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Management of Anaphylaxis
1. “I’m all Itchy”
Anaphylaxis in the Pediatric ER
Dr. Rebecca Starr
Pediatric Emergency Medicine Fellow
February 6, 2014
certifiedallergysa.com
2. Objectives
Discuss the most current definition of anaphylaxis
Explain the causes and pathophysiology of anaphylaxis
Analyze symptoms and be able to diagnose and
effectively treat anaphylaxis
Review biphasic anaphylactic reactions
List appropriate discharge materials from the ED
3. Question 1
A 5 year old M who has experienced a severe allergic
reaction to shrimp in the past needs a CT scan with IV
and oral contrast. What precautions should you take?
A. NS bolus and diphenhydramine
B. NS bolus, diphenhydramine, and prednisone
C. This patient can not receive contrast
D. Reassurance, there is no associated risk for a reaction
between shellfish and contrast
4. Question 2
You have been asked by a local school to provide
recommendations about the use of self injectable
epinephrine for anaphylaxis. What is the BEST response
to give regarding anaphylaxis?
A. A patient should not receive a second dose of epinephrine
unless a physician is present
B. Epinephrine reaches higher peak plasma concentrations
when injected into the thigh rather than the arm
C. Families should keep one epinephrine auto injector in the
car in case a reaction occurs after school
D. Subcutaneous injection of epinephrine is preferable to
intramuscular injection
5. Question 3
A 14 y/o M who has seasonal allergies and moderate
persistent asthma is currently receiving allergen
immunotherapy. Today in clinic he received his usual
allergen injection, but after 10 minutes, he started coughing
and complaining of dyspnea and throat swelling. On
physical exam he exhibits moderate respiratory distress and
has diffuse expiratory wheezing on auscultation. No
oropharyngeal edema noted. Vitals signs include a pulse ox
of 97%, BP of 130/70, and HR of 90. Of the following, the
MOST appropriate next action is to administer:
A. A short acting beta-2 agonist nebulization
B. An oral antihistamine
C. An oral corticosteroid
D. Intramuscular epinephrine
6. Question 4
A 10 y/o M with a history of peanut allergy presents with diffuse
itching and trouble breathing after eating a friend’s candy bar
that contained nuts during school lunch. At the nurse’s office
the patient received IM epinephrine with his EpiPen with
symptom resolution. EMS was called and the patient was
brought to the local pediatric ED (about a 12 minute ride). On
arrival to the ED, the patient is again complaining of itching
with an urticarial rash on his chest and per EMS the patient
began vomiting as they were pulling up to the ambulance bay.
Arrival vitals include a pulse ox of 96%, BP of 88/67, and HR of
95. Of the following, the MOST appropriate treatment plan is:
A. Intramuscular epinephrine, oral antihistamine, oral
corticosteroid, and a short acting beta-2 agonist neb treatment
B. Intramuscular epinephrine, IV antihistamine, IV corticosteroid,
NS bolus
C. Intramuscular epinephrine, IV antihistamine, IV Zantac, NS
bolus
D. Intramuscular epinephrine, oral antihistamine, and oral
corticosteroid
8. Anaphylaxis 411
“Severe allergic reaction that can be life threatening”
IgE-mediated hypersensitivity reaction resulting in the
release of potent chemical mediators
Mast Cells
Basophils
Affects multiple organ systems
Respiratory
Cardiovascular
Gastrointestinal
Dermatologic
Clinical Diagnosis
Biphasic Reactions
Russell et al.,Pediatric Emergency Care, 2010
10. History
First death from anaphylaxis was documented in
Egyptian hieroglyphics in 2641 BC
Pharaoh Menes dying after a hornet sting
Questionable and now not supported by historians
11.
12. History
First described in scientific literature in 1902 by two
French physiologists, Charles Richet and Paul Portier
Prince Albert I of Monaco
Investigating jellyfish toxins
Initially coined “aphylaxis” with “a” meaning contrary to
and “phylaxis” meaning protection
Richet won the Nobel Prize in Medicine
Lane et al, Pediatric Emergency Care, 2007
13. Pediatric Epidemiology
10.5 per 100,000
Increasing over the past 4 decades
2:1 Male to female ratio
25% require admission
1500 deaths per year in US (adults and children)
40% had prior history of allergic reaction
Only 20% of prior anaphylaxis patients had an Epipen
available during repeat anaphylaxis encounter
Lane et al, Pediatric Emergency Care, 2007
Russell et al.,Pediatric Emergency Care, 2010
14. Pediatric Epidemiology
Severity of a previous reaction does not predict the
severity of a subsequent reaction
Previous anaphylactic reactions = higher risk for
reoccurrence
Lane et al, Pediatric Emergency Care, 2007
16. Causes of Anaphylaxis
Food
Leading cause of all anaphylaxis in children
50% of anaphylactic triggers
Peanuts, tree nuts and shellfish are the most common
Usually the most life-threatening reactions
Older children
Milk, soy, eggs
Most common in younger children
Potential to outgrow
Food dyes
Lane et al, Pediatric Emergency Care, 2007
Russell et al.,Pediatric Emergency Care, 2010
17. Causes of Anaphylaxis
Medications
24% of anaphylactic triggers
Antibiotics most common- PCN and cross reaction drugs to
PCN
Penicillin-allergic individuals have a 4-10% risk of allergic
reaction to a cephalosporin
Only antibiotic that can have skin testing (for IgE mediated rxn)
NSAIDs
Latex- chronic patients and multiple surgeries
IV contrast
Propofol- sedative medication that contains eggs and soy
Blood products, IVIG, etc
Lane et al, Pediatric Emergency Care, 2007
18. Causes of Anaphylaxis
Hymenoptera envenomation
12% of anaphylactic triggers
Honeybees, yellow jackets, hornets, wasps, and fire ants
Life threatening reactions require venom immunotherapy
20-60% risk per sting of anaphylaxis
Lane et al, Pediatric Emergency Care, 2007
19. Causes of Anaphylaxis
Immunizations- estimated 1.5 events per 1 million
MMR and influenza are the most common
Prepared using chick-derived cells
AAP recommends giving MMR to children with egg
sensitivity
Per CDC, egg sensitivity a contraindication for influenza
vaccine
Unknown exposure
16% of anaphylactic triggers
20. Contrast Media
Anaphylactoid reaction- not IgE mediated
Osmolality-hypertonicity reaction
Triggers degranulation of mast cells and basophils
Association of shellfish allergy and contrast media
(because of iodine content) is a myth
Pretreatment with prednisone and
diphenhydramine is only indicated in documented
history of an adverse reaction to contrast media
21. Question 1
A 5 year old M who has experienced a severe allergic
reaction to shrimp in the past needs a CT scan with IV
and oral contrast. What precautions should you take?
A. NS bolus and diphenhydramine
B. NS bolus, diphenhydramine, and prednisone
C. This patient can not receive contrast
D. Reassurance, there is no associated risk for a reaction
between shellfish and contrast
22. Question 1
A 5 year old M who has experienced a severe allergic
reaction to shrimp in the past needs a CT scan with IV
and oral contrast. What precautions should you take?
A. NS bolus and diphenhydramine
B. NS bolus, diphenhydramine, and prednisone
C. This patient can not receive contrast.
D. Reassurance, there is no associated risk for a
reaction between shellfish and contrast.
23. Route of Exposure
Insect stings and parenterally injected medication may
have rapid onset of symptoms
PO ingestions may develop over several minutes to
hours
Most symptoms occur within 5-30 minutes post
exposure
Lane et al, Pediatric Emergency Care, 2007
24. Pathophysiology
First time exposure to the allergen
Specific IgE antibodies are formed around the allergen
and bind to Fc receptors on mast cells
Repeat allergen exposure and binding of the allergen to
IgE antibodies causes degranulation of mast cell
Massive release of chemical mediators including:
Histamine
Prostaglandin D2
Leukotrienes
Platelet activating factor
Tryptase
Lane et al, Pediatric Emergency Care, 2007
25. Pathophysiology
Effect of Chemical Mediators after release
Increased vascular permeability
Bronchospasm
Vasodilatation
Altered smooth muscle tone
Within 10 minutes the circulating blood volume can
decrease by 35% during anaphylaxis
Lane et al, Pediatric Emergency Care, 2007
26. Symptoms
Respiratory: 94%
Cutaneous: 80- 90%
GI: 10-46%
CV: 30%
Russell et al.,Pediatric Emergency Care, 2010
30. IM Epinephrine
First line therapy!
Has alpha-1, beta-1, and beta-2 agonist actions
Increased vascular resistance and decreased mucosal
edema (alpha-1)
Increased inotrophy and chronotrophy (beta-1)
Increased bronchodilation and decreases release of mast
cell and basophil mediators (beta-2)
Only 18% reported use in pediatric anaphylaxis cases
31. IM vs. Sub-q
IM substantially better than sub-q
Faster peak plasma concentrations
Anterolateral thigh (vastus lateralis)
32. IM Epinephrine
Dose: 0.01mg/kg of 1:1000
Max dose is 0.3mg
May repeat every 5-15 minutes
20% require subsequent dosing
EpiPen:
2 fixed doses: 0.15mg and 0.3mg
< 22kg give EpiPen Jr (0.15mg)
>22kg give EpiPen (0.3mg)
Lane et al, Pediatric Emergency Care, 2007
34. Question 2
You have been asked by a local school to provide
recommendations about the use of self injectable
epinephrine for anaphylaxis. What is the BEST response
to give regarding anaphylaxis?
A. A patient should not receive a second dose of epinephrine
unless a physician is present
B. Epinephrine reaches higher peak plasma concentrations in
injected into the thigh rather than the arm
C. Families should keep one epinephrine auto injector in the
car in case a reaction occurs after school
D. Subcutaneous injection of epinephrine is preferable to
intramuscular injection
35. Question 2
You have been asked by a local school to provide
recommendations about the use of self injectable
epinephrine for anaphylaxis. What is the BEST response
to give regarding anaphylaxis?
A. A patient should not receive a second dose of epinephrine
unless a physician is present
B. Epinephrine reaches higher peak plasma
concentrations in injected into the thigh rather than
the arm
C. Families should keep one epinephrine auto injector in the
car in case a reaction occurs after school
D. Subcutaneous injection of epinephrine is preferable to
intramuscular injection
36. Question 3
A 14 y/o M who has seasonal allergies and moderate
persistent asthma is currently receiving allergen
immunotherapy. Today in clinic he received his usual
allergen injection, but after 10 minutes, he started coughing
and complaining of dyspnea and throat swelling. On
physical exam he exhibits moderate respiratory distress and
has diffuse expiratory wheezing on auscultation. No
oropharyngeal edema noted. Vitals signs include a pulse ox
of 97%, BP of 130/70, and HR of 90. Of the following, the
MOST appropriate next action is to administer:
A. A short acting beta-2 agonist nebulization
B. An oral antihistamine
C. An oral corticosteroid
D. Intramuscular epinephrine
37. Question 3
A 14 y/o M who has seasonal allergies and moderate
persistent asthma is currently receiving allergen
immunotherapy. Today in clinic he received his usual
allergen injection, but after 10 minutes, he started coughing
and complaining of dyspnea and throat swelling. On
physical exam he exhibits moderate respiratory distress and
has diffuse expiratory wheezing on auscultation. No
oropharyngeal edema noted. Vitals signs include a pulse ox
of 97%, BP of 130/70, and HR of 90. Of the following, the
MOST appropriate next action is to administer:
A. A short acting beta-2 agonist nebulization
B. An oral antihistamine
C. An oral corticosteroid
D. Intramuscular epinephrine
38. Treatment
IM Epinephrine
May repeat
IV fluids- 20ml/kg bolus
Repeat boluses if hypotension persists
IV Epinephrine for persistent hypotension/symptoms
0.01mg/kg of 1:10,000
Max dose 1gm
Histamine (H1/H2) blockers
Benadryl (H1) and Zantac (H2)
Slow onset of action
Shown to be effective on dermatologic manifestations especially
in combo
Albuterol treatment if indicated
Russell et al.,Pediatric Emergency Care, 2010
39. Role of Corticosteroids?
Corticosteroids
NO clinical evidence-based support for steroids in acute
management of anaphylaxis
NO support for steroids against biphasic reactions
Reported use of corticosteroids is more prevalent than
IM epinephrine in anaphylaxis
Lane et al, Pediatric Emergency Care, 2007
Russell et al.,Pediatric Emergency Care, 2010
40. Question 4
A 10 y/o M with a history of peanut allergy presents with
diffuse itching and trouble breathing after eating a friend’s
candy bar that contained nuts during school lunch. At the
nurse’s office the patient received IM epinephrine with his
EpiPen with symptom resolution. EMS was called and the
patient was brought to the local pediatric ED (about a 12
minute ride). On arrival to the ED, the patient is again
complaining of itching with an urticarial rash on his chest and
per EMS the patient began vomiting as they were pulling up to
the ambulance bay. Arrival vitals include a pulse ox of 96%, BP
of 88/67, and HR of 95. Of the following, the MOST appropriate
treatment plan is:
A. Intramuscular epinephrine, oral antihistamine, oral
corticosteroid, and a short acting beta-2 agonist neb treatment
B. Intramuscular epinephrine, IV antihistamine, IV corticosteroid,
NS bolus
C. Intramuscular epinephrine, IV antihistamine, IV Zantac, NS
bolus
D. Intramuscular epinephrine, oral antihistamine, oral
corticosteroid
41. Question 4
A 10 y/o M with a history of peanut allergy presents with
diffuse itching and trouble breathing after eating a friend’s
candy bar that contained nuts during school lunch. At the
nurse’s office the patient received IM epinephrine with his
EpiPen with symptom resolution. EMS was called and the
patient was brought to the local pediatric ED (about a 12
minute ride). On arrival to the ED, the patient is again
complaining of itching with an urticarial rash on his chest and
per EMS the patient began vomiting as they were pulling up to
the ambulance bay. Arrival vitals include a pulse ox of 96%, BP
of 88/67, and HR of 95. Of the following, the MOST appropriate
treatment plan is:
A. Intramuscular epinephrine, oral antihistamine, oral
corticosteroid, and a short acting beta-2 agonist neb treatment
B. Intramuscular epinephrine, IV antihistamine, IV corticosteroid,
NS bolus
C. Intramuscular epinephrine, IV antihistamine, IV Zantac,
NS bolus
D. Intramuscular epinephrine, oral antihistamine, oral
corticosteroid
42. Biphasic Reactions
Delayed anaphylactic reaction developing after initial
reaction has resolved
About 1-20% of all anaphylactic reactions
6% in pediatric anaphylaxis
Asymptomatic intervals range from 1-28 hours
Can occur up to 72 hours from initial reaction
Length of observation?
Suggested 8-24 hours in literature
“The only intervention that has been shown to reduce
the prevalence and severity of biphasic allergic reactions
is early treatment with IM epinephrine”
Lane et al, Pediatric Emergency Care, 2007
44. Criteria for Admission
Unresolved symptoms
High risk for biphasic reaction
Delayed epinephrine treatment
Co-morbidities
Social
45. Outpatient Management
Prescription for EpiPen
Parents can get at our pharmacy
Educate parents
Symptoms of anaphylaxis
Use of EpiPen
Referral to allergist
School forms
Peds ED Portal
51. Summary
Anaphylaxis- acute onset, involvement of 2 or more organ
systems or presence of hypotension
Severity of a previous reaction does not predict the severity
of a subsequent reaction
Patients with previous anaphylactic reactions are at a higher
risk for reoccurrence
First line treatment is IM epinephrine
< 22kg give EpiPen Jr (0.15mg)
>22kg give EpiPen (0.3mg)
Early IM epinephrine can reduce the risk of a biphasic
reaction
Discharge home with EpiPen, education, allergist referral,
and school forms
52.
53. References
Lee, J.M. and Greenes, D.S., Biphasic Anaphylactic
Reactions in Pediatrics. Pediatrics. 2000;106(4):762-6.
Nowak, R., Farrar, J.R., Brenner, B.E. et al., Customizing
anaphylaxis guidelines for emergency medicine. The
Journal of Emergency Medicine. 2013;45(2):299-305.
Lane, R.D. and Bolte, R.G., Pediatric anaphylaxis.
Pediatric Emergency Care. 2007;23(1):49-56.
Russell, S., Monroe, K., and Losek, J., Anaphylaxis
management in the pediatric emergency department.
Pediatric Emergency Care. 2010;26(2):71-76.