AnaphylaxisAnaphylaxis

Alex Pearce-SmithAlex Pearce-Smith

ScenarioScenario

• A patient who is well but has been A patient who is well but has been called in for a medication review has called in for a medication review has just sat down. Suddenly the practice just sat down. Suddenly the practice nurse bursts in and announces that a nurse bursts in and announces that a patient to whom she has just patient to whom she has just vaccinated seems to be having a vaccinated seems to be having a severe reaction.severe reaction.

In Groups/Pairs Think In Groups/Pairs Think About….About….

• What do you do initially?What do you do initially?

• What is your assessment?What is your assessment?

• What are the signs of anaphylaxis?What are the signs of anaphylaxis?

AssessmentAssessment

• Excuse yourself from patient – go straight to sick Excuse yourself from patient – go straight to sick patient and assess - ?help ABCDE.patient and assess - ?help ABCDE.

• Severe/Life threatening features in anaphylaxis.Severe/Life threatening features in anaphylaxis.– A Swelling, Hoarseness, Stridor.A Swelling, Hoarseness, Stridor.– B RR, Wheeze, Sats <92%.B RR, Wheeze, Sats <92%.– C Pale, clammy, Low BP.C Pale, clammy, Low BP.– D Confused/Drowsy/Coma.D Confused/Drowsy/Coma.

Recognising AnaphylaxisRecognising Anaphylaxis

• Anaphylaxis likely when ALL 3 criteria metAnaphylaxis likely when ALL 3 criteria met

1.1. Sudden onset and rapidly progressing Sudden onset and rapidly progressing symptoms.symptoms.

2.2. Life threatening Life threatening Airway/Breathing/Circulatory problems. Airway/Breathing/Circulatory problems.

3.3. Skin/Mucosal changes (angio-oedema, Skin/Mucosal changes (angio-oedema, flushing or urticaria)flushing or urticaria)

• PMH and circumstances may help (ie given PMH and circumstances may help (ie given vaccine).vaccine).

Skin ChangesSkin Changes

• Usually first feature but may be absent in upto Usually first feature but may be absent in upto 20% of cases.20% of cases.

• May be subtle or dramatic.May be subtle or dramatic.• May be just skin, just mucosal or both. May be just skin, just mucosal or both. • Maybe patchy or generalised erythematous rash.Maybe patchy or generalised erythematous rash.• May be urticaria – usually itchy.May be urticaria – usually itchy.• Angioedema is similar to urticaria but affects the Angioedema is similar to urticaria but affects the

deeper tissues – usually eyelids and lips but deeper tissues – usually eyelids and lips but sometimes mouth and throat. sometimes mouth and throat.

• Not an indicator of severity – most systemic skin Not an indicator of severity – most systemic skin reactions do not end up as anaphylaxis. reactions do not end up as anaphylaxis.

Skin PresentationsSkin Presentations

Differential DiagnosesDifferential Diagnoses

• Vasovagal attack.Vasovagal attack.

• Panic attack.Panic attack.

• Idiopathic urticaria.Idiopathic urticaria.

• Breath-holding episode in a child. Breath-holding episode in a child.

ManagementManagement

• ABC assessment indicates severe/life-ABC assessment indicates severe/life-threatening.threatening.– Lie flat, feet up*. Lie flat, feet up*. – Remove trigger (e.g. bee sting).Remove trigger (e.g. bee sting).– IM adrenaline 0.5mg adult (over 12) less for IM adrenaline 0.5mg adult (over 12) less for

children/babies. children/babies. – Oxygen. Oxygen. – Fluid Challenge (crystalloid).Fluid Challenge (crystalloid).– Chloramphenamine and hydrocortisone. Chloramphenamine and hydrocortisone. – Some should be calling 999.Some should be calling 999.

ManagementManagement

• Should go to hospital for further Should go to hospital for further management/observation – 6hrs management/observation – 6hrs minimum but most discharged by 24 hrs minimum but most discharged by 24 hrs if good response. if good response.

• Various indicators for longer observation. Various indicators for longer observation.

• Review by senior clinician before Review by senior clinician before discharge. discharge.

• Specialist follow up in allergy clinic. Specialist follow up in allergy clinic.

Common TriggersCommon Triggers

• Food (especially nuts)Food (especially nuts)

• Drugs Drugs – Antibiotics esp penicillin and Antibiotics esp penicillin and

cephalosporincephalosporin– Anaesthetic drugsAnaesthetic drugs– Other drugs esp NSAIDs. Other drugs esp NSAIDs.

• Venom – esp wasp stings. Venom – esp wasp stings.

MortalityMortality

• Less than 1% mortality.Less than 1% mortality.• About 20 deaths per year in UK recorded About 20 deaths per year in UK recorded

due to anaphylaxis but may be due to anaphylaxis but may be underestimate.underestimate.

• Asthmatics more at risk.Asthmatics more at risk.• Deaths happen quickly after contact with Deaths happen quickly after contact with

allergen.allergen.– Food 30 mins.Food 30 mins.– Venom 15 mins.Venom 15 mins.– IV medications 5 mins.IV medications 5 mins.

In conclusionIn conclusion

• If severe or life-threatening symptoms and If severe or life-threatening symptoms and clinical suspicion of anaphylaxis – give clinical suspicion of anaphylaxis – give adrenaline.adrenaline.

• Remember ABC – you may not get beyond Remember ABC – you may not get beyond A. A.

For More InformationFor More Information

• For details about the recommended For details about the recommended recognition and management of recognition and management of anaphylaxis including correct paediatric anaphylaxis including correct paediatric dosages etc go to Resuscitation Council dosages etc go to Resuscitation Council Website.Website.

• http://www.resus.org.uk/pages/http://www.resus.org.uk/pages/reaction.pdfreaction.pdf