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:

https://www.aaaai.org/Aaaai/media/MediaLibrary/PDF%20Documents/Practice%20and%20Parameters/Anaphylaxis-Practice-Parameter-2014.pdf