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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)

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

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. 

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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