1. Im all Itchy Anaphylaxis in the Pediatric ER Dr. Rebecca
Starr Pediatric Emergency Medicine Fellow February 6, 2014
certifiedallergysa.com
2. Objectives Discuss the most current definition of
anaphylaxis Explain the causes and pathophysiology of anaphylaxis
Analyze symptoms and be able to diagnose and effectively treat
anaphylaxis Review biphasic anaphylactic reactions List appropriate
discharge materials from the ED
3. Question 1 A 5 year old M who has experienced a severe
allergic reaction to shrimp in the past needs a CT scan with IV and
oral contrast. What precautions should you take? A. NS bolus and
diphenhydramine B. NS bolus, diphenhydramine, and prednisone C.
This patient can not receive contrast D. Reassurance, there is no
associated risk for a reaction between shellfish and contrast
4. Question 2 You have been asked by a local school to provide
recommendations about the use of self injectable epinephrine for
anaphylaxis. What is the BEST response to give regarding
anaphylaxis? A. A patient should not receive a second dose of
epinephrine unless a physician is present B. Epinephrine reaches
higher peak plasma concentrations when injected into the thigh
rather than the arm C. Families should keep one epinephrine auto
injector in the car in case a reaction occurs after school D.
Subcutaneous injection of epinephrine is preferable to
intramuscular injection
5. Question 3 A 14 y/o M who has seasonal allergies and
moderate persistent asthma is currently receiving allergen
immunotherapy. Today in clinic he received his usual allergen
injection, but after 10 minutes, he started coughing and
complaining of dyspnea and throat swelling. On physical exam he
exhibits moderate respiratory distress and has diffuse expiratory
wheezing on auscultation. No oropharyngeal edema noted. Vitals
signs include a pulse ox of 97%, BP of 130/70, and HR of 90. Of the
following, the MOST appropriate next action is to administer: A. A
short acting beta-2 agonist nebulization B. An oral antihistamine
C. An oral corticosteroid D. Intramuscular epinephrine
6. Question 4 A 10 y/o M with a history of peanut allergy
presents with diffuse itching and trouble breathing after eating a
friends candy bar that contained nuts during school lunch. At the
nurses office the patient received IM epinephrine with his EpiPen
with symptom resolution. EMS was called and the patient was brought
to the local pediatric ED (about a 12 minute ride). On arrival to
the ED, the patient is again complaining of itching with an
urticarial rash on his chest and per EMS the patient began vomiting
as they were pulling up to the ambulance bay. Arrival vitals
include a pulse ox of 96%, BP of 88/67, and HR of 95. Of the
following, the MOST appropriate treatment plan is: A. Intramuscular
epinephrine, oral antihistamine, oral corticosteroid, and a short
acting beta-2 agonist neb treatment B. Intramuscular epinephrine,
IV antihistamine, IV corticosteroid, NS bolus C. Intramuscular
epinephrine, IV antihistamine, IV Zantac, NS bolus D. Intramuscular
epinephrine, oral antihistamine, and oral corticosteroid
7. What is Anaphylaxis? Big Bang
8. Anaphylaxis 411 Severe allergic reaction that can be life
threatening IgE-mediated hypersensitivity reaction resulting in the
release of potent chemical mediators Mast Cells Basophils Affects
multiple organ systems Respiratory Cardiovascular Gastrointestinal
Dermatologic Clinical Diagnosis Biphasic Reactions Russell et
al.,Pediatric Emergency Care, 2010
9. Clinical Definition
10. History First death from anaphylaxis was documented in
Egyptian hieroglyphics in 2641 BC Pharaoh Menes dying after a
hornet sting Questionable and now not supported by historians
11. History First described in scientific literature in 1902 by
two French physiologists, Charles Richet and Paul Portier Prince
Albert I of Monaco Investigating jellyfish toxins Initially coined
aphylaxis with a meaning contrary to and phylaxis meaning
protection Richet won the Nobel Prize in Medicine Lane et al,
Pediatric Emergency Care, 2007
12. Pediatric Epidemiology 10.5 per 100,000 Increasing over the
past 4 decades 2:1 Male to female ratio 25% require admission 1500
deaths per year in US (adults and children) 40% had prior history
of allergic reaction Only 20% of prior anaphylaxis patients had an
Epipen available during repeat anaphylaxis encounter Lane et al,
Pediatric Emergency Care, 2007 Russell et al.,Pediatric Emergency
Care, 2010
13. Pediatric Epidemiology Severity of a previous reaction does
not predict the severity of a subsequent reaction Previous
anaphylactic reactions = higher risk for reoccurrence Lane et al,
Pediatric Emergency Care, 2007
14. Causes of Anaphylaxis
15. Causes of Anaphylaxis Food Leading cause of all anaphylaxis
in children 50% of anaphylactic triggers Peanuts, tree nuts and
shellfish are the most common Usually the most life-threatening
reactions Older children Milk, soy, eggs Most common in younger
children Potential to outgrow Food dyes Lane et al, Pediatric
Emergency Care, 2007 Russell et al.,Pediatric Emergency Care,
2010
16. Causes of Anaphylaxis Medications 24% of anaphylactic
triggers Antibiotics most common- PCN and cross reaction drugs to
PCN Penicillin-allergic individuals have a 4-10% risk of allergic
reaction to a cephalosporin Only antibiotic that can have skin
testing (for IgE mediated rxn) NSAIDs Latex- chronic patients and
multiple surgeries IV contrast Propofol- sedative medication that
contains eggs and soy Blood products, IVIG, etc Lane et al,
Pediatric Emergency Care, 2007
17. Causes of Anaphylaxis Hymenoptera envenomation 12% of
anaphylactic triggers Honeybees, yellow jackets, hornets, wasps,
and fire ants Life threatening reactions require venom
immunotherapy 20-60% risk per sting of anaphylaxis Lane et al,
Pediatric Emergency Care, 2007
18. Causes of Anaphylaxis Immunizations- estimated 1.5 events
per 1 million MMR and influenza are the most common Prepared using
chick-derived cells AAP recommends giving MMR to children with egg
sensitivity Per CDC, egg sensitivity a contraindication for
influenza vaccine Unknown exposure 16% of anaphylactic
triggers
19. Contrast Media Anaphylactoid reaction- not IgE mediated
Osmolality-hypertonicity reaction Triggers degranulation of mast
cells and basophils Association of shellfish allergy and contrast
media (because of iodine content) is a myth Pretreatment with
prednisone and diphenhydramine is only indicated in documented
history of an adverse reaction to contrast media
20. Question 1 A 5 year old M who has experienced a severe
allergic reaction to shrimp in the past needs a CT scan with IV and
oral contrast. What precautions should you take? A. NS bolus and
diphenhydramine B. NS bolus, diphenhydramine, and prednisone C.
This patient can not receive contrast D. Reassurance, there is no
associated risk for a reaction between shellfish and contrast
21. Question 1 A 5 year old M who has experienced a severe
allergic reaction to shrimp in the past needs a CT scan with IV and
oral contrast. What precautions should you take? A. NS bolus and
diphenhydramine B. NS bolus, diphenhydramine, and prednisone C.
This patient can not receive contrast. D. Reassurance, there is no
associated risk for a reaction between shellfish and contrast.
22. Route of Exposure Insect stings and parenterally injected
medication may have rapid onset of symptoms PO ingestions may
develop over several minutes to hours Most symptoms occur within
5-30 minutes post exposure Lane et al, Pediatric Emergency Care,
2007
23. Pathophysiology First time exposure to the allergen
Specific IgE antibodies are formed around the allergen and bind to
Fc receptors on mast cells Repeat allergen exposure and binding of
the allergen to IgE antibodies causes degranulation of mast cell
Massive release of chemical mediators including: Histamine
Prostaglandin D2 Leukotrienes Platelet activating factor Tryptase
Lane et al, Pediatric Emergency Care, 2007
24. Pathophysiology Effect of Chemical Mediators after release
Increased vascular permeability Bronchospasm Vasodilatation Altered
smooth muscle tone Within 10 minutes the circulating blood volume
can decrease by 35% during anaphylaxis Lane et al, Pediatric
Emergency Care, 2007
25. Symptoms Respiratory: 94% Cutaneous: 80- 90% GI: 10-46% CV:
30% Russell et al.,Pediatric Emergency Care, 2010
28. IM Epinephrine First line therapy! Has alpha-1, beta-1, and
beta-2 agonist actions Increased vascular resistance and decreased
mucosal edema (alpha-1) Increased inotrophy and chronotrophy
(beta-1) Increased bronchodilation and decreases release of mast
cell and basophil mediators (beta-2) Only 18% reported use in
pediatric anaphylaxis cases
29. IM vs. Sub-q IM substantially better than sub-q Faster peak
plasma concentrations Anterolateral thigh (vastus lateralis)
30. IM Epinephrine Dose: 0.01mg/kg of 1:1000 Max dose is 0.3mg
May repeat every 5-15 minutes 20% require subsequent dosing EpiPen:
2 fixed doses: 0.15mg and 0.3mg < 22kg give EpiPen Jr (0.15mg)
>22kg give EpiPen (0.3mg) Lane et al, Pediatric Emergency Care,
2007
31. EpiPen www.allergywindow.com Russell et al.,Pediatric
Emergency Care, 2010
32. Question 2 You have been asked by a local school to provide
recommendations about the use of self injectable epinephrine for
anaphylaxis. What is the BEST response to give regarding
anaphylaxis? A. A patient should not receive a second dose of
epinephrine unless a physician is present B. Epinephrine reaches
higher peak plasma concentrations in injected into the thigh rather
than the arm C. Families should keep one epinephrine auto injector
in the car in case a reaction occurs after school D. Subcutaneous
injection of epinephrine is preferable to intramuscular
injection
33. Question 2 You have been asked by a local school to provide
recommendations about the use of self injectable epinephrine for
anaphylaxis. What is the BEST response to give regarding
anaphylaxis? A. A patient should not receive a second dose of
epinephrine unless a physician is present B. Epinephrine reaches
higher peak plasma concentrations in injected into the thigh rather
than the arm C. Families should keep one epinephrine auto injector
in the car in case a reaction occurs after school D. Subcutaneous
injection of epinephrine is preferable to intramuscular
injection
34. Question 3 A 14 y/o M who has seasonal allergies and
moderate persistent asthma is currently receiving allergen
immunotherapy. Today in clinic he received his usual allergen
injection, but after 10 minutes, he started coughing and
complaining of dyspnea and throat swelling. On physical exam he
exhibits moderate respiratory distress and has diffuse expiratory
wheezing on auscultation. No oropharyngeal edema noted. Vitals
signs include a pulse ox of 97%, BP of 130/70, and HR of 90. Of the
following, the MOST appropriate next action is to administer: A. A
short acting beta-2 agonist nebulization B. An oral antihistamine
C. An oral corticosteroid D. Intramuscular epinephrine
35. Question 3 A 14 y/o M who has seasonal allergies and
moderate persistent asthma is currently receiving allergen
immunotherapy. Today in clinic he received his usual allergen
injection, but after 10 minutes, he started coughing and
complaining of dyspnea and throat swelling. On physical exam he
exhibits moderate respiratory distress and has diffuse expiratory
wheezing on auscultation. No oropharyngeal edema noted. Vitals
signs include a pulse ox of 97%, BP of 130/70, and HR of 90. Of the
following, the MOST appropriate next action is to administer: A. A
short acting beta-2 agonist nebulization B. An oral antihistamine
C. An oral corticosteroid D. Intramuscular epinephrine
36. Treatment IM Epinephrine May repeat IV fluids- 20ml/kg
bolus Repeat boluses if hypotension persists IV Epinephrine for
persistent hypotension/symptoms 0.01mg/kg of 1:10,000 Max dose 1gm
Histamine (H1/H2) blockers Benadryl (H1) and Zantac (H2) Slow onset
of action Shown to be effective on dermatologic manifestations
especially in combo Albuterol treatment if indicated Russell et
al.,Pediatric Emergency Care, 2010
37. Role of Corticosteroids? Corticosteroids NO clinical
evidence-based support for steroids in acute management of
anaphylaxis NO support for steroids against biphasic reactions
Reported use of corticosteroids is more prevalent than IM
epinephrine in anaphylaxis Lane et al, Pediatric Emergency Care,
2007 Russell et al.,Pediatric Emergency Care, 2010
38. Question 4 A 10 y/o M with a history of peanut allergy
presents with diffuse itching and trouble breathing after eating a
friends candy bar that contained nuts during school lunch. At the
nurses office the patient received IM epinephrine with his EpiPen
with symptom resolution. EMS was called and the patient was brought
to the local pediatric ED (about a 12 minute ride). On arrival to
the ED, the patient is again complaining of itching with an
urticarial rash on his chest and per EMS the patient began vomiting
as they were pulling up to the ambulance bay. Arrival vitals
include a pulse ox of 96%, BP of 88/67, and HR of 95. Of the
following, the MOST appropriate treatment plan is: A. Intramuscular
epinephrine, oral antihistamine, oral corticosteroid, and a short
acting beta-2 agonist neb treatment B. Intramuscular epinephrine,
IV antihistamine, IV corticosteroid, NS bolus C. Intramuscular
epinephrine, IV antihistamine, IV Zantac, NS bolus D. Intramuscular
epinephrine, oral antihistamine, oral corticosteroid
39. Question 4 A 10 y/o M with a history of peanut allergy
presents with diffuse itching and trouble breathing after eating a
friends candy bar that contained nuts during school lunch. At the
nurses office the patient received IM epinephrine with his EpiPen
with symptom resolution. EMS was called and the patient was brought
to the local pediatric ED (about a 12 minute ride). On arrival to
the ED, the patient is again complaining of itching with an
urticarial rash on his chest and per EMS the patient began vomiting
as they were pulling up to the ambulance bay. Arrival vitals
include a pulse ox of 96%, BP of 88/67, and HR of 95. Of the
following, the MOST appropriate treatment plan is: A. Intramuscular
epinephrine, oral antihistamine, oral corticosteroid, and a short
acting beta-2 agonist neb treatment B. Intramuscular epinephrine,
IV antihistamine, IV corticosteroid, NS bolus C. Intramuscular
epinephrine, IV antihistamine, IV Zantac, NS bolus D. Intramuscular
epinephrine, oral antihistamine, oral corticosteroid
40. Biphasic Reactions Delayed anaphylactic reaction developing
after initial reaction has resolved About 1-20% of all anaphylactic
reactions 6% in pediatric anaphylaxis Asymptomatic intervals range
from 1-28 hours Can occur up to 72 hours from initial reaction
Length of observation? Suggested 8-24 hours in literature The only
intervention that has been shown to reduce the prevalence and
severity of biphasic allergic reactions is early treatment with IM
epinephrine Lane et al, Pediatric Emergency Care, 2007
41. Biphasic Reactions Lee et al, Pediatrics, 2013
42. Criteria for Admission Unresolved symptoms High risk for
biphasic reaction Delayed epinephrine treatment Co-morbidities
Social
43. Outpatient Management Prescription for EpiPen Parents can
get at our pharmacy Educate parents Symptoms of anaphylaxis Use of
EpiPen Referral to allergist School forms Peds ED Portal
44. Patient Education Hold for 10 seconds! Look at expiration
date! www.drug3k.com
45. How to use EpiPen EpiPen Video
46. EpiPen 2.0? Auvi Q
47. Summary Anaphylaxis- acute onset, involvement of 2 or more
organ systems or presence of hypotension Severity of a previous
reaction does not predict the severity of a subsequent reaction
Patients with previous anaphylactic reactions are at a higher risk
for reoccurrence First line treatment is IM epinephrine < 22kg
give EpiPen Jr (0.15mg) >22kg give EpiPen (0.3mg) Early IM
epinephrine can reduce the risk of a biphasic reaction Discharge
home with EpiPen, education, allergist referral, and school
forms
48. References Lee, J.M. and Greenes, D.S., Biphasic
Anaphylactic Reactions in Pediatrics. Pediatrics.
2000;106(4):762-6. Nowak, R., Farrar, J.R., Brenner, B.E. et al.,
Customizing anaphylaxis guidelines for emergency medicine. The
Journal of Emergency Medicine. 2013;45(2):299-305. Lane, R.D. and
Bolte, R.G., Pediatric anaphylaxis. Pediatric Emergency Care.
2007;23(1):49-56. Russell, S., Monroe, K., and Losek, J.,
Anaphylaxis management in the pediatric emergency department.
Pediatric Emergency Care. 2010;26(2):71-76.
