Post on 23-Dec-2015
transcript
AnaphylaxisDr. Jen LeppardEmergency Physician, TOH
LMCC Objectives
History and Physical of allergic reaction pts
Investigations to identify allergens
Manage urticaria and anaphylaxis in ED
Determine urticaria with systemic diseases
CDMQ: What can cause allergic reactions? (5)
Urticaria: triggers
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Drugs (Antibiotics especially)Food allergensInsectsPhysical stressors (cold, exercise)Respiratory allergy (Pollen)
(Quick) Pathophysiology
LMCC Objectives
History and Physical of allergic reaction pts
Investigations to identify allergens
Manage urticaria and anaphylaxis in ED
Determine urticaria with systemic diseases
History and Physical
• HPI of ingestion/exposure• Detective work• Allergic and atopic history• Symptoms and physical
exam based on systems involved
What systems are involved?
Systems Involved
Blood Vessels
Photo credit: kiwinky, Flickr commons
Blood Vessels
Photo credit: kiwinky, Flickr commons
© anaphylaxisweb
© anaphylaxisweb
Soft tissues
50% has angioedema (lips/face/upper airway)
If airway/tongue -> potential airway obstruction
Lungs
GI tract
LMCC Objectives
History and Physical of allergic reaction pts
Investigations to identify allergens
Manage urticaria and anaphylaxis in ED
Determine urticaria with systemic diseases
Investigations for allergic reaction/anaphylaxis in ED
No Labs
Maybe skin testing later
LMCC Objectives
History and Physical of allergic reaction pts
Investigations to identify allergens
Manage urticaria and anaphylaxis in ED
Determine urticaria with systemic diseases
Definition of anaphylaxis
MCQ 5: Who does not have anaphylaxis?
A. Ate peanut butter. Swollen lips and wheezing. VS normal.
B. Shrimp fest at Red Lobsters. Vomiting and tight throat. VS normal.
C. Stung by bee. Low BP.D. Flu shot. Hives. VS normal. E. Hay fever, swollen throat, low BP.
Anaphylaxis Definition
> 2 systems: 1. Airway2. CVS (BP)3. GI4. Skin
OR
Just BP
CDMQ: Management steps of patient with swollen tongue, hives, BP 80/50, O2 85% (6)
swollen tongue, hives, BP 80/50, O2 85%
ABCsAirway:
Epinephrine 0.3cc 1:1000 IM Intubate if needed
(indications?)
Breathing: Bronchodilators (Ventolin) if
wheezy Supplemental O2
Bronchodilators
Epinephrine
swollen tongue, hives, BP 80/50, O2 85%
Circulation IV NS 1-2L bolus (Epi 0.3cc of 1:1000 IM) (Epi infusion)
Fluids (+ epi)
swollen tongue, hives, BP 80/50, O2 85%
Other Medications H1 Blocker: Benadryl 50mg
IV or 50mg PO H2 Blocker: Ranitidine
50mg IV or 150mg PO
Steroids: Solumedrol 125mg IV or Prednisone 50mg PO
Iv fluid 1-2 L bolus (1)Drugs (3)
Antihistamines (H1- Benadryl, H2- Ranitidine)Steroids: Prednisone or Solu-Medrol
Antihistamines
H1: Benadryl (Diphenhydramine)H2: Ranitidine
Other Drugs to Consider
Glucagon: if on beta blockers, and refractory hypotension
Nebulized racemic epi: for upper airway edema
Discharge instructions
Allergy testing outpatient
Carry Epi-Pen at all times
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Discharge meds
Epi Pen Steroid (Prednisone PO)
2nd phase reaction (6-72 hours)
Continue Antihistamines
LMCC Objectives
History and Physical of allergic reaction pts
Investigations to identify allergens
Manage urticaria and anaphylaxis in ED
Determine urticaria with systemic diseases
Urticaria- vasodilation- leaky vessels
Acute or Chronic
Typically IgE mediated hypersensitvity
Photo credit: kiwinky, Flickr commons
Systemic illness -> urticariaSerum sickness
Viral/bacterial infections
Vasculitis
Photo credit: mrmason.ca
Systemic illness: serum sickness
Photo credit: mrmason.ca
Systemic illness: serum sickness
Fever, rash, arthralgia, GI, malaiseRelated to drugs (eg. septra, cefprozil)
Photo credit: Dermatolog Information System
Systemic urticaria: Viral/Bacterial infection
Photo credit: Dermatology image atlas
Systemic urticaria: Vasculitis
Associated with
SLE, Sjogrens, LeukemiaDrugs
Systemic unwell: Arthralgia, fever, abdo pain, lymphadenopathy
LMCC Objectives
History and Physical of allergic reaction pts
Determine urticaria with systemic diseases
Investigations to identify allergens
Manage urticaria and anaphylaxis in ED