., cramps, vomiting)

3. Anaphylaxis should be suspected when patients are exposed to a known allergen and develop hypotension

Diagnosing Anaphylaxis
The diagnosis of anaphylaxis is clinical. Unfortunately, diagnosis is not always easy or clear
symptom onset may be delayed symptoms mimic other presentations (e.g., syncope, gastroenteritis, and anxiety) anaphylaxis may be a component of other diseases (e.g., asthma) the inciting substance may not be known (food allergy)

Management: Investigation
Investigation
Diagnosis of anaphylaxis is made clinically Laboratory investigations have a limited role to play. Tests are available but they are rarely useful or collected in clinical emergency practice.

Management: Investigation
Histamine & tryptase assessment
May be helpful in confirming the diagnosis if a patient is seen shortly after an episode. Plasma histamine levels rise within 10 minutes of onset but fall again within 30 minutes. Serum mature tryptase (previously called betatryptase) levels peak 60-90 minutes after the start of an episode and may persist for as long as 5 hours.

Management: Treatment
1. Assess Airway, Breathing, Circulation 2. Drug Treatment of Anaphylaxis and Allergic Reactions First-Line Therapy
Epinephrine Oxygen IV fluids

Second Line Therapy

H1 Blockers H2 Blockers Corticosteroids

Management Done On This Patient

Hydrocort 200mg
All patients with anaphylaxis should receive corticosteroids. Methylprednisolone or hydrocortisone are equally appropriate. Methylprednisolone produces less fluid retention than hydrocortisone and is preferred for elderly patients and for those patients in whom fluid retention would be problematic (e.g., renal and cardiac impairment).

Management Done On This Patient

Treatment
Chlorphenamine (Piriton ) 4 mg stat
All patients with anaphylaxis should receive a h-1 blocker, such as diphenhydramine/chlorphenamine. H-2 blockers, such as ranitidine or cimetidine, may be given as well because its effective in shock refractory to epinephrine, fluids, steroids, and h-1 blockers. Cimetidine should not be used for patients who are elderly (side effects), have multiple comorbidities (interference with metabolism of many drugs), have renal or hepatic impairment, or whose anaphylaxis is complicated by beta-blocker use (prolongs metabolism of beta-blockers and may prolong anaphylactic state). After the initial IV dose of steroids and antihistamines, the patient may be switched to oral medication

Managing Anaphylaxis
Emergency Treatment
Airway, Breathing, Circulation Decontamination Adrenaline Crystalloids

Second-line Therapy
Corticosteroids Antihistamines Bronchodilators Glucagon

 Airway, Breathing, Circulation

Secure airway. Detect angioedema (e.g.: stridor, respiratory distress, hypoxia). Intubate if needed. Oxygen IV fluids

Decontamination a.k.a. termination of exposure

Remove stinging bits Gastric lavage is not recommended in food-borne

 Adrenaline - mixed 1- and 2-receptor agent

IM epinephrine

1-receptor reduces mucosal edema and membrane leakage and treats hypotension 2-receptor bronchodilates and controls mediator release repeated every 5 to 10 minutes according to response or relapse

If the patient is refractory to treatment, or with signs of cardiovascular compromise or collapse, then institute an IV infusion of epinephrine.
Followed by infusion

On scene - epi-pen (injectable epinephrine) if available

EpiPen (0.3 milligram epinephrine for adults) EpiPen Junior (0.15 milligram epinephrine for children <30 kg)

 Caution is warranted in patients taking blockers, because epinephrine use may result in severe hypertension secondary to unopposed -adrenergic stimulation.

Injections into the thigh are more effective at achieving peak blood levels than are injections into the deltoid area

 Crystalloids
Hypotension is present due distributive shock and responds to fluid resuscitation. Patients should receive an NS bolus of 1 to 2 L (10 to 20 mL/kg in children) concurrently with the epinephrine infusion.

Managing Anaphylaxis
Emergency Treatment
Circulation, Airway, Breathing Decontamination Adrenaline Crystalloids

Second-line Therapy
Corticosteroids Antihistamines Bronchodilators Glucagon

Rapid administration of Adrenaline !!!

 Corticosteroids
Methylprednisolone, or Hydrocortisone

Methylprednisolone produces less fluid retention than hydrocortisone and is preferred for elderly patients and for those patients in whom fluid retention would be problematic (e.g., renal and cardiac impairment).

 Antihistamines
Histamine-1 blocker, such as diphenhydramine Histamine-2 blockers, such as ranitidine or cimetidine

Cimetidine should not be used for patients who are elderly (side effects), have multiple comorbidities (interference with metabolism of many drugs), have renal or hepatic impairment, or whose anaphylaxis is complicated by -blocker use (prolongs metabolism of -blockers and may prolong anaphylactic state).

 Bronchodilators
If wheezing present, give intermittent/ continuous nebulized albuterol/ salbutamol If no response, can add:
Anticholinergics (ipratropium bromide) [Atrovent] Magnesium sulfate

Glucagon
Used in patients using -blocker having stubborn hypotension despite IV fluids & adrenaline.

Drug Treatment of Anaphylaxis and Allergic Reactions Drug First-Line Therapy Epinephrine IM: 0.30.5 milligram (0.30.5 mL of 1:1000 dilution); or EpiPen 0.3 milligram epinephrine (or equivalent preformulated product) IM: 0.01 milligram/kg (0.01 mL/kg of 1:1000 dilution) or EpiPen Junior 0.15 milligram of epinephrine (or equivalent preformulated product) Adult Dose Pediatric Dose

Oxygen IV fluids: NS or LR

IV single dose: 10 micrograms over 510 min; 1:100,000 dilution given as 0.1 milligram in 10 mL at 1 mL/min IV infusion: 14 micrograms IV infusion: 0.10.3 /min microgram/kg/min; maximum, 1.5 micrograms/kg/min Titrate to SaO2 90% Titrate to SaO2 90%
12 L bolus 1015 mL/kg bolus

Drug Treatment of Anaphylaxis and Allergic Reactions Drug H1 Blockers Diphenhydramine H2 Blockers Adult Dose 2550 milligrams every 6 h IV, IM, or PO Pediatric Dose 1 milligram/kg every 6 h IV, IM, or PO Second-Line Therapy

Ranitidine Cimetidine Corticosteroids Hydrocortisone

50 milligrams IV over 5 min 300 milligrams IV 250500 milligrams IV

0.5 milligram/kg IV over 5 min 48 milligrams/kg IV 510 milligrams/kg IV (maximum, 500 milligrams) 12 milligrams/kg IV (maximum, 125 milligrams) 12 milligrams/d PO divided twice a day or daily

Methylprednisolone 80125 milligrams IV Prednisone 4060 milligrams/day PO divided twice a day or daily

Drug Treatment of Anaphylaxis and Allergic Reactions

Drug Adult Dose Pediatric Dose

Second-Line Therapy
Treatment of Bronchospasm, Add: Albuterol Single treatment: 2.55.0 milligrams Single treatment: 1.252.5 nebulized (0.51.0 mL of 0.5% milligrams nebulized (0.250.5 mL solution) of 0.5% solution)
46 puffs with holding chamber Both repeated every 20 min as needed Continuous nebulization: 510 milligrams/h 46 puffs with holding chamber repeated every 20 min Both repeated every 20 min as needed Continuous nebulization: 35 milligrams/h

Ipratropium bromide

Single treatment: 250500 micrograms nebulized

46 puffs with holding chamber Both repeated every 20 min as needed

Single treatment: 125250 micrograms nebulized

46 puffs with holding chamber Both repeated every 20 min as needed

Magnesium 2 grams IV over 20 min 2550 milligrams/kg IV over 20 min sulfate Treatment for Patients on -Blockers with Refractory Hypotension, Add: Glucagon 1 milligram IV every 5 min until hypotension 50 micrograms/kg IV every resolves, followed by 515 micrograms/min 5 min infusion

Disposition
Admission/discharge?
Only 4% admitted. Duration of observation based on experience rather than clear evidence Observation of several hours after ending treatment is routine Factors to be noted upon:
Past history of severe reaction Patients using -blockers Distance from medical care Age, other comorbidities

Outpatient Care And Prevention

Discharge Planning for Patients with Anaphylaxis Education Identification of inciting allergen, if possible Instructions on avoiding future exposure Instructions on use of medications and epinephrine autoinjector Advise about personal identification/allergy alert tag Medications Diphenhydramine, 2550 milligrams PO for several days Prednisone, 4060 milligrams PO for several days Epinephrine autoinjector for future reactions Referral to allergist

Thank you