emergency - anaphylaxis
TRANSCRIPT
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ANAPHYLAXIS & ANAPHYLACTOID REACTIONS
Immediate hypersensitivity reactions involving ageneralized response to a specific antigen
Anaphylax i s involves antigen & IgE antibodies andrequires previous sensitization to an antigen
Anaphylac to id Reac tions are mediated by histamine andmay occur with the first exposure to an antigen
Approximately 500 deaths occur per year in the U.S. fromanaphylaxis, PCN allergy accounts for 75% of deaths
Typical Substances (used in dental office) that can trigger an allergic Rx;
AntibioticsNarcotics
Latex Aminoester Local Anesthestic Agents
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ANAPHYLAXIS & ANAPHYLACTOID REACTIONS
Prevent ion
1) Obtain a careful history of previous allergicreactions, atopy or asthma
2) Administer ProphylaxisCorticosteroids
Dexamethasone IV, Adult 20 mgPediatric Dosage IV 0.6 mg/kg
Methylprednisolone IV, Adult 100 mgPediatric Dosage IV,IM 30 g/kg
H1 AntagonistDiphenhydramine IV, Adult 25 50 mg
Pediatric Dosage IV, 2-5 mg/kg
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ANAPHYLAXIS & ANAPHYLACTOID REACTIONS
Assesment
Determine if patient is in mild or severe distress:
Mild Distress: itching, isolated urticaria,nausea, no respiratory distress.
Severe Distress: poor air entry, flaring,grunting, cyanosis, stridor, bronchospasm,abdominal cramps, respiratory distress,tachycardia, shock, edema of lips, tongue or face and generalized urticaria.
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ANAPHYLAXIS & ANAPHYLACTOID REACTIONS
Manifes ta t ions Cardiac
Hypotension may be only early sign of anaphylaxis of anesthestized patient
Cardiovascular CollapsePulmonary Hypertension
Arrhythmias, Pulmonary Edema Awake Patient - may Complain of Dizziness or Decreased
Level of Consciousness (masked by sedation)
Respiratory
Bronchospasm Stridor, laryngeal edemaIncreased PIP Pulmonary EdemaHypoxemia If Awake Complaint of Dypsnea/Chest tightness
Cutaneous
Rash, Flush, Hives, Puritis, Angioedema
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ANAPHYLAXIS & ANAPHYLACTOID REACTIONS
Management
Determine presence of upper airway involvement (stridor) or lower airwaysymptoms (wheezing). These may coexist. Maintain an open airway and assistventilations as needed. This may include repositioning of the airway, suctioning, or
use of airway adjuncts (oropharyngeal airway) as indicated.
Maintain the patients airway & support oxygenation and ventilation Increase FiO2 to 100%Intubate if necessaryThe airway & larynx can become very edematous
If bronchospasm is present in the normotensive patient, volatile agents maybe administered to counteract bronchospasm
Contact Code Team or 911 depending on location
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ANAPHYLAXIS & ANAPHYLACTOID REACTIONS
Management
Expand the circulating volume rapidlyImmediate fluid needs may be massive
Administer Epinephrine IVEpinephrine is the drug of choice for treatment of anaphylaxisFor hypotension, 10 50 mcg increments, repeat prn
Administer a H1 antagonistH1 Blockers
Diphenhydramine IV, 1 mg/kg up to a maximum of 50 kg
In the absence of any other known cause, consider latex allergy
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ANAPHYLAXIS & ANAPHYLACTOID REACTIONS
Management
The recommended epinephrine dose for anaphylaxisin children is 0.01 mg/kg, not to exceed 0.30 mg.
The preferred route of administration for first-aidtreatment is intramuscular injection of epinephrine intothe vastus lateralis of the lateral thigh, which allowsearly peak epinephrine concentration needed for effective management.
Intravenous administration of epinephrine carriesincreased risks for dilution errors and dosing errors,which may lead to overdose and adverse effects suchas cardiac dysrhythmias.
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ANAPHYLAXIS & ANAPHYLACTOID REACTIONS
Epinephr ine
Based on patient weight:
10 kg or less:Consider use of ampule of epinephrine with needle andsyringe to draw correct dose (0.01 mg/kg) of epinephrine.
10 to 25 kg: Autoinjection with 0.15 mg of epinephrine.
25 kg or more: Autoinjection with 0.30 mg of epinephrine.
A second dose of epinephrine is required for anaphylaxis in up to 35% of cases.Epinephrine may be repeated 5 to 20 minutes after the initial dose.
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ANAPHYLAXIS & ANAPHYLACTOID REACTIONS
Monitor Vital Signs & Keep Patient Warm
Provide Advanced Airway Management if Indicated
Initiate IV Normal Saline KVO titrated to appropriate BP for age(expected fluid bolus will be @ 20 mL/kg)
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ANAPHYLAXIS & ANAPHYLACTOID REACTIONSSevere Distress
Epinephrine (1:1,000) , 0.01 mg/kg subcutaneouslyup to maximum single dose 0.3 mg.
Epinephrine 1:1,000 ; administer 0.1 mg/kg via ETfollowed by 2.0 cc sterile Normal Saline solution.
Epinephrine infusion 1:1,000 (1 mg/ml) administer 0.1 to 1.0 mcg/kg/min .
Large Bore IV normal saline, titrate to appropriate BP for age. (expected fluid bolus will be @ 20 mL/kg)
Diphenhydramine HCL (Benadryl ) 1.0 mg/kg up to maximum single dose of 50 mg via deep intramuscular injection (IM) or IV push.
Albuterol Sulfate 0.5% (via nebulizer)
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ANAPHYLAXIS & ANAPHYLACTOID REACTIONS
Epinephrine Solutions
Epinephrine vials are also labeled by concentration of aratio of medication per mL. For example, a solution maybe labeled as 1:100,000. This concentration represents1000mg/100,000mL or 0.01mg/mL.
CONCENTRATION DOSAGE EQUIVALENCE PERCENT
1:1,000 1mg/mL 0.1%
1:10,000 0.1mg/mL 0.01%
1:100,000 0.01mg/mL 0.001%
1:200,000 0.005mg/mL 0.0005%
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ANAPHYLAXIS & ANAPHYLACTOID REACTIONS
Epinephrine drug of choice for anaphylaxis
Drug Action;
Alp ha effec ts produce peripheral vasoconstriction which;1) Increases coronary and cerebral perfusion2) Increases blood pressure in anaphylaxis
Beta 1 effects; 1) Increases Heart Rate2) Improves Force of Ventricular Contractions
Beta 2 effects produce bronchodilation
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ANAPHYLAXIS & ANAPHYLACTOID REACTIONS
Adminster Corticosteroids
Dexamethasone IV,
Methylprednisolone IV,
0.15-0.6 mg/kg IV/IM; not to exceed 20 mg
1-2 mg/kg/dose PO/IM to max 100mg IV bolus
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ANAPHYLAXIS & ANAPHYLACTOID REACTIONS
Complications
Inability to intubate, ventilate, or oxygenate
Cardiac Arrest
Hypertension, tachycardia from vasopressors