Anaphylaxis is often one of the first emergencies which is taught to the residents. But how good are we in treating anaphylaxis - as emergency health care providers? Well, the literature says that the DOC for anaphylaxis
(Epinephrine) is under-utilised, under prescribed for future use!
Let us familiarise ourselves once again with the management of anaphylaxis, no groundbreaking information here, just a review of what we are supposed to do.
Diagnostic criteria: Likely if any one of these criteria are met:
- Acute onset illness with involvement of skin and/or mucosa accompanied by either respiratory compromise, falling blood pressure or end organ dysfunction.
- Two or more of the following symptoms occurring rapidly after exposure to the likely allergen: involvement of skin and/or mucosa, signs of respiratory compromise, falling blood pressure or end organ dysfunction and persistent GI symptoms.
- Falling blood pressure within minutes to several hours following exposure to a known allergen.
(Note: Do not equate anaphylaxis with hypotension/shock. Hypotension is not mandatory to administer epinephrine)
Signs and symptoms: It is primarily a clinical diagnosis. Labs are rarely helpful.
Skin is almost always involved in about 80% of the cases. Other major systems which can be involved are:
Skin: flushing, urticaria, angioedema, warmth, swelling, conjunctival injection
RS: Nasal congestion, Coryza, rhinorhea, sneezing, throat tightness, wheezing, SOB, cough, hoarseness of voice
CVS: dizziness, weakness, syncope, chest pain, palpitations
GI: Dysphagia, nausea and vomiting, diarrhoea, bloating, cramps
CNS: headache, dizziness, blurred vision, seizure (rare)
Management
ABCs (Anticipate challenging airway, keep plan B ready)
O2, fluids and epinephrine
IM Epi 0.5mg 1:1000 anterolateral thigh, repeat q5-10min x 3
Adjuncts
Steroids, H1/H2 blockers, bronchodilators
For those on beta blockers : glucagon
Other vasopressors : epi, vasopressin, nor epi infusion
Decide on admission discharge based on doses of epi required, age, comorbidities.
Bottomline:
Know the diagnostic criteria for anaphylaxis
Don't delay epinephrine
Hypotension is not mandatory to diagnose anaphylaxis
Fluids, O2 and Epinephrine - treatment for anaphylaxis (not steroids and antihistaminics)
Give epi pen and educate them at discharge
Check out the recent guidelines for more info: