ThisThis is a Test is a Test

It is It is ONLYONLY a Test a Test

A 16 y/o girl just passed out after receiving her A 16 y/o girl just passed out after receiving her penicillin shot for strep throat (“doesn’t penicillin shot for strep throat (“doesn’t swallow pills”). Which of the following will be swallow pills”). Which of the following will be most useful to know in treating her:most useful to know in treating her:

AA Her Blood Pressure Her Blood Pressure

BB Her Glucose level Her Glucose level

CC Her Heart Rate Her Heart Rate

DD Your Heart Rate Your Heart Rate

Which of the following is the safest and Which of the following is the safest and most efficient route to administer most efficient route to administer epinephrine in an allergy emergency:epinephrine in an allergy emergency:

AA IV IV

BB Sub Q Sub Q

CC IM IM

DD PR PR

Which of the following potential Which of the following potential allergens do not generally cross-react:allergens do not generally cross-react:

A.A. COX-2 inhibitors & Ibuprofen COX-2 inhibitors & Ibuprofen

B.B. Filberts & Pecans Filberts & Pecans

C.C. Peanuts & Tofurky Peanuts & Tofurky

D.D. Lobster & Shrimp Lobster & Shrimp

A first year PEM fellow attending A first year PEM fellow attending conference developed a sudden onset conference developed a sudden onset of urticaria, lip swelling and DIB. The of urticaria, lip swelling and DIB. The etiology is most likely a reaction to:etiology is most likely a reaction to:

AA smelling someone else’s lunch smelling someone else’s lunch

BB a spider bite a spider bite

CC another “billing talk” by Dr Linzer another “billing talk” by Dr Linzer

When advising parents/patients on how When advising parents/patients on how to administer an “epi-pen” you should to administer an “epi-pen” you should tell them to:tell them to:

A.A. hold it against the triceps and squeeze the hold it against the triceps and squeeze the triggertrigger

B.B. “stab” it into the anterior thigh “stab” it into the anterior thigh

C.C. hold it against the lateral thigh and push hold it against the lateral thigh and push

Which is NOT a clinical presentation of Which is NOT a clinical presentation of anaphylaxis:anaphylaxis:

A.A. Vomiting and Diarrhea Vomiting and Diarrhea

B.B. Syncope Syncope

C.C. Altered Mental Status Altered Mental Status

D.D. Itchy Tongue Itchy Tongue

In counseling a 50kg 15 year old after a In counseling a 50kg 15 year old after a severe episode of anaphylaxis to a bee sting severe episode of anaphylaxis to a bee sting your best advice is that if they get stung your best advice is that if they get stung again they first should takeagain they first should take

A. (2) 25mg diphenhydramine capsules POA. (2) 25mg diphenhydramine capsules PO

B. (5) tsp diphenhydramine elixer POB. (5) tsp diphenhydramine elixer PO

C. .5mg epinephrine SQC. .5mg epinephrine SQ

D. 60mg prednisone POD. 60mg prednisone PO

Which of the following treatments has been Which of the following treatments has been shown to decrease the incidence of biphasic shown to decrease the incidence of biphasic reactions:reactions:

A. CorticosteroidsA. Corticosteroids

B. EpinephrineB. Epinephrine

C. DiphenhydramineC. Diphenhydramine

D. RanitidineD. Ranitidine

ANAPHYLAXISANAPHYLAXIS

Michael Greenwald, MDMichael Greenwald, MDPediatric Emergency Medicine

Emory UniversityChildren’s Healthcare of Atlanta @ Egleston

ObjectivesObjectives Recognize patients with, or at risk for, Recognize patients with, or at risk for,

anaphylactic reactionanaphylactic reaction Understand the immunologic basis for Understand the immunologic basis for

anaphylactic reactionsanaphylactic reactions Know the interventions appropriate for Know the interventions appropriate for

anaphylactic reactionsanaphylactic reactions Know the appropriate medical follow-up Know the appropriate medical follow-up

Historical BackgroundHistorical Background anaana- - backwardbackward phylaxisphylaxis- - protectionprotection Portier and Richet: Portier and Richet: reactions in dogs reactions in dogs

exposed to sea anenome toxinexposed to sea anenome toxin First documented case: First documented case: Egyptian pharoah Egyptian pharoah

2640 B.C. dies after wasp sting2640 B.C. dies after wasp sting

Defining AnaphylaxisDefining Anaphylaxis AcuteAcute SystemicSystemic Allergic Allergic (i.e. requires prior exposure)(i.e. requires prior exposure)

Special Features of AnaphylaxisSpecial Features of Anaphylaxis Spectrum of severitySpectrum of severity Variety of manifestations Variety of manifestations Uniphasic, biphasic or protractedUniphasic, biphasic or protracted

EpidemiologyEpidemiology► Top triggers: Top triggers: thenthen

penicillinpenicillin insect venominsect venom foodfood

►

► Top triggers: Top triggers: nownow Latex (27%)Latex (27%) Food (25%)Food (25%) Drugs (16%)Drugs (16%) Venoms (15%)Venoms (15%)

Anaphylaxis EpidemiologyAnaphylaxis Epidemiology

► 84,000 cases/year in US84,000 cases/year in US 1% fatal1% fatal Kids > adultsKids > adults

► Food Allergy Food Allergy under 4 y/o: 6-8%under 4 y/o: 6-8% After 10 y/o: 2%After 10 y/o: 2% 29,000 cases food induced anaphylaxis/year29,000 cases food induced anaphylaxis/year

► 2000 hospitalizations2000 hospitalizations► 150 deaths; high association with asthma, peanut/tree nut allergy150 deaths; high association with asthma, peanut/tree nut allergy

Peanuts are # 1 and increasing in Western nationsPeanuts are # 1 and increasing in Western nations

Hypersensitivity review: Gell and Hypersensitivity review: Gell and Coombs ClassificationCoombs Classification

Type IType I - Anaphylactic - Anaphylactic

Type IIType II - Cytotoxic - Cytotoxic

Type IIIType III - Immune Complex - Immune Complex

Type IVType IV - Delayed Type - Delayed Type

Type IType I - Anaphylactic - Anaphylactic►Immediate: Exposure to reaction < Exposure to reaction <

30minutes30minutes►Late Phase: Exposure to reaction: 2-12 Exposure to reaction: 2-12

hourshours Exposure to reaction:Exposure to reaction: <30minutes <30minutes Effector cell:Effector cell: IgE IgE Antigen:Antigen: pollens, foods, drugs, venoms pollens, foods, drugs, venoms Mediators:Mediators: histamine, leukotrienes histamine, leukotrienes Manifestations:Manifestations: anaphylaxis, allergic rhinitis, allergic asthma, anaphylaxis, allergic rhinitis, allergic asthma,

urticariaurticaria

Type IIType II - Cytotoxic - Cytotoxic

• Exposure to reaction:Exposure to reaction: variable (minutes variable (minutes to hours)to hours)

• Effector cell:Effector cell: IgG, IgMIgG, IgM

• Target:Target: Red blood cells, Lung tissueRed blood cells, Lung tissue

• Mediators:Mediators: ComplementComplement

• Examples:Examples: Immune hemolytic anemia, Rh Immune hemolytic anemia, Rh hemolytic disease, Goodpasture syndromehemolytic disease, Goodpasture syndrome

Type IIIType III - Immune Complexes - Immune Complexes

• Exposure to reaction:Exposure to reaction: 6 - 21 days6 - 21 days

• Effector cell:Effector cell: Antigen with AntibodyAntigen with Antibody

• Target:Target: Vascular endotheliumVascular endothelium

• Mediators:Mediators: Complement, AnaphylatoxinComplement, Anaphylatoxin

• Symptoms:Symptoms: fever, urticaria, arthralgia, fever, urticaria, arthralgia, arthritis, lymphadenopathyarthritis, lymphadenopathy

• Examples:Examples: Serum sickness, PSGNSerum sickness, PSGN

Type IVType IV - Delayed Type - Delayed Type• Exposure to reaction:Exposure to reaction: 24-48 hours24-48 hours

• Effector cell:Effector cell: LymphocytesLymphocytes

• Antigen:Antigen: Chemicals, Mycobacterium tuberculosisChemicals, Mycobacterium tuberculosis

• Mediators:Mediators: LymphokinesLymphokines

• Examples:Examples: Contact dermatitis, Tuberculin skin Contact dermatitis, Tuberculin skin reactionsreactions

Anaphylaxis and Her CousinAnaphylaxis and Her Cousin AnaphylaxisAnaphylaxis

IgE mediatedIgE mediated IgG - immune complex mediatedIgG - immune complex mediated

AnaphylactoidAnaphylactoid direct stimulation of mast cells and basophilsdirect stimulation of mast cells and basophils unknown mechanismunknown mechanism

IgE - mediated AnaphylaxisIgE - mediated Anaphylaxis►Prior exposure requiredPrior exposure required►Allergen-IgE binding induces release of Allergen-IgE binding induces release of

mediators:mediators: histaminehistamine prostaglandinsprostaglandins platelet activating factorplatelet activating factor tryptasetryptase

IgG -immune complex mediatedIgG -immune complex mediated► complement activated by immune complement activated by immune

complexes or other agents complexes or other agents Tissue antigens - RBC, WBC, PltsTissue antigens - RBC, WBC, Plts Serum proteins - Immunoglobulin, cryoprecipitinSerum proteins - Immunoglobulin, cryoprecipitin

► anaphylatoxins: C3a, C5aanaphylatoxins: C3a, C5a

Anaphylactoid : Anaphylactoid : Direct Direct stimulationstimulation

► direct stimulation of mast cells and direct stimulation of mast cells and basophilsbasophils

► unknown mechanismunknown mechanism - suspect high - suspect high osmolarityosmolarity

► examples:examples: radiocontrast media (not assoc radiocontrast media (not assoc w/ iodine, shellfish allergy), mannitol, w/ iodine, shellfish allergy), mannitol, opiates, curare, dextran, chemotherapeutic opiates, curare, dextran, chemotherapeutic agentsagents

Unexplained AnaphylaxisUnexplained Anaphylaxis► Unknown mechanism: Unknown mechanism:

ASA and other NSAIDSASA and other NSAIDS preservativespreservatives exerciseexercise mastocytosismastocytosis cholinergic urticaria with anaphylaxischolinergic urticaria with anaphylaxis progesterone: “catamenial anaphylaxis”progesterone: “catamenial anaphylaxis”

Unexplained AnaphylaxisUnexplained Anaphylaxis► Idiopathic anaphylaxis: unknown triggerIdiopathic anaphylaxis: unknown trigger

up to 37% of all reactionsup to 37% of all reactions clinically indistinguishable from other formsclinically indistinguishable from other forms particularly stressful to patientsparticularly stressful to patients

EpidemiologyEpidemiology► Patients at risk: Patients at risk:

Does atopic history matter?Does atopic history matter? Who gets the worst reactions?Who gets the worst reactions? Latex Latex

AllergensAllergens DrugsDrugs FoodsFoods VenomsVenoms LatexLatex

Defining Drug ReactionsDefining Drug Reactions► PredictablePredictable Drug ReactionsDrug Reactions

80% of all adverse effects80% of all adverse effects dose dependentdose dependent related to known pharmacological effectrelated to known pharmacological effect

► UnpredictableUnpredictable Drug reactions Drug reactions not dose dependentnot dose dependent occurs in susceptible individualsoccurs in susceptible individuals unrelated to known pharmacological effectunrelated to known pharmacological effect

DrugsDrugs► AntimicrobialsAntimicrobials

Penicillin: 2 potential groups of allergensPenicillin: 2 potential groups of allergens• Major determinant: Major determinant: Benzyl penicilloylBenzyl penicilloyl• Minor determinants: Minor determinants: penicillin, penicilloate, penicillin, penicilloate,

penilloate, penicilloylaminepenilloate, penicilloylamine

CephalosporinsCephalosporins SulfonamidesSulfonamides

DrugsDrugs► NSAIDS NSAIDS

bronchospasm in 2-10% of asthmaticsbronchospasm in 2-10% of asthmatics unknown mechanism: IgE and mast cells not unknown mechanism: IgE and mast cells not

involvedinvolved

DrugsDrugs► Macromolecules: Macromolecules:

protamineprotamine insulininsulin IVIGIVIG

►2 recognized mechanisms2 recognized mechanisms►IgA deficiency high riskIgA deficiency high risk►slow infusion and pretreatslow infusion and pretreat

DrugsDrugs Chemotherapeutic agents: L-AsparaginaseChemotherapeutic agents: L-Asparaginase Vaccinations: MMR?Vaccinations: MMR? ImmunotherapyImmunotherapy

17 fatalities reported 1985-1989 (10 million shots given 17 fatalities reported 1985-1989 (10 million shots given annually)annually)

precautions for medical facility:precautions for medical facility: observe 20 minuteobserve 20 minute medications and airway support availablemedications and airway support available

DrugsDrugs Radiocontrast mediaRadiocontrast media

mast cell degranulation from anaphlatoxins of mast cell degranulation from anaphlatoxins of complement cascadecomplement cascade

►older agents:older agents: Hypaque, Renigrafin Hypaque, Renigrafin►mild reaction in 5%, severe - 1/1000mild reaction in 5%, severe - 1/1000, death - , death -

1/10-40,000 exposures1/10-40,000 exposures

risk factors: risk factors: ►atopic/asthma history atopic/asthma history ►adultadult

FoodsFoods Tree nuts: Tree nuts: 1% Americans (3 million) allergic1% Americans (3 million) allergic Legumes: Legumes: 25-35% also allergic to tree nuts25-35% also allergic to tree nuts ShellfishShellfish FishFish Milk Milk EggsEggs Food additives: sulfitesFood additives: sulfites

Foods That May Contain Peanut Foods That May Contain Peanut OilOil

► Arachis oil (peanut oil)Arachis oil (peanut oil)► Baked Goods and mixesBaked Goods and mixes► Biscuits, cookies, pastriesBiscuits, cookies, pastries► CandyCandy► CerealsCereals► ChocolateChocolate► Emulsifiers, flavoringsEmulsifiers, flavorings► Ethnic foods: African, Ethnic foods: African,

Chinese, Mexican, Thai, Chinese, Mexican, Thai, VietnameseVietnamese

► Ice CreamIce Cream► MargarineMargarine► Milk formulaMilk formula► Satay Sauce (thai sauce)Satay Sauce (thai sauce)► Soft drinksSoft drinks► SoupsSoups► Sunflower seedsSunflower seeds► Vegetable fats and oilsVegetable fats and oils

Venoms/AntiveninsVenoms/Antivenins 5 major stinging insects in the US:5 major stinging insects in the US:

honeybeeshoneybees waspswasps yellow jacketsyellow jackets hornetshornets fire antsfire ants

Rabies and snake antiveninRabies and snake antivenin

LatexLatex

► incidence low, except for risk groups:incidence low, except for risk groups:► >1000 episodes and 15 deaths attributed>1000 episodes and 15 deaths attributed► surgical and dental procedures highest risksurgical and dental procedures highest risk► RAST testing availableRAST testing available

Exercise-inducedExercise-induced Variety of forms of exercise Variety of forms of exercise

not heat alonenot heat alone not associated with atopy/asthmanot associated with atopy/asthma strong genetic predispositionstrong genetic predisposition

histamine and parasympathetic tone, histamine and parasympathetic tone, sympathetic tonesympathetic tone

Exercise-inducedExercise-induced► 4 phases: 4 phases:

ProdromeProdrome: fatigue, warmth, pruritis & : fatigue, warmth, pruritis & erythemaerythema

EarlyEarly: urticaria, angioedema: urticaria, angioedema Fully establishedFully established: (30’- 4 hours) stridor, : (30’- 4 hours) stridor,

choking, N/V/D, syncope, hypotensionchoking, N/V/D, syncope, hypotension LateLate: fatigue, warmth, headache, lasts up to 72 : fatigue, warmth, headache, lasts up to 72

hourshours

Exercise-inducedExercise-induced► DiagnosisDiagnosis: may resemble asthma or : may resemble asthma or

cholinergic urticariacholinergic urticaria very unpredictable; some associated with foodsvery unpredictable; some associated with foods

► ManagementManagement:: recognize early signs and restrecognize early signs and rest avoid hot, humid weatheravoid hot, humid weather exercise with a partnerexercise with a partner

SymptomsSymptoms► Manifestations in the “shock organs”Manifestations in the “shock organs”

skin, respiratory tract, gastrointestinal tract, skin, respiratory tract, gastrointestinal tract, cardiovascular systemcardiovascular system

► Why there?Why there? rich in mast cellsrich in mast cells sensitive to effects of mast cell mediatorssensitive to effects of mast cell mediators exposure to high concentrations of antigenexposure to high concentrations of antigen

SkinSkin► Early signs:Early signs:

Flushing, feeling warmFlushing, feeling warm ErythemaErythema PruritisPruritis

► UrticariaUrticaria► AngioedemaAngioedema► PallorPallor

RespiratoryRespiratory► Upper airwayUpper airway

Nose & eyes: pruritis and watery discharge, Nose & eyes: pruritis and watery discharge, sneezingsneezing

Lips & tongue: swelling and pruritisLips & tongue: swelling and pruritis Larynx & epiglottis: edema with hoarseness, Larynx & epiglottis: edema with hoarseness,

dysphonia to asphyxiadysphonia to asphyxia

► Bronchi: bronchospasm with wheezing, Bronchi: bronchospasm with wheezing, decreased aeration, to apnea, asphyxiadecreased aeration, to apnea, asphyxia

GastrointestinalGastrointestinal►not only with food triggersnot only with food triggers

►crampy abdominal pain, nausea, vomiting, crampy abdominal pain, nausea, vomiting, watery diarrhea, gastointestinal bleeding, watery diarrhea, gastointestinal bleeding, fecal incontinencefecal incontinence

CardiovascularCardiovascular► Intravascular volume depletionIntravascular volume depletion► Direct effects on the heart:Direct effects on the heart:

arrythmiasarrythmias reduced contractility reduced contractility reduced coronary blood flowreduced coronary blood flow

► Early: dizziness and confusion dizziness and confusion ► May progress to: syncope, seizures, loss of syncope, seizures, loss of

consciousness shock, cardiac arrestconsciousness shock, cardiac arrest

Other symptoms of anaphylaxisOther symptoms of anaphylaxis► Neurologic: HA, Mental Status changes Neurologic: HA, Mental Status changes ► Uterine contractionUterine contraction► Urinary incontinenceUrinary incontinence► Anxiety, Feeling of “impending doom”Anxiety, Feeling of “impending doom”

Natural history of anaphylactic Natural history of anaphylactic reactionsreactions

► Onset of reaction after exposure: seconds Onset of reaction after exposure: seconds to several hours. Depends on to several hours. Depends on patient’s sensitivitypatient’s sensitivity dose of allergendose of allergen route of entryroute of entry

►Biphasic reactions Biphasic reactions (1 – 28 hrs)(1 – 28 hrs) 5-23% in adults; 6% in kids5-23% in adults; 6% in kids Food, venom, medication induced anaphylaxisFood, venom, medication induced anaphylaxis Second reaction may be worseSecond reaction may be worse

Making the correct diagnosisMaking the correct diagnosis

► May look just like:May look just like: Asthma exacerbationAsthma exacerbation Croup or foreign body aspirationCroup or foreign body aspiration Cardiogenic syncopeCardiogenic syncope food poisoning or gastroenteritisfood poisoning or gastroenteritis

Vasovagal vs. AnaphylaxisVasovagal vs. Anaphylaxis► VasovagalVasovagal

pallorpallor diaphoresisdiaphoresis bradycardia or NSRbradycardia or NSR

► AnaphylaxisAnaphylaxis tachycardiatachycardia flushingflushing urticaria/pruritis/ bronchospasmurticaria/pruritis/ bronchospasm

Differential DiagnosisDifferential Diagnosis► Related DiseasesRelated Diseases

Serum SicknessSerum Sickness Systemic MastosytosisSystemic Mastosytosis Urticaria PigmentosaUrticaria Pigmentosa

► Unique presentationsUnique presentations MI, PE, CVA, Seizure, asphyxia, hypoglycemiaMI, PE, CVA, Seizure, asphyxia, hypoglycemia

Making the correct diagnosisMaking the correct diagnosis► Detailed history as close to the event as Detailed history as close to the event as

possiblepossible All foods in prior 6-12 hoursAll foods in prior 6-12 hours Consider all ingredientsConsider all ingredients Look for likely suspects: e.g. legumesLook for likely suspects: e.g. legumes Write it and keep itWrite it and keep it

►Prick skin tests: Best Screening testPrick skin tests: Best Screening test high false positives; very low false negativeshigh false positives; very low false negatives may require food challengemay require food challenge

Less common lab testsLess common lab tests

► histamine vs. tryptase levelhistamine vs. tryptase level transienttransient Tryptase NOT elevated in food-induced anaphylaxisTryptase NOT elevated in food-induced anaphylaxis

► RAST: RAST: measures specific IgE, less sensitive than skin prick Useful in pt.s who can’t d/c antihistamines or w/skin

condition

► Coombs test - Type IICoombs test - Type II► complement levels - Type IIIcomplement levels - Type III► patch testing - Type IVpatch testing - Type IV

TreatmentTreatment Prevention, education and observationPrevention, education and observation Early interventionEarly intervention MedicationsMedications Managing a difficult airwayManaging a difficult airway

Early intervention: epinephrineEarly intervention: epinephrine► Injection Kits:Injection Kits: Epipen, Ana-kit, Anaguard Epipen, Ana-kit, Anaguard►When to give?When to give?►How to administer?How to administer?

location: SC vs IM, site of stingerlocation: SC vs IM, site of stinger dosingdosing Inhaled epinephrineInhaled epinephrine

►Precautions:Precautions: Beta-blockers and TricyclicsBeta-blockers and Tricyclics

Medical adjunctsMedical adjuncts

► AntihistaminesAntihistamines Use in all casesUse in all cases H1 blockers: route and typeH1 blockers: route and type H2 blockersH2 blockers

► SteroidsSteroids Use in all significant casesUse in all significant cases PO (liquid), IM or IV: 2mg/kg (max 60 mg?)PO (liquid), IM or IV: 2mg/kg (max 60 mg?) Prevents delayed reactionsPrevents delayed reactions

► Bronchodilators & aminophyllineBronchodilators & aminophylline

Supportive treatment and airway Supportive treatment and airway issuesissues

► Hypotension may not respond to epinephrineHypotension may not respond to epinephrine► Aggressive use of IVF + Trendelenberg, Aggressive use of IVF + Trendelenberg,

vasopressors if necessaryvasopressors if necessary► MAST trousers, glucagon and naloxone also MAST trousers, glucagon and naloxone also

reported helpfulreported helpful► Laryngeal edema and angioedema of the face Laryngeal edema and angioedema of the face

pose critical airway challengespose critical airway challenges

PreventionPrevention Food allergies:Food allergies:

Avoid entire food group if sensitive to one member Avoid entire food group if sensitive to one member (unless proven safe)(unless proven safe)

Canned fish (heated) may be tolerated if tested Canned fish (heated) may be tolerated if tested under controlled settingunder controlled setting

Beware baked goodsBeware baked goods Learn ingredients, pseudonyms and synonymsLearn ingredients, pseudonyms and synonyms

Drug allergies:Drug allergies: desensitization: a temporary measuredesensitization: a temporary measure premedicate and observe closelypremedicate and observe closely

Prevention, education and Prevention, education and observationobservation

Venom allergies:Venom allergies: Don’t entice the insects: sights and smellsDon’t entice the insects: sights and smells Who gets venom immunotherapy?Who gets venom immunotherapy?

Educate Educate allall caretakers caretakers 4 hour observation/ hospital observation if 4 hour observation/ hospital observation if

not resolving rapidlynot resolving rapidly

Which of the following is the Which of the following is the safestsafest and and most most efficientefficient route to administer epinephrine in route to administer epinephrine in an allergy emergency:an allergy emergency:

AA IV IV

BB Sub Q Sub Q

CC IM IM

D D PR PR

Syncope after shotSyncope after shot

A 16 y/o girl just passed out after receiving her A 16 y/o girl just passed out after receiving her penicillin shot for strep throat (“doesn’t swallow penicillin shot for strep throat (“doesn’t swallow pills”). Which of the following will be most useful to pills”). Which of the following will be most useful to know in treating her:know in treating her:

AA Her Blood Pressure Her Blood Pressure

BB Her Glucose level Her Glucose level

CC Her Heart Rate Her Heart Rate

DD Your Heart Rate Your Heart Rate

A first year PEM fellow attending conference A first year PEM fellow attending conference developed a sudden onset of urticaria, lip developed a sudden onset of urticaria, lip swelling and DIB. The etiology is most swelling and DIB. The etiology is most likely a reaction to:likely a reaction to:

A A smelling someone else’s lunch smelling someone else’s lunch

B B a spider bitea spider bite

C C another “billing talk” by Dr Linzer another “billing talk” by Dr Linzer

Allergen FamiliesAllergen Families

Which of the following potential allergens do Which of the following potential allergens do not generally cross-react:not generally cross-react:

A.A. COX-2 inhibitors & Ibuprofen COX-2 inhibitors & Ibuprofen

B.B. Filberts & Pecans Filberts & Pecans

C.C. Peanuts & Tofurky Peanuts & Tofurky

D.D. Lobster & Shrimp Lobster & Shrimp

Using the “Epi-Pen”Using the “Epi-Pen”

When advising parents/patients on how to When advising parents/patients on how to administer an “epipen” you should tell them administer an “epipen” you should tell them to:to:

A.A. hold it against the triceps and squeeze the hold it against the triceps and squeeze the triggertrigger

B.B. “stab” it into the anterior thigh “stab” it into the anterior thigh

C.C. hold it against the lateral thigh and push hold it against the lateral thigh and push

Presentations of AnaphylaxisPresentations of Anaphylaxis

Which is NOT a clinical presentation of Which is NOT a clinical presentation of anaphylaxis:anaphylaxis:

A.A. Vomiting and Diarrhea Vomiting and Diarrhea

B.B. Syncope Syncope

C.C. Altered Mental Status Altered Mental Status

D.D. Itchy Tongue Itchy Tongue

E.E. None of the above None of the above

First line therapyFirst line therapy

In counseling a 50kg 15 year old after a severe In counseling a 50kg 15 year old after a severe episode of anaphylaxis to a bee sting your best episode of anaphylaxis to a bee sting your best advice is that if they get stung again they first advice is that if they get stung again they first should takeshould take

A.A. (2) 25mg diphenhydramine capsules PO (2) 25mg diphenhydramine capsules PO

B.B. (5) tsp diphenhydramine elixer PO (5) tsp diphenhydramine elixer PO

C.C. .5mg epinephrine SQ .5mg epinephrine SQ

D.D. 60mg prednisone PO 60mg prednisone PO

Which of the following treatments has been Which of the following treatments has been shown to decrease the incidence of biphasic shown to decrease the incidence of biphasic reactions:reactions:

A. CorticosteroidsA. Corticosteroids

B. EpinephrineB. Epinephrine

C. DiphenhydramineC. Diphenhydramine

D. RanitidineD. Ranitidine

Summary:Summary: Various mechanisms and presentationsVarious mechanisms and presentations

May resemble common illnessesMay resemble common illnesses

Early recognition and treatmentEarly recognition and treatment

Prevention is critical Prevention is critical