anaphylaxis: rapid recognition and treatment miha mežnar md medical intensive care unit general...
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Anaphylaxis: Rapid recognition and treatment
Miha Mežnar MDMedical intensive care unit
General hospital Celje, Slovenia
Anaphylaxis: Rapid recognition and treatment
Fatal anaphylaxis
Minutes to cardiac arrest
Median Range
55 iatrogenic 5 1 – 80
37 food 30 6 – 360
32 venom 15 4 – 120
Pumphrey RSH, Clinical and experimental allergy, 2000
Anaphylaxis: Rapid recognition and treatment
recognition
• Underrecognized, undertreated• Most important dg marker is trigger• Over 40 symptoms and signs described
cutaneuos >80%
respiratory up to 70%
gastrointestinal up to 40%
cardiovascular up to 35%
Diagnostic criteria
• Criterion 1: acute onset (minutes – hours) involving skin and/or mucosa + at least one:– Respiratory compromise– Reduced blood pressure
• Criterion 2: At least 2 of the following, minutes – hours after exposure TO A LIKELY ALLERGEN FOR THAT PATIENT:– Skin/mucosal involvement– Respiratory compromise– Reduced blood pressure– Gastrointestinal symptoms
• Criterion 3: Reduced blood pressure minutes – hours after exposure TO A KNOWN ALLERGEN FOR THAT PATIENT
J Allergy Clin Immunol, 2006
Potentional pitfalls in recognition of anaphylaxis
• Absent / missed skin symptoms
• Non-specific signs of hypotension (confusion, collapse, incontinence...)
• Certain conditions (surgery)
• DD – asthma exacerbation
– Lab tets to support Dg (tryptase)
Anaphylaxis: Rapid recognition and treatment
Fatal anaphylaxis: risk factors
• Concomitant asthma
• No epinephrine
• Non effective epinephrine
• Upright posture
• Other cardiopulmonary disease
Fatal anaphylaxis: risk factors
• Concomitant asthma
• No epinephrine
• Non effective epinephrine
• Upright posture
• Other cardiopulmonary disease
Fatal anaphylaxis
First adrenaline
None Before arrest After arrest
55 iatrogenic 6 9 40
37 food 13 8 16
32 venom 29 0 4
Pumphrey RSH, Clinical and experimental allergy, 2000
Adrenaline
• Review of literature:
Database searchEmbase 223Medline 92Lilacs 13Cochrane 10CINAHL 5BIOSIS 14Web of science 25
Included: 0
Excluded: all 382
Sheikh A, Allergy 2009
Treatment
• Removal of the causing agent• Epinephrine
– 0.3 – 0.5 mg (0.01mg/kg) i.m. (vastus lateralis), repeat 5 – 15 minutes– i.v. – titrate the dose
• Oxygen• Intubate, if stridor or arrest• Trendelenburg position• i. v. Fluids (cristalloids vs. colloids?)
– Steroides, antihistamines, inhaled beta agonists, glucagon of secondary (and questionable) importance