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ANAPHYLAXIS: EPINEPHRINE & ALBUTEROL

ANAPHYLAXIS

Table B.9 RESPIRATORY AND ALLERGIC REACTION MEDICATIONS

7/1/17 1/1/18 & 1/14/19

ANAPHYLAXISDefinition

• Severe allergic reaction to any stimulus• Foods• Drugs• Envenomations• Exercise• Cold• Heat• Idiopathic

ANAPHYLAXISDefinition

• Sudden in onset and may progress to life-threatening severity over minutes to hours.

ANAPHYLAXISMulti-system Signs and Symptoms

P. Lieberman et al. Anaphylaxis – Practice Parameter Update 2015. Ann Allergy Asthma Immunol 115 (2015) 341e384

ANAPHYLAXISMulti-system Signs and Symptoms

P. Lieberman et al. Anaphylaxis – Practice Parameter Update 2015. Ann Allergy Asthma Immunol 115 (2015) 341e384

RFFE.ORG

ANAPHYLAXIS: DiagnosisNIAID/FAAN Criteria

Manivannan V., Decker W.W., Stead L.G., et al: National Institute of Allergy and Infectious Disease and Food Allergy and Anaphylaxis Network criteria for anaphylaxis. Int J Emerg Med 2009; 2: pp. 3-5

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ANAPHYLAXIS: DiagnosisNIAID/FAAN Criteria

Manivannan V., Decker W.W., Stead L.G., et al: National Institute of Allergy and Infectious Disease and Food Allergy and Anaphylaxis Network criteria for anaphylaxis. Int J Emerg Med 2009; 2: pp. 3-5

• 97% Sensitive, 82% Specific• 98% NPV, 69% PPV

• Useful but cannot replace clinical judgement• Variable presentation and progression

Campbell R.L., Hagan J.B., Manivannan V., et al: Evaluation of National Institute of Allergy and Infection Disease/Food Allergy & Anaphylaxis Network criteria for the diagnosis of anaphylaxis in emergency department patients. J Allergy Clin Immunol 2012; 129: pp. 748-752

RFFE.ORG

ANAPHYLAXIS: Diagnosis

Campbell R, Li J, Nicklas R, et al. Emergency Department diagnosis and treatment of anaphylaxis: a practice parameter. Annals of Allergy, Asthma & Immunology, 2014-12-01, Volume 113, Issue 6, Pages 599-608

NIAID/FAAN Criteria good at finding anaphylaxis but not perfect : 97% sensitive

• Hypotension• May present with hypotension alone• Frequently presents without

hypotension

• Cutaneous manifestations• Usually present• Absence does not exclude anaphylaxis

RFFE.ORG

ANAPHYLAXIS: Diagnosis

Campbell R, Li J, Nicklas R, et al. Emergency Department diagnosis and treatment of anaphylaxis: a practice parameter. Annals of Allergy, Asthma & Immunology, 2014-12-01, Volume 113, Issue 6, Pages 599-608

RFFE.ORG

ANAPHYLAXIS: Diagnosis

Campbell R, Li J, Nicklas R, et al. Emergency Department diagnosis and treatment of anaphylaxis: a practice parameter. Annals of Allergy, Asthma & Immunology, 2014-12-01, Volume 113, Issue 6, Pages 599-608

RFFE.ORG

ANAPHYLAXIS: Diagnosis

Campbell R, Li J, Nicklas R, et al. Emergency Department diagnosis and treatment of anaphylaxis: a practice parameter. Annals of Allergy, Asthma & Immunology, 2014-12-01, Volume 113, Issue 6, Pages 599-608

NIAID/FAAN not great at differentiating anaphylaxis from other causes: 69% PPV

• Hypotension• Cardiogenic shock• Distributive shock• Obstructive shock• Hypovolemic shock

• Pre-syncope or syncope• Vasovagal• Cardiogenic

• Angioedema• Hereditary angioedema or ACE

inhibitor angioedema• Stridor:

• Vocal cord dysfunction

• Respiratory distress• Asthma• PE• CHF

• Isolated skin reaction• Adverse drug reactions

• Mast cell disorders• Cutaneous flushing

• Metastatic carcinoma• VIP-producing tumor

• Psychiatric disorders• Panic attacks

RFFE.ORG

ANAPHYLAXIS: Diagnosis

Campbell R, Li J, Nicklas R, et al. Emergency Department diagnosis and treatment of anaphylaxis: a practice parameter. Annals of Allergy, Asthma & Immunology, 2014-12-01, Volume 113, Issue 6, Pages 599-608

• Risk factors for fatal anaphylaxis• Asthma• History of severe anaphylaxis

• Adolescents or young adults• Tree or peanut allergy

• History of biphasic reaction• Cardiovascular disease• Beta-blocker medications• Delayed administration of epinephrine• Advanced age

RFFE.ORG

ANAPHYLAXIS: EMT Management

• Rapid assessment of airway, breathing and circulation• Angioedema of face, lips, tongue• Stridor• Hoarseness• Difficulty speaking• Respiratory distress• Weak or absent pulse• Hypotension• Altered mental status

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ANAPHYLAXIS: EMT Management

A, B, Cs:• AIRWAY & BREATHING

• Hypoxia• Asphyxia with upper airway angioedema• Bronchospasm

• CIRCULATION• Hypotension• Cardiac arrest• Arrhythmias with treatment may occur

RFFE.ORG

ANAPHYLAXIS: EMT A-B-C Management

• AIRWAY & BREATHING (Hypoxia / Apnea):• Supplemental oxygen for all anaphylaxis

• Do not wait for hypoxia or respiratory distress • Continuously monitor closely to watch for

deterioration• Oral/nasal airways, SGA, BVM

RFFE.ORG

ANAPHYLAXIS: EMT A-B-C Management

• CIRCULATION (Hypotension / Cardiac Arrest):• Prevent or counteract circulatory collapse by treating

patient in supine position • Not if worsens respiratory distress• Place pregnant patients on their left side

• IV/IO access if permitted (EMT-I)• Standard CPR/BLS• Avoid compression-only CPR

RFFE.ORG

ANAPHYLAXIS: EMT Management

• Epinephrine 1:1000 anterolateral thigh immediately after the diagnosis of ongoing anaphylaxis is made!

• 0.3-0.5 mg IM adults• 0.01 mg/kg (max 0.3 mg) IM peds

• Epinephrine is first, second and third line treatment of anaphylaxis!

RFFE.ORG

EPINEPHRINE 1:1000

• Vasoconstriction• Cardiac chronotropic and inotropic effects• Bronchodilatation• Suppression histamine and other mediator release

from mast cells and basophils

• Effects:• Increased cardiac output• Increased peripheral vascular resistance• Decreased mucosal edema• Decreased airway resistance.

Simons F.E.: First aid treatment of anaphylaxis to food: focus on epinephrine. J Allergy Clin Immunol 2004; 113: pp. 837-844

RFFE.ORG

EPINEPHRINE 1:1000

• Epinephrine is first, second and third line treatment of anaphylaxis!

• Epinephrine 1:1000 anterolateral thigh immediately after the diagnosis of ongoing anaphylaxis is made!

• 0.3-0.5 mg IM adults• 0.01 mg/kg (max 0.3 mg) IM peds

• 0.3 mg = 0.3 cc of 1:1000• 0.5 mg = 0.5 cc of 1:1000

• Repeat every 5-15 minutes x 3• Draw up multiple doses

RFFE.ORG

INTRAMUSCULAR (IM) EPINEPHRINE 1:1000Anterolateral Thigh (Preferred Site)Highest and most rapid peak plasma concentration

Lateral Shoulder (Alternate Site)No subcutaneous administration!

Simons F.E., Roberts J.R., Gu X., and Simons K.J.: Epinephrine absorption in children with a history of anaphylaxis. J Allergy Clin Immunol 1998; 101: pp. 33-37. Simons F.E., Gu X., and Simons K.J.: Epinephrine absorption in adults: intramuscular subcutaneous injection. J Allergy Clin Immunol 2001; 108: pp. 871-876

RFFE.ORG

ANAPHYLAXIS: Fatal

Liew W.K., Williamson E., and Tang M.L.: Anaphylaxis fatalities and admissions in Australia. J Allergy Clin Immunol 2009; 123: pp. 434-442

Greenberger P., Rotskoff B.D., and Lifschvitz B.: Fatal anaphylaxis: post-mortem findings and associated comorbid diseases. Ann Allergy Asthma Immunol 2007; 98: pp. 252-257 Immunol 2009; 123: pp. 434-442

RFFE.ORG

ANAPHYLAXIS: Fatal

Median Time to Cardiopulmonary Arrest in Fatal Anaphylaxis

Allergy Type Minutes to Cardiopulmonary Arrest

Food 30

Hymenoptera venom 15

In-Hospital Medication 5 Humphrey R.S.: Lessons for management of anaphylaxis from a study of fatal reactions. Clin Exp Allergy 2000; 30: pp. 1144-1150.Humphrey R.S.: Fatal anaphylaxis in the UK: 1992–2001. Novartis Found Symp 2004; 257: pp. 116-128

• Delayed administration of epinephrine is associated with poor outcomes and increased mortalityManivannan V., Decker W.W., Stead L.G., et al: National Institute of Allergy and Infectious Disease and Food Allergy and Anaphylaxis Network criteria for anaphylaxis. Int J Emerg Med 2009; 2: pp. 3-5

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ANAPHYLAXIS: EMT Management

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ALBUTEROL

• Bronchospasm may persist despite treatment with epinephrine

• β-adrenergic agonists, such as albuterol, should be readily available for bronchospasm that has not responded to epinephrine

• Albuterol • Metered-dose inhaler (2–6 inhalations) [VO]• Nebulizer (2.5–5 mg in 3 mL of saline and

repeated as necessary)

ANAPHYLAXIS

Table B.9 RESPIRATORY AND ALLERGIC REACTION MEDICATIONS

7/1/17 1/1/18 & 1/14/19

RFFE.ORG

ANAPHYLAXIS: EMT Management

EMT actions

Emergent transport to hospital

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ANAPHYLAXIS: EMT Management

Case Presentation:

• 15 year old male with history of near-fatal anaphylaxis to peanuts who inadvertently ingested one peanut 5 minutes prior to your arrival.

• Parents called EMS because developed urticaria and generalized flushing within 1 minute of eating peanut. Forget their Epi-Pen at home.

• Patient has no difficulty breathing, no wheezing, blood pressure and pulse are normal but he is anxious

RFFE.ORG

ANAPHYLAXIS: EMT Management

Manivannan V., Decker W.W., Stead L.G., et al: National Institute of Allergy and Infectious Disease and Food Allergy and Anaphylaxis Network criteria for anaphylaxis. Int J Emerg Med 2009; 2: pp. 3-5

• Patients with anaphylaxis can present with symptoms not meeting the criteria for anaphylaxis and yet require epinephrine treatment.

• Do not rely on signs of shock for the diagnosis of anaphylaxis.

• Delayed administration of epinephrine is associated with poor outcomes and increased mortality.

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ANAPHYLAXIS: DiagnosisKey Points

• Broad spectrum of anaphylaxis presentations that require clinical judgment.

• May progress rapidly from mild manifestations involving 1 organ system to severe involvement of multiple organ systems. Give oxygen and closely monitor A-B-Cs!

• Timely administration of epinephrine (0.3-0.5 mg IM every 3-5 minutes) is first, second and third-line treatment of anaphylaxis.

• No absolute contraindications to administration of epinephrine in the setting of anaphylaxis.

• Inhaled beta-agonists may be used for bronchospasm not responding to epinephrine.

• H1/H2 antihistamines and corticosteroids may be useful theoretic adjuncts, but have slow onsets of action and should never delay administration of epinephrine

• Treat in supine position, establish 2 large bore IVs or IO to administer large volumes crystalloid for patients with circulatory collapse.

Campbell RL, Li JT, Nicklas RA, et al: Members of the Joint Task Force; Practice Parameter Workgroup. Ann Allergy Asthma Immunol. Emergency department diagnosis and treatment of anaphylaxis: a practice parameter. 2014 Dec;113(6):599-608. doi: 10.1016/j.anai.2014.10.007.