When & how to use epinephrine-Lockey - World Allergy Organization

141 Pages·2010·1.33 MB·English

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
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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?
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?
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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.
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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
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[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)
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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.
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• 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 8
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
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• Simons FER. J Allergy Clin Immunol 2007;120:537-40
Anaphylaxis from World Allergy Organization:
Statement on Epinephrine
• Anaphylaxis is an acute and potentially lethal
multisystem allergic reaction in which some or all of
the following signs and symptoms occur: diffuse
erythema, pruritus, urticaria and/or angioedema;
bronchospasm; laryngeal edema; hypotension;
cardiac arrhythmias; feeling of impending doom;
unconsciousness and shock. Other earlier or
concomitant signs and symptoms can include itchy
nose, eyes, pharynx, genitalia, palms, and soles;
rhinorrhea; change in voice; metallic taste; nausea,
vomiting, diarrhea, abdominal cramps, and
bloating; lightheadedness; headache; uterine
cramps; and generalized warmth.
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Kemp SF, Lockey RF, Simons FER, et al. Allergy 2008;63:1061-1070