Emergency - Anaphylaxis

7/27/2019 Emergency - Anaphylaxis

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ANAPHYLAXIS & ANAPHYLACTOID REACTIONS

Immediate hypersensitivity reactions involving ageneralized response to a specific antigen

Anaphylax i s involves antigen & IgE antibodies andrequires previous sensitization to an antigen

Anaphylac to id Reac tions are mediated by histamine andmay occur with the first exposure to an antigen

Approximately 500 deaths occur per year in the U.S. fromanaphylaxis, PCN allergy accounts for 75% of deaths

Typical Substances (used in dental office) that can trigger an allergic Rx;

AntibioticsNarcotics

Latex Aminoester Local Anesthestic Agents


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Prevent ion

1) Obtain a careful history of previous allergicreactions, atopy or asthma

2) Administer ProphylaxisCorticosteroids

Dexamethasone IV, Adult 20 mgPediatric Dosage IV 0.6 mg/kg

Methylprednisolone IV, Adult 100 mgPediatric Dosage IV,IM 30 g/kg

H1 AntagonistDiphenhydramine IV, Adult 25 50 mg

Pediatric Dosage IV, 2-5 mg/kg


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Assesment

Determine if patient is in mild or severe distress:

Mild Distress: itching, isolated urticaria,nausea, no respiratory distress.

Severe Distress: poor air entry, flaring,grunting, cyanosis, stridor, bronchospasm,abdominal cramps, respiratory distress,tachycardia, shock, edema of lips, tongue or face and generalized urticaria.


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Manifes ta t ions Cardiac

Hypotension may be only early sign of anaphylaxis of anesthestized patient

Cardiovascular CollapsePulmonary Hypertension

Arrhythmias, Pulmonary Edema Awake Patient - may Complain of Dizziness or Decreased

Level of Consciousness (masked by sedation)

Respiratory

Bronchospasm Stridor, laryngeal edemaIncreased PIP Pulmonary EdemaHypoxemia If Awake Complaint of Dypsnea/Chest tightness

Cutaneous

Rash, Flush, Hives, Puritis, Angioedema


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Management

Determine presence of upper airway involvement (stridor) or lower airwaysymptoms (wheezing). These may coexist. Maintain an open airway and assistventilations as needed. This may include repositioning of the airway, suctioning, or

use of airway adjuncts (oropharyngeal airway) as indicated.

Maintain the patients airway & support oxygenation and ventilation Increase FiO2 to 100%Intubate if necessaryThe airway & larynx can become very edematous

If bronchospasm is present in the normotensive patient, volatile agents maybe administered to counteract bronchospasm

Contact Code Team or 911 depending on location


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Management

Expand the circulating volume rapidlyImmediate fluid needs may be massive

Administer Epinephrine IVEpinephrine is the drug of choice for treatment of anaphylaxisFor hypotension, 10 50 mcg increments, repeat prn

Administer a H1 antagonistH1 Blockers

Diphenhydramine IV, 1 mg/kg up to a maximum of 50 kg

In the absence of any other known cause, consider latex allergy


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Management

The recommended epinephrine dose for anaphylaxisin children is 0.01 mg/kg, not to exceed 0.30 mg.

The preferred route of administration for first-aidtreatment is intramuscular injection of epinephrine intothe vastus lateralis of the lateral thigh, which allowsearly peak epinephrine concentration needed for effective management.

Intravenous administration of epinephrine carriesincreased risks for dilution errors and dosing errors,which may lead to overdose and adverse effects suchas cardiac dysrhythmias.


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Epinephr ine

Based on patient weight:

10 kg or less:Consider use of ampule of epinephrine with needle andsyringe to draw correct dose (0.01 mg/kg) of epinephrine.

10 to 25 kg: Autoinjection with 0.15 mg of epinephrine.

25 kg or more: Autoinjection with 0.30 mg of epinephrine.

A second dose of epinephrine is required for anaphylaxis in up to 35% of cases.Epinephrine may be repeated 5 to 20 minutes after the initial dose.


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Monitor Vital Signs & Keep Patient Warm

Provide Advanced Airway Management if Indicated

Initiate IV Normal Saline KVO titrated to appropriate BP for age(expected fluid bolus will be @ 20 mL/kg)


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ANAPHYLAXIS & ANAPHYLACTOID REACTIONSSevere Distress

Epinephrine (1:1,000) , 0.01 mg/kg subcutaneouslyup to maximum single dose 0.3 mg.

Epinephrine 1:1,000 ; administer 0.1 mg/kg via ETfollowed by 2.0 cc sterile Normal Saline solution.

Epinephrine infusion 1:1,000 (1 mg/ml) administer 0.1 to 1.0 mcg/kg/min .

Large Bore IV normal saline, titrate to appropriate BP for age. (expected fluid bolus will be @ 20 mL/kg)

Diphenhydramine HCL (Benadryl ) 1.0 mg/kg up to maximum single dose of 50 mg via deep intramuscular injection (IM) or IV push.

Albuterol Sulfate 0.5% (via nebulizer)


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Epinephrine Solutions

Epinephrine vials are also labeled by concentration of aratio of medication per mL. For example, a solution maybe labeled as 1:100,000. This concentration represents1000mg/100,000mL or 0.01mg/mL.

CONCENTRATION DOSAGE EQUIVALENCE PERCENT

1:1,000 1mg/mL 0.1%

1:10,000 0.1mg/mL 0.01%

1:100,000 0.01mg/mL 0.001%

1:200,000 0.005mg/mL 0.0005%


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Epinephrine drug of choice for anaphylaxis

Drug Action;

Alp ha effec ts produce peripheral vasoconstriction which;1) Increases coronary and cerebral perfusion2) Increases blood pressure in anaphylaxis

Beta 1 effects; 1) Increases Heart Rate2) Improves Force of Ventricular Contractions

Beta 2 effects produce bronchodilation


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Adminster Corticosteroids

Dexamethasone IV,

Methylprednisolone IV,

0.15-0.6 mg/kg IV/IM; not to exceed 20 mg

1-2 mg/kg/dose PO/IM to max 100mg IV bolus


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Complications

Inability to intubate, ventilate, or oxygenate

Cardiac Arrest

Hypertension, tachycardia from vasopressors

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Emergency - Anaphylaxis