case studies in anaphylaxis - the conference exchange...intramuscular 4. subcutaneous use your...
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Anaphylaxis
Gabriel Ortiz, MPAS, PA-C, DFAAPA Pediatric Pulmonary Services- El Paso Texas
Co-founder, Past-Pres. AAPA-Allergy Asthma
Immunology AAPA Liaison to American Academy of Allergy
Asthma Immunology (AAAAI) AAAAI Liaison to AAPA
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Faculty Disclosure for Gabriel Ortiz, MPAS, PA-C
Consultant- Merck, Mylan, Sunovion, TEVA
Speakers Bureau- Aerocrine, Genentech, Merck,
Mylan, Sunovion, TEVA
Thermo Fisher Scientific,
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Learning Objectives
• 1. Implement guideline-based strategies for
the accurate diagnosis of anaphylaxis
• 2. Explain the rationale for the appropriate
use of injectable epinephrine as first-line
therapy for the treatment of anaphylaxis
• 3. Discuss the use of an emergency action plan
that includes education on risk factors
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Classification, Risk Factors, and Signs and Symptoms
of Anaphylaxis
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Classification of Human Anaphylaxis
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IgE = immunoglobulin E; FcɛRI = high-affinity IgE receptor; OSCS = over-sulfated chondroitin sulfate.
Simons FER, et al. J Allergy Clin Immunol. 2010;125:S161-S181.
Human Anaphylaxis
Nonimmunologic Immunologic
Idiopathic
IgE, FcRI Non-IgE, FcRI Physical Other
Foods, venoms, latex, drugs
Dextran, OSCS (contaminant in heparin)
Exercise, cold
Drugs such as NSAIDs, opioids, neuromuscular blocking agents, radiocontrast media
ANAPHYLACTOID
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Factors That Increase Risk of an Event or Potentiate Its Severity
Simons FER, et al. WAO Journal. 2011;4:13-37.
Infants Cannot describe their symptoms
Adolescents and young adults Increased risk-taking behaviors
Surgery, labor and delivery Risk from medications (eg, antibiotic to prevent neonatal group B strep infection)
Elderly Increased risk of fatality from medication or venom-triggered anaphylaxis
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Factors That Increase Risk of an Event or Potentiate Its Severity (cont’d)
Comorbid Diseases
Concurrent Medications/Ethanol/Recreational Drug Use
Allergic rhinitis and eczema a
Asthma and other respiratory diseases
Cardiovascular diseases
Psychiatric illness (eg, depression)
-adrenergic blockers and ACE inhibitors (may result in more severe reaction, may reduce effectiveness of epinephrine)
Ethanol/sedatives/hypnotics/antidepressants/ recreational drugs (potentially affect recognition
of anaphylaxis triggers and symptoms)
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aAtopic diseases are a risk factor for anaphylaxis triggered by food, exercise, and latex, but not for insect stings, β-lactam antibiotics, or insulin. ACE = angiotensin converting enyzme.
Simons FER, et al. WAO Journal. 2011;4:13-37.
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Frequency and Occurrence of Signs and Symptoms of Anaphylaxis
Signs and Symptoms Percenta
Cutaneous
Urticaria or angioedema
Flushing
Pruritus without rash
85-90
45-55
2-5
Respiratory
Dyspnea, wheeze
Upper airway angioedema
Rhinitis
45-50
50-60
15-20
Hypotension, dizziness, or syncope 30-35
Abdominal
Nausea, vomiting, diarrhea, or cramping pain
25-30
Miscellaneous
Headache
Substernal pain
Seizure
Sense of impending doom
5-8
4-6
1-2
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aPercentages are approximations.
Lieberman P, et al. J Allergy Clin Immunol. 2010;126:477-480.
ACTION ITEM: Recognize that cutaneous symptoms are present in as many as 90% of
anaphylaxis cases, and in the absence of a known allergen, involvement of ≥2 systems is indicative of anaphylaxis
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Anaphylaxis Is Likely When 1 of the Following Criteria Is Met
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Sudden onset of an illness, with involvement of the skin, mucosal tissue, or both
(minutes to several hours):
1. Sudden respiratory symptoms
2. Sudden reduced BP or symptoms of end-organ dysfunction
2 or more of the following that occur suddenly after exposure to a likely allergen
or other trigger for that patient (minutes to several hours):
1. Sudden skin or mucosal symptoms
2. Sudden respiratory symptoms
3. Sudden reduced BP or symptoms of end-organ dysfunction
4. Sudden gastrointestinal symptoms
Reduced BP after exposure to a known allergen for that patient
(minutes to several hours)
1
AND at least 1 of these:
2
OR
3
OR
BP = blood pressure; GI = gastrointestinal.
Simons FER, et al. WAO Journal. 2011;4:13-37.
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Use your keypad to vote now!
Which of the following is the ideal route of delivery for epinephrine?
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1. Inhaled
2. Intravenous
3. Intramuscular
4. Subcutaneous
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Use your keypad to vote now!
A second dose of epinephrine can be administered after the first dose
in as little as:
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1. 5 minutes
2. 10 minutes
3. 20 minutes
4. 40 minutes
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Case Study: John, 7-Year-Old Boy
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Case Study: John, 7-Year-Old Boy (cont’d)
• Review of allergic history:
– No history of anaphylaxis before recent event
– Developed localized hives on neck after drinking milk at 1 year of age
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Pharmacologic Management of Anaphylaxis
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Acute Management When Anaphylaxis Is Suspected
• Administer IM epinephrinea quickly – Repeat every 5 to 10 minutes if necessary
• Place patient in supine position with legs elevated
• Consider oxygen for patients who: – Have prolonged reactions
– Have pre-existing hypoxemia or myocardial dysfunction
– Receive inhaled beta-agonists as treatment for bronchospasm
– Require multiple doses of epinephrine
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aIM epinephrine (to lateral aspect of thigh) from 1:1,000 dilution (1 mg/mL) injected as 0.2 to 0.5 mL (0.01 mg/kg in children, maximum dose 0.3 mg) to control symptoms and increase blood pressure Lieberman P, et al. J Allergy Clin Immunol. 2010;126:477-480.
ACTION ITEM: Intramuscular epinephrine can be administered every 5 to 10 minutes if necessary
for the treatment of patients with anaphylaxis
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Additional Measures When Anaphylaxis Is Suspected
• Evaluate hypotension and need for IV fluids
• Individualize observation
17 IV = intravenous.
Lieberman P, et al. J Allergy Clin Immunol. 2010;126:477-480.
In general Persistent hypotension <90/60 mm Hg
Children >1 to 10 years Systolic <70 mm Hg + (2x age in years)
>10 years Systolic <90 mm Hg
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Other Factors to Consider When Treating an Anaphylactic Episode
• Types of supportive treatments
– IV fluids for hypotension
– Antihistamines, corticosteroids, vasopressors, or glucagon
• Severity and rate of progression of the episode
• Onset of action and method of administration of the drug(s) administered
18 Lieberman P, et al. J Allergy Clin Immunol. 2010;126:477-480.