TREATMENT OF SEVERE ANAPHYLACTIC REACTIONS

MANAGEMENT OF ACUTE ANAPHYLAXIS : 

MANAGEMENT OF ACUTE ANAPHYLAXIS Dr LH MabuzaBTh (UNISA), MBChB, M Fam Med (MEDUNSA), FCFP (SA)Family Medicine & Primary Health Care (UL)

Severe Anaphylactic Reactions : 

Severe Anaphylactic Reactions Manifestation Respiratory difficulty Signs of shock/hypotension Involvement of skin/mucosal tissue GI symptoms

Manifestations of severe anaphylaxis : 

Manifestations of severe anaphylaxis Respiratory Difficulty Progressive stridor, wheezing, dyspnoea Reduced PEF Hypoxaemia

Manifestations of severe anaphylaxis : 

Manifestations of severe anaphylaxis Signs of shock/Hypotension Lightheadedness, hypotonia, syncope Systolic BP < 90mmHg, or > 30% decrease from patient’s baseline Incontinence

Manifestations of severe anaphylaxis : 

Manifestations of severe anaphylaxis Involvement of skin/mucosal tissue Generalised hives, pruritis Pale or flushed Swollen face, lips, tongue, uvula Rhinitis

Manifestations of severe anaphylaxis : 

Manifestations of severe anaphylaxis GI symptoms Crampy abdominal pains Nausea, vomiting, diarrhoea

Manifestations of severe anaphylaxis : 

Manifestations of severe anaphylaxis Note: Reactions may be slow, progressive, or rapidly fatal within minutes. Manifestations may be delayed, or persist > 24hrs May recur (biphasic) up to 36hrs after initial onset Generally, the shorter the interval between exposure and reaction, the more severe the reaction

Management of Anaphylaxis : 

Management of Anaphylaxis It consist of the following measures: 1. Remove or stop the precipitating agent 2. Administer drugs Oxygen Adrenalin Establish Rapid IV access (crystalloid fluids) Glucagon Antihistamin Corticosteroids Inhaled beta-agonists H2 Receptor blocker 3. Admission for observation 4. Preventing recurrence

Management of Anaphylaxis : 

Management of Anaphylaxis Oxygen (if available) Must be given as soon as possible Maintain airway patency Give high flow oxygen Use a rebreather mask Position patient in a semi-Fowler’s position (unless hypotensive) to assist breathing Pulse oxymetry if available, and monitor vital signs continuously If progressive airway obstruction, intubate or consider cricothyrotomy

Management of Anaphylaxis : 

Management of Anaphylaxis Adrenalin (1mg/ml 1:1000) Should be given imi, never subcut > 12 yrs: 0.5ml 6-12 yrs: 0.3ml 2-5 yrs: 0.2ml < 2 yrs: 0.1ml Repeat every 5-15minutes if no improvement

Management of Anaphylaxis : 

Management of Anaphylaxis Caution on adrenalin: IVI adrenalin is potentially hazardous in anaphylaxis, should only be considered if life-threatening hypotension persists despite imi adrenalin and aggressive fluid resuscitation. Dilute 1mg adrenalin in 200ml normal saline, and slowly infuse at 1ml/minute (5microgram/min) with continuous ECG monitoring

Management of Anaphylaxis : 

Management of Anaphylaxis Crystalloids These should be given if hypotensive or unresponsive to adrenalin Establish rapid IV access Rapidly infuse 1-4 litres of crystalloid (Ringer Lactate or Normal Saline) 20ml/kg for children Repeat IV infusion prn, as large amounts may be required

Management of Anaphylaxis : 

Management of Anaphylaxis Glucagon Adult: 1-2mg IM or slowly IV every 5min if not responsive to adrenalin, and especially if on beta-blockers Child: 20microgram/kg (maximum 1mg) Watch out for nausea, vomiting and hyperglycaemia

Management of Anaphylaxis : 

Management of Anaphylaxis Antihistamin Promethazine should be given IM or slowly IV > 12 yrs: 25mg 6-12 yrs: 12.5mg 2-5 yrs: 6.25mg

Management of Anaphylaxis : 

Management of Anaphylaxis Corticosteroids Hydrocortisone (IM or slowly IV) For prevention or shortening protracted reactions > 12yrs: 200mg 6-12 yrs: 100mg 2-5 yrs: 50mg

Management of Anaphylaxis : 

Management of Anaphylaxis Inhaled beta-agonists Nebulised salbutamol 5mg, and ipratropium 0.5mg To be given every 15 min if bronchospasm is a measure feature or no response to given drugs, Especially if the patient is on beta-blockers

Management of Anaphylaxis : 

Management of Anaphylaxis H2 receptor blockers Ranitidine Adult: 50mg IM or slowly IV (diluted in 20ml over 2min) Child: 1mg/kg (max. 50mg) OR Cimetidine Adult: 300mg IM or slowly IV (diluted in 20ml over 2min) Child: 5mg/kg (max. 300mg)

Management of Anaphylaxis : 

Management of Anaphylaxis Admit for observation 8-24hrs Recurrence may occur

Management of Anaphylaxis : 

Management of Anaphylaxis Prevention of recurrence Identify the causative agent Arrange for a “Medic Alert” bracelet Educate patient and family on the use of self-injectable adrenalin device (EpiPen). The EpiPen kit is a must for every patient who has had a severe reaction before. It should on their person at all times!