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Treatment of Anaphylaxis-Lockey - World Allergy Organization PDF

142 Pages·2010·1.33 MB·English
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Preview Treatment of Anaphylaxis-Lockey - World Allergy Organization

Anaphylaxis Risk Assessment, Use of Epinephrine Richard F. Lockey, M.D. Division of Allergy and Immunology Department of Internal Medicine University of South Florida College of Medicine James A. Haley Veterans’ Hospital Tampa, Florida 1 • ASTHMA IS A RISK FACTOR FOR • ANAPHYLAXIS 2 Questions 1. How is anaphylaxis defined? 2. Can you predict the seriousness of a reaction by the presenting signs and symptoms? 3. Can you predict the seriousness of the reaction by identifying the route of antigen presentation, parenteral or oral? 4. Can the time of onset predict a more serious reaction? 5. How should epinephrine be administered? 6. When should epinephrine be administered? 7. Is epinephrine safe? 3 Questions 1. How is anaphylaxis defined? 2. Can you predict the seriousness of a reaction by the presenting signs and symptoms? 3. Can you predict the seriousness of the reaction by identifying the route of antigen presentation, parenteral or oral? 4. Can the time of onset predict a more serious reaction? 5. How should epinephrine be administered? 6. When should epinephrine be administered? 7. Is epinephrine safe? 4 Mechanisms underlying human anaphylaxis. Anaphylaxis might be immune mediated or might occur through direct (nonimmune) perturbation of mast cells. Idiopathic anaphylaxis, currently a diagnosis of exclusion, presents opportunities for elucidation of pathophysiologic mechanisms. 5 Simons FER. J Allergy Clin Immunol 2006;1;17:366-77 Second NIAID Food Allergy and Anaphylaxis Network Symposium Anaphylaxis is highly likely when any one of the following 3 criteria are fulfilled: 1. Acute onset of an illness (minutes to several hours) with involvement of the skin, mucosal tissue, or both (eg, generalized hives, pruritus or flushing, swollen lips-tongue-uvula) AND AT LEAST ONE OF THE FOLLOWING a. Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, reduced PEF, hypoxemia) b. Reduced BP or associated symptoms of end-organ dysfunction (eg, hypotonia 6 [collapse], syncope, incontinence) Second NIAID Food Allergy and Anaphylaxis Network Symposium (cont’d) 2. Two or more of the following that occur rapidly after exposure to a likely allergen for that patient (minutes to several hours): a. Involvement of the skin-mucosal tissue (eg, generalized hives, itch-flush, swollen lips- tongue-uvula) b. Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, reduced PEF, hypoxemia) c. Reduced BP or associated symptoms (eg, hypotonia [collapse], syncope, incontinence) d. Persistent gastrointestinal symptoms (eg, crampy abdominal pain, vomiting) 7 Second NIAID Food Allergy and Anaphylaxis Network Symposium (cont’d) 3. Reduced BP after exposure to known allergen for that patient (minutes to several hours): a. Infants and children: low systolic BP (age specific) or greater than 30% decrease in systolic BP* b. Adults: systolic BP of less than 90 mm Hg or greater than 30% decrease from that person's baseline PEF, Peak expiratory flow; BP, blood pressure. * Low systolic blood pressure for children is defined as less than 70 mm Hg from 1 month to 1 year, less than (70 mm Hg + [2 × age]) from 1 to 10 years, and less than 90 mm Hg from 11 to 17 years. 8 • Sampson HA et al. J Allergy Clin Immunol 2006;117:391-7 Second NIAID Food Allergy and Anaphylaxis Network Symposium (cont’d) When a patient fulfills any of the 3 criteria of anaphylaxis outlined above, the patient should receive epinephrine immediately because epinephrine is the treatment of choice in anaphylaxis. There undoubtedly will be patients who present with symptoms not yet fulfilling the criteria of anaphylaxis yet in whom it would be appropriate to initiate therapy with epinephrine, such as a patient with a history of near-fatal anaphylaxis to peanut who ingested peanut and within minutes is experiencing urticaria and generalized flushing. • Sampson HA et al. J Allergy Clin Immunol 2006;117:391-7 9 Anapahylaxis in Infants: Can Recognition and Management be Improved? Anaphylaxis signs in infants: obvious but may be nonspecific Skin/mucus membranes: rapid onset of hives (potentially difficult to discern in infants with acute atopic dermatitis; scratching and excoriations, as such, will be absent in young infants); angioedema (face, tongue, oropharynx) Respiratory: rapid onset of coughing, choking, stridor, wheezing, dyspnea, apnea, cyanosis Gastrointestinal: sudden, profuse vomiting Cardiovascular: weak pulse, arrhythmia, diaphoresis/sweating, pallor, collapse/unconsciousness Central nervous system: rapid onset of unresponsiveness, lethargy, or hypotonia; seizures 10 • Simons FER. J Allergy Clin Immunol 2007;120:537-40

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end-organ dysfunction (eg, hypotonia hypotonia [collapse], syncope, incontinence) d Grading System for Generalized Hypersensitivity Reactions ( 1149.
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