gerard fennessy: anaphylaxis - the dying breaths
DESCRIPTION
Fennessy adds an unexpected high note to the topic of managing the anaphylactic patient.TRANSCRIPT
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