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I have completed bits of my EM training from India. Currently I am boarded with credentials from Christian Medical College, Vellore and also from the prestigious Royal College of Emergency Medicine, UK.  I am currently working in London as an A&E doctor, trying to appreciate the differences in the practise and culture of Emergency Medicine across different healthcare systems. I have always been an avid FOAMed supporter because FOAMed played an indispensable role during the days of my initial training. Through this blog, I aspire to disseminate knowledge and stay up to date with the EM literature. 

Thursday, January 22, 2015

Anaphylaxis - how are we doing?

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:
  1. Acute onset illness with involvement of skin and/or mucosa accompanied by either respiratory compromise, falling blood pressure or end organ dysfunction. 
  2. 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. 
  3. 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:









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