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Fennessy adds an unexpected high note to the topic of managing the anaphylactic patient.
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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
Recommended