Management of Anaphylaxis
*Management of Anaphylaxis*
What we will do , we will discuss Anaphylaxis Management in general and then we will discuss a case specific variation afterwards.
*How to differentiate Anaphylaxis from general hypersensitivity reactions?*
*criterias -*
*Acute onset of an illness (minutes to hours), with involvement of the skin, mucosal tissues*
AND
*At least one of the following:*
*Respiratory compromise*
*Reduced blood pressure ( Hypotension)*
🌸NB - *Isolated Hypotension* after exposure of known allergen to that patient is *treated as Anaphylaxis* though no skin rashes and other allergic signs are absent.
When we say *Anaphylactic Shock - Hypotension is must* with other signs of Anaphylaxis.
*🌸Emergency Management🌸*
*1) Give Shock position -* It is the position of a person who is lying flat on their back with the legs elevated approximately 8-12 inches.
In case of pregnant lady left lateral position can be considered.
*2) Check Response -* If patient is collapsed tap on his shoulder and ask him a question - Are you alright?
*3) If Unresponsive - Immediately activate EMS system* Call 108 or any Cardiac Ambulance which has AED inside.
*4) Check for Carotid pulse and breathing* - If patient is pulse less and not breathing start with CPR
*🌸Don't forget ABC Management along with early administration of IM Epinephrine*
🌸Maintain Airway initially with OPA / NPA as per consciousness of patient.
🌸If Angioedema then early intubation is indicated.
🌸Start with high flow oxygen.
🌸If severe bronchial spasm start *Nebulisation with Salbutamol and Budecort.* You can *use Adrenalin also for Nebulisation* for upper Airway vasoconstriction and Laryngeal oedema.
*🌸Bag mask ventilation* if patient is not adequately breathing and maintaining oxygen saturation.
*🌸 Take IV access with large bore needle* and start fast fluid replacement if patient is in Hypotension and shock . Choice of fluid will be *Normal Saline ( NS 0.9% )*
🌸Give *1 to 2 litres of NS fast* through bilateral venous access immediately if patient is in shock . In children also give IV fluid in large doses ( 20 ml / kg or even higher doses )
*🌸 Early adminstration of IM Adrenalin is life saving in confirmed Anaphylaxis*
All patient who fulfill the criteria for anaphylaxis require the administration of epinephrine. Epinephrine is the only drug to show a mortality benefit in the management of anaphylaxis.
*✅Adrenalin ( Timing - Route - Location - Dose )*
*Timing-* Epinephrine should be administered *as soon as* the diagnosis of anaphylaxis is confirmed.
*Route -* Always initial first 2 doses through *intramuscular route*. Adrenalin ( 1:1000 )
As there is no adequate capillary refill during shock- subcutaneous route has no absorption or very poor delayed absorption.
While IV Adrenalin will cause arrhythmias and other untoward side effects.
*Location-* *Intramuscular administration of epinephrine in the anterolateral thigh* reaches the maximal epinephrine serum concentration approximately 7 times faster compared to the arm ( deltoid ). *So no deltoid*
*Dose -* correct dose of epinephrine for the treatment of anaphylaxis is 0.01mg/kg (to a max of 0.5mg) IM, repeated after 5 mins if there’s no clinical improvement.
So in adults give 1st dose of 0.5 ml IM - wait for 5 minutes look for any improvement in Hypotension or other signs of shock - if no improvement then give 2nd dose of 0.5 ml Adrenalin ( 1:1000 )
*Any patient weighing 50Kg or more should receive 0.5mg of epinephrine IM*
*🌸The most common cause of death in anaphylaxis is not giving epinephrine at the right time at the correct dose*
*🌸For quick adminstration Adrenalin epipen available in prefilled form with 0.3 mg Adrenalin*
🌸 If patient is not responding to 2 IM doses of Adrenalin and still remains in Hypotension and other signs are not relieved then give *IV 0.1 mg Adrenalin in 1:10,000 concentration.*
*IV Adrenalin-* slow push of 0.5 to 1 mL of 0.1 mg/mL (1:10,000) epinephrine solution ("cardiac" epinephrine ) available in 10 mL prefilled syringes, containing 1 mg of epinephrine, and stocked on resuscitation crash cart.
*🌸 2nd line treatment in Anaphylaxis*
🌸 Antihistamines ( H1 receptor blockers ) - Give Diphenhydramine ( Benadryl) - 25 - 50 mg IV
🌸 H2 receptor blocker like Ranitidine - 50 mg IV every 5 minutes.
*🌸Steroids ??? Are they really helpful?*
Remember that steroids take 4-6hrs to become effective, so (in contradistinction to epinephrine) there is no rush to administer them.
Generally in acute event in first 30 minutes Steroids are not helpful but in biphasic reaction or late manifestations Steroids will be helpful.
*Inj Hydrocort - 200 mg IV*
OR
*Inj Dexamethasone 8 mg IV* ( comparatively delayed onset but long acting)
The onset of action of glucocorticoids takes several hours. Therefore, these medications do not relieve the initial symptoms and signs of anaphylaxis.
*IV Vasopressin is indicated if patient remains in Hypotension despite Adrenalin adminstration*
*If patient is on Beta blockers then more severe Anaphylaxis will occur - in such cases additional Inj Glucagon - 1 to 5 mg IV slow bolus indicated*
To make it simple Emergency Management of Anaphylaxis will consist of -
✅Airway Management,
✅Oxygenation / Bag mask ventilation , Nebulisation
✅IV fluid Management with NS 1 to 2 lit
✅Early 2 doses of 0.5 mg Intramuscular Adrenalin
✅Antihistamines - ( H1 ) Diphenhydramine 50mg IV , ( H2 ) Ranitidine 50mg IV
✅Steroids- Inj Hydrocort 200 mg IV / Inj Dexamethasone 8 mg
What we will do , we will discuss Anaphylaxis Management in general and then we will discuss a case specific variation afterwards.
*How to differentiate Anaphylaxis from general hypersensitivity reactions?*
*criterias -*
*Acute onset of an illness (minutes to hours), with involvement of the skin, mucosal tissues*
AND
*At least one of the following:*
*Respiratory compromise*
*Reduced blood pressure ( Hypotension)*
🌸NB - *Isolated Hypotension* after exposure of known allergen to that patient is *treated as Anaphylaxis* though no skin rashes and other allergic signs are absent.
When we say *Anaphylactic Shock - Hypotension is must* with other signs of Anaphylaxis.
*🌸Emergency Management🌸*
*1) Give Shock position -* It is the position of a person who is lying flat on their back with the legs elevated approximately 8-12 inches.
In case of pregnant lady left lateral position can be considered.
*2) Check Response -* If patient is collapsed tap on his shoulder and ask him a question - Are you alright?
*3) If Unresponsive - Immediately activate EMS system* Call 108 or any Cardiac Ambulance which has AED inside.
*4) Check for Carotid pulse and breathing* - If patient is pulse less and not breathing start with CPR
*🌸Don't forget ABC Management along with early administration of IM Epinephrine*
🌸Maintain Airway initially with OPA / NPA as per consciousness of patient.
🌸If Angioedema then early intubation is indicated.
🌸Start with high flow oxygen.
🌸If severe bronchial spasm start *Nebulisation with Salbutamol and Budecort.* You can *use Adrenalin also for Nebulisation* for upper Airway vasoconstriction and Laryngeal oedema.
*🌸Bag mask ventilation* if patient is not adequately breathing and maintaining oxygen saturation.
*🌸 Take IV access with large bore needle* and start fast fluid replacement if patient is in Hypotension and shock . Choice of fluid will be *Normal Saline ( NS 0.9% )*
🌸Give *1 to 2 litres of NS fast* through bilateral venous access immediately if patient is in shock . In children also give IV fluid in large doses ( 20 ml / kg or even higher doses )
*🌸 Early adminstration of IM Adrenalin is life saving in confirmed Anaphylaxis*
All patient who fulfill the criteria for anaphylaxis require the administration of epinephrine. Epinephrine is the only drug to show a mortality benefit in the management of anaphylaxis.
*✅Adrenalin ( Timing - Route - Location - Dose )*
*Timing-* Epinephrine should be administered *as soon as* the diagnosis of anaphylaxis is confirmed.
*Route -* Always initial first 2 doses through *intramuscular route*. Adrenalin ( 1:1000 )
As there is no adequate capillary refill during shock- subcutaneous route has no absorption or very poor delayed absorption.
While IV Adrenalin will cause arrhythmias and other untoward side effects.
*Location-* *Intramuscular administration of epinephrine in the anterolateral thigh* reaches the maximal epinephrine serum concentration approximately 7 times faster compared to the arm ( deltoid ). *So no deltoid*
*Dose -* correct dose of epinephrine for the treatment of anaphylaxis is 0.01mg/kg (to a max of 0.5mg) IM, repeated after 5 mins if there’s no clinical improvement.
So in adults give 1st dose of 0.5 ml IM - wait for 5 minutes look for any improvement in Hypotension or other signs of shock - if no improvement then give 2nd dose of 0.5 ml Adrenalin ( 1:1000 )
*Any patient weighing 50Kg or more should receive 0.5mg of epinephrine IM*
*🌸The most common cause of death in anaphylaxis is not giving epinephrine at the right time at the correct dose*
*🌸For quick adminstration Adrenalin epipen available in prefilled form with 0.3 mg Adrenalin*
🌸 If patient is not responding to 2 IM doses of Adrenalin and still remains in Hypotension and other signs are not relieved then give *IV 0.1 mg Adrenalin in 1:10,000 concentration.*
*IV Adrenalin-* slow push of 0.5 to 1 mL of 0.1 mg/mL (1:10,000) epinephrine solution ("cardiac" epinephrine ) available in 10 mL prefilled syringes, containing 1 mg of epinephrine, and stocked on resuscitation crash cart.
*🌸 2nd line treatment in Anaphylaxis*
🌸 Antihistamines ( H1 receptor blockers ) - Give Diphenhydramine ( Benadryl) - 25 - 50 mg IV
🌸 H2 receptor blocker like Ranitidine - 50 mg IV every 5 minutes.
*🌸Steroids ??? Are they really helpful?*
Remember that steroids take 4-6hrs to become effective, so (in contradistinction to epinephrine) there is no rush to administer them.
Generally in acute event in first 30 minutes Steroids are not helpful but in biphasic reaction or late manifestations Steroids will be helpful.
*Inj Hydrocort - 200 mg IV*
OR
*Inj Dexamethasone 8 mg IV* ( comparatively delayed onset but long acting)
The onset of action of glucocorticoids takes several hours. Therefore, these medications do not relieve the initial symptoms and signs of anaphylaxis.
*IV Vasopressin is indicated if patient remains in Hypotension despite Adrenalin adminstration*
*If patient is on Beta blockers then more severe Anaphylaxis will occur - in such cases additional Inj Glucagon - 1 to 5 mg IV slow bolus indicated*
To make it simple Emergency Management of Anaphylaxis will consist of -
✅Airway Management,
✅Oxygenation / Bag mask ventilation , Nebulisation
✅IV fluid Management with NS 1 to 2 lit
✅Early 2 doses of 0.5 mg Intramuscular Adrenalin
✅Antihistamines - ( H1 ) Diphenhydramine 50mg IV , ( H2 ) Ranitidine 50mg IV
✅Steroids- Inj Hydrocort 200 mg IV / Inj Dexamethasone 8 mg
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