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History of anaphylaxis
Triggers
i. Food (most common in children/teens)
ii. Medications (most common in adults)
iii. Stinging insects
ii.
1.
2.
3.
4.
iii.
Hypotension after exposure to a known antigen for that patient (SBP <90 or
30% decrease from baseline)
Pathophysiology
Multiple types of shock at play in anaphylaxis
Distributive
Hypovolemic (Patients lose about 35% of blood volume into interstitial tissue)
Cardiogenic (High concentration of mast cells around coronary vessels,
Exposure causes release of mediators that cause coronary vasospasm, This
leads to cardiac dysfunction, Reversible with treatment)
Labs
Limited role (histamine/tryptase levels), Clinical diagnosis
Treatment
1.
2.
3.
Lay them supine (Literature says that sitting patients up increases risk of
cardiac arrest)
Fluid rehydration
4.
Epinephrine
i.
ii.
iii.
iv.
5.
Secondary medications
ii.
H2-blockers (ranitidine)
i.
ii.
iii.
iv.
Disposition
Controversy surrounds how long to observe patients to monitor for the biphasic
reaction (? 6 -8 12hrs or ADMIT)
~5% of patients will develop a biphasic reaction (re-develop symptoms after
resolution of initial symptoms)
1.
2.
3.
BOTTOM LINE
1. Dont be afraid of epinephrine! Its the only drug that will save a life in
anaphylaxis.
2. Discharge with H1/H2 blockers/Steroids/Epinephrine prescription!
Further Reading:
https://www.aaaai.org/Aaaai/media/MediaLibrary/PDF%20Documents/Practice%20a
nd%20Parameters/Anaphylaxis-Practice-Parameter-2014.pdf
Zilberstein J, McCurdy MT, Winters ME. Anaphylaxis. J Emerg Med. 2014 Aug; 47(2):182-7.
Nowak R, Farrar JR, Brenner BE, et al. Customizing anaphylaxis guidelines for emergency
medicine. J Emerg Med. 2013 Aug; 45(2): 299-306.
Grunau BE, Li J, Yi TW, et al. Incidence of clinically important biphasic reactions in
emergency department patients with allergic reactions or anaphylaxis. Ann Emerg Med. 2014
Jun; 63(6): 736-44.
Questions/Comments/
Feedback
Lakshay
Chanana
MB
BS,
FEM
(Vellore),
MCEM
(UK)
drlakshay_em@yahoo.com
EM
Academy
@
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