Anaphylaxis The Dying Breaths

Dr Gerard FennessyICU RegistrarThe Royal Melbourne HospitalVictoria, Australia

Definition and Causes

Clinical Aspects

Investigations and Treatment

Reprise Starring a famous movie star

Anaphylaxis

NZ trained

◦ Joint ICU and ED training

Royal Melbourne Hospital

About me…

Mt Ruapehu

Mt Ruapehu

…and it was a quiet day on the MV Pacific Carnival Princess Cruise Liner…

A – no stridor, able to talk

B – no wheeze, sats 100% RR 14

C – PR 100 BP 140/100

Would you give her adrenaline?

…and it was a quiet day on the MV Pacific Carnival Princess Cruise Liner…

Adrenaline

Adrenaline

Adrenaline

Epinephrine

Anaphylaxis: the last slide…

Presentation is VARIABLE

Diagnosis is CLINICAL

Requires URGENT treatment

No consensus on definition

hypersensitivity reaction

severe, life-threatening

generalised or systemic

may have skin and mucosal changes

ERC Resuscitation 2010

European Resuscitation Council Guidelines for Resuscitation 2010. Resuscitation 81 (2010) 1219–1276

Compromise to…

Incidence

Incidence

Incidence

Adults

1:3400 per year

1:500 – 1:1000 ED presentations

<1 in 1,000,000

Within 5-30 minutes of exposure

Fatalities

Highly Popular Disease

http://www.ifr.ac.uk/

IgE

“anaphylactoid reaction”

identical presentation and treatment

Non-allergic anaphylaxis

Causes

Food

Hymenoptera

Drugs

Cephalosporin and Penicillin Cross-Reactivity

The Journal of Emergency Medicine, Vol. 42, No. 5, pp. 612–620, 2012

The Journal of Emergency Medicine, Vol. 42, No. 5, pp. 612–620, 2012

Β-lactam ring

R ≈ side chain

The Journal of Emergency Medicine, Vol. 42, No. 5, pp. 612–620, 2012

Penicillin allergic patients more allergic to EVERYTHING

Until mid-1980s penicillins and cephalorsporins made

using the same mold

The Journal of Emergency Medicine, Vol. 42, No. 5, pp. 612–620, 2012

Cross reactivity:

1% who state penicillin allergy

2% with confirmed penicillin allergy

1st and 2nd generation only

The Journal of Emergency Medicine, Vol. 42, No. 5, pp. 612–620, 2012

Negligible cross-reactivity with 3rd and 4th generation

cephalosporins

MOST 1st and 2nd generation (cefaclor, cefalexin etc)

and

ALL 3rd and 4th generation(ceftriaxone)

Cephalosporins and Penicillin Negligible Cross-reactivity

Mild◦ Skin, angioedema

Moderate◦ Dyspnoea, stridor, wheeze, GI upset

Severe◦ Cyanosis, hypotension, collapse

Clinical findings

Urticaria

Pruritis

Erythema

Angioedema

Clinical – Cutaneous 80-90%

Hoarseness

Stridor

Wheeze

Bronchospasm

Hypoxia

Respiratory

Patrick J. Lynch, medical illustrator; C. Carl Jaffe, MD, cardiologist

Hypotension

Tachycardia

Arrythmia

Syncope

Myocardial Depression

Cardiovascular

Investigations

Mast cell tryptase

◦ 1-6 hours after event

◦ not sensitive or specific

◦ serial measurements may be useful

Tryptase

Treatment

Adrenaline

Adrenaline

Adrenaline

Epinephrine

Airway swelling

Bronchospasm

Hypotension

Adrenaline

Give it EARLY

IM ◦ 0.3-0.5mg Repeat PRN

IV◦ 10-20 mcg/min

Nebulised

http://www.firstaidforlife.org.uk/courses/acute-allergic-reaction-and-how-to-use-and-epipen/

Antihistamines

Steroids

Glucagon

Uncertain Benefit

A bit of light entertainment…

Brown A. Current management of anaphylaxis. Emergencias 2009; 21: 213-223.

Campagna JD, Bond MC, Schabelman E, Hayes BD. The use of cephalosprins in penicillin allergic patients: a literature review. Journal of Emergency Medicine 2012. 42(5); 612–620.

deShazo R. Anaphylaxis: My “Top 10′′ List. Southern Medical Journal 2007: 100(3), 233­234.

Dewachter P, Mouton-Faivre C, Emala CW. Anaphylaxis and Anesthesia, Controversies and New Insights. Anesthesiology 2009; 111:1141–50.

Worth A, Soar J, Sheikh A. Management of anaphylaxis in the emergency setting. Expert Rev. Clin. Immunol; 2010. 6(1), 89–100.

Not sponsored by Epipen nor Zovirax nor Seasame Street

Thanks to Stephen Odgers (backing vocals and guitar) and Jim Henson

References and Acknowledgements