emergency medicine case - anaphylaxis

7/29/2019 Emergency Medicine Case - Anaphylaxis

1/6

1

DEPARTMENT OF EMERGENCY MEDICINE

Case:

Date of Interview: April 7, 2013

Time of Interview: 7:00pm

Informant: Patient

Reliability: 100% (Good)

General Data:

RS, 50 year old, male, married, Filipino, Roman Catholic in religion and works as an office employee. He was born on

May 22, 1962 and now lives in 53 Sanada St. Sta., Cecilia Village, Las Pinas City. The interview took place at CC Ext 1 in the

Department of Emergency Medicine. The patient was brought to University of Perpetual Help Rizal, Las Pias City, Emergency

Room on April 7, 2013.

Chief Complaint:

Difficulty of breathing

History of Present Illness

30 minutes prior to consult, the patient verbalized that he was eating, pancit canton, bread and drank coffee and

water with his family for his afternoon meal. After few minutes, the patient experienced difficulty of breathing with onset of

pruritus that is generalized. He also verbalized feeling of lump in his throat.

The patient had no fever, headache, dizziness, episodes of vomiting, dysuria, diarrhea, abdominal and muscle pain

No medications were taken thus prompted him to consult to ER at University of Perpetual Help Rizal.

Past Medical History

Aside from the patients current condition which was his first episode of attack, he has a history of hypertension with

the highest blood pressure of 140/90 and normal blood pressure of 120/80.

No maintenance medications for his hypertensions were taken. He has no known allergies and there were no

previous surgeries done from the patient and his last meal was at 6:00pm.

Family History.

The patient is the breadwinner in the family. His father has history of hypertension. Other than that, all members of

the family are asymptomatic.

Personal and Social History

The patient has history of cigarette smoking with 1 pack per year and was advised to quit smoking. He is an occasiona

drinker and does not use any prohibited drugs. During his free time, he makes sure that he plays tennis 2-3 times a week withhis son and friends. He eats his meal 3 times a day which consists of meat, seafood, vegetables, juice and water.

Review of System

Pertinent positives are difficulty of breathing, shortness of breath, flushed skin, and erythema at both eyes

Physical Examination

General Appearance: The patient came in ambulatory with the assistance of his son. He is not in cardiorespiratory distress


2/6

2

Mental Status: awake, alert, cooperative, conscious and coherent, oriented to 3 spheres

Skin: Flushed, warm to touch, erythema at both eyes

HEENT: (+) Edema at palate and tonsillopharyngeal wall, (+) swollen lips, external ear canal has some cerumen and redness,

pupils equally reactive to light, 2-3 mm in diameter

Chest/Lungs: Symmetrical chest expansion, clear breath sounds, no crackles, no wheezes, no retractions

Heart: Adynamic precordium, Normal rate and regular rhythm, no murmur

Abdomen: Soft, non-tender, normoactive bowel sounds, no rashes, no lesions

Extremities: Non-edematous, full equal pulses, non-atrophic extremities, no spasticity, no tremors, no tics, no rigidity

Neuro: Cranial nerves are all intact

CN 1 - N/A CN 2 Pupils equally reactive to light, 2-3 mm in diameter CN 3,4,6 Extraocular movements are intact CN 5 (+) isocorneal reflex CN 7 Facial symmetry CN 8 Intact gross hearing CN 9 no uvula deviation CN 10 intact gag reflex CN 11- good shoulder shrug CN 12 no tongue deviationSensory Response: 100%

Motor Response: 5/5Reflexes: ++

DIFFERENTIAL DIAGNOSIS

Rule In Rule Out

1. Anaphylaxis Respiratory compromise(dyspnea)

Reduced blood pressure

Involvement of the mucosal tissue

Pruritus, generalized

Eye redness

Sense of fullness in throatLaryngeal Edema - Lump in the throat

Cutaneous Flushing

2. Vasovagal Reaction Pruritus in the presence of a slow pulserate

Painful intervention such as an injection

Manifested by pallor, light-headedness,

nausea,

profuse diaphoresis and syncope.

and normal blood pressure

3. Angioedema Pronounced itchiness or local erythemaThroat tightness, voice changes, and

difficulty of breathing

Swelling of the face (eg, eyelids, lips),

tongue, hands, and feet

Abdominal pain can sometimes be the

only presenting symptom

WORKING IMPRESSION:

- ANAPHYLAXIS, ETIOLOGY TO BE DETERMINED


3/6

3

DISCUSSION:

ANAPHYLAXIS is a medical emergency that requires immediate diagnosis and treatment. Anaphylaxis is a serious allergic

reaction that is rapid in onset and may cause death.

3 Clinical Criteria to consider Anaphylaxis:

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.)

Reduced blood pressure

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

Clinical Manifestations of Anaphylaxis

System Signs and Symptoms

Respiratory 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

COMMON CAUSES OF ANAPHYLAXIS:

DRUGS:

1. B-lactams antibiotics2. Acetylsalicylic acid3. Vancomycin

NSAIDS (Non-steroidal Anti-Inflammatory Drugs)

FOODS:1. Shellfish, nuts, eggs, milk, salicylatesOTHERS:

1. Insect bites, vaccines, latex*Histamine vasodilation, increases permeability, heart rate, cardiac contraction

*Prostaglandin D2 is a bronchoconstrictor, pulmonary and coronary vasoconstrictor and peripheral vasodilator.


4/6

4

Clinical Allergic Reactions:

1. Diffuse Urticaria2. Angioedema

Classic Presentation of Anaphylaxis

1. Pruritus2. Cutaneous Flushing3. Urticaria4. Sense of fullness in throat5. Lump in the throat

PATHOPHYSIOLOGY

Activation of mast cells and baso hils

Releases mediators from secretorygranules (histamine, tryptase,

carboxpeptidase A, proteoglycans.

TNF- is releases as a preformed

mediator and as a late phase mediator

with other cytokines and chemokines.

Histamine

stimulates

vasodilation and

increases vascular

permeability, heart

rate, cardiac

contraction, and

glandular

secretion.

Prostaglandin D2 is a

bronchoconstrictor,

pulmonary and

coronary

vasoconstrictor, and

peripheral vasodilator.

Leukotrienes

produce

bronchoconstrictio

n, increase vascular

permeability, and

promote airway

remodeling.

Platelet-activating

factor is also a

potent

bronchoconstricto

r and increases

vascular

permeability.

Tumor necrosis

factor-activates

neutrophils,

recruits other

effector cells, and

enhances

chemokine

synthesis.

Presents with generalized urticaria and angioedema, bronchospasm, and other respiratory

symptoms; hypotension, syncope, and other cardiovascular symptoms; and nausea, cramping,

and other GI symptoms

ANAPHYLAXIS

Crosslinking of IgE and aggregation of the

high affinity receptors for IgE.


5/6

5

LABORATORY RESULTS

02 SAT at room air = 87% -> 99% CO2 12L ECG Advised, however opted to obscure 02 inhalation at 3 liters/min via nasal cannula Hooked to cardiac monitor and pulse oximeter IVF PNSS. 1 liter,fast drip 300 cc now then regular of MF Epinephrine 0.3 scc SQ Famotidine Diphenhydramine50 mg IV Hydrocortisone Famotidine fast drip another 2

FINAL DIAGNOSIS:

ANAPHYLAXIS SECONDARY TO FOOD INTAKE

TREATMENT:

Administration of epinephrine. the single most important step in treatment is the rapid Epinephrine is the drug of choice and the first drug that should be administered in acute anaphylaxis

FIRST-LINE THERAPY

ABCs (airway, breathing, circulation) of resuscitation.)

- The first-line therapies for anaphylaxis (EPINEPHRINE, IV FLUIDS, and OXYGEN) have immediate effect during theacute stage of anaphylaxis.

- Vital signs, IV access, oxygen administration, cardiac monitoring, and pulse oximetry measurements should beinitiated immediately.

- EPINEPHRINE is a mixed 1- and 2-receptor agent. The 1-receptor activation reduces mucosal edema andmembrane leakage and treats hypotension, whereas the 2 receptor activation provides bronchodilation and controls

mediator release.

- In patients without signs of cardiovascular compromise or collapse, IM epinephrine can be administered.o The dose is epinephrine, 0.3 to 0.5 milligram (0.3 to 0.5 mL of the 1:1000 dilution) IM repeated every 5 to

10 minutes according to response or relapse

- If the patient is refractory to treatment despite repeated IM epinephrine, or with signs of cardiovascular compromiseor collapse, then institute an IV infusion of epinephrine.

-o Initially, epinephrine, 100 micrograms (0.1 milligram) IV, should be given as a 1:100,000 dilution.o This can be done by placing epinephrine, 0.1 milligram (0.1 mL of the 1:1000 dilution), in 10 mL of norma

saline (NS) solution and infusing it over 5 to 10 minutes (a rate of 1 to 2 mL/min).

o If the patient is refractory to the initial bolus, then an epinephrine infusion can be started by placingepinephrine, 1 milligram (1.0 mL of the 1:1000 dilution), in 500 mL of 5% dextrose in water or NS and

administering at a rate of 1 to 4 micrograms/min (0.5 to 2 mL/min), titrating to effect.


6/6

6

SECOND LINE THERAPY

1. Diphenhydramineo Adult Dose: 2550 milligrams every 6 h IV, IM, or POo Pediatric Dose: 1 milligram/kg every 6 h IV, IM, or PO

2. Ranitidineo Adult Dose: 50 milligrams IV over 5 mino Pediatric Dose: 0.5 milligram/kg IV over 5 min

3. Hydrocortisoneo Adult Dose: 250500 milligrams IVo Pediatric Dose: 510 milligrams/kg IV (maximum, 500 milligrams)

4. Methylprednisoloneo Adult Dose: 80125 milligrams IVo Pediatric Dose: 12 milligrams/kg IV (maximum, 125 milligrams)

PREVENTION

1. Educationo Identification of inciting allergen, if possibleo Instructions on avoiding future exposureo Instructions on use of medications and epinephrine autoinjectoro Advise about personal identification/allergy alert tag

2. Medicationso Diphenhydramine, 25-50 mg PO for several dayso Prednisone 40-60 mg PO for several dayso Epinephrine autoinjector for future reactions

3. Referral to allergistReference: Tintinalli Emergency-Medicine, Section 3, Chapter 27, 7ed, 2010.

emergency medicine case - anaphylaxis

Documents