Anaphylaxis may be trickier than you think, but there’s no confusion about the treatment: aggressive administration of EPINEPHRINE.

Patients DO NOT have to present with integumentary involvement to be in anaphylaxis – up to 20% of patients experiencing anaphylaxis will have absent or unrecognized skin signs.

Patients DO NOT have to exhibit hypotension to diagnose ongoing anaphylaxis.

Anaphylaxis is unpredictable in time to onset, and the severity of presenting signs and symptoms exist on a spectrum. Stay ahead of the curve and give epi early.

World Allergy Organization’s Clinical Criteria for Anaphylaxis [1]:

Anaphylaxis is highly likely when any one of the following three criteria is fulfilled:

1. Acute onset of an illness (minutes to several hours) with involvement of the skin, mucosal tissue, or both (eg, generalized urticaria, itching or flushing,

swollen lips-tongue-uvula)

AND AT LEAST ONE OF THE FOLLOWING:

Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, reduced PEF, hypoxemia) Reduced blood pressure or associated symptoms of end-organ dysfunction (eg. hypotonia collapse, syncope, incontinence)

2. Two or more of the following that occur rapidly after exposure to a likely allergen for that patient (minutes to several hours):

Involvement of the skin-mucosal tissue (eg, generalized urticaria, itch-flush, swollen lips-tongue-uvula) Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, reduced PEF, hypoxemia) Reduced blood pressure or associated symptoms (eg, hypotonia collapse, syncope, incontinence) Persistent gastrointestinal symptoms (eg, crampy abdominal pain, vomiting)

3. Reduced blood pressure after exposure to known allergen for that patient (minutes to several hours):

Infants and children: low systolic blood pressure (age-specific) or greater than 30% decrease in systolic blood pressure. Adults: systolic blood pressure of less than 90 mm Hg or greater than 30% decrease from that person’s baseline.

1st Line:

IM Epi -> IV Fluids -> IV epi PRN.

IM epi should be administered in the lateral thigh

If the patient is know to be on beta blockers, give glucagon 1mg IVP if available

2nd Line:

Inhaled beta agonists, antihistamines, and glucocorticoids.

Refractory anaphylaxis

Methylene Blue

Transport to an ECMO-capable facility

Podcast Time!

References

1. Simons, F. E. R., Ardusso, L. R. F., & Bilò, M. B. (2011). World Allergy Organization Guidelines for the Assessment and Management of Anaphylaxis. World Allergy Organization Journal, (February), 13–37. https://doi.org/10.1097/WOX.0b013e318211496c

2. Biteker, M. (2010). A new classification of Kounis syndrome. International Journal of Cardiology. https://doi.org/10.1016/j.ijcard.2010.05.020

3. Lopez, P. R., & Peiris, A. N. (2010). Kounis syndrome. Southern Medical Journal. https://doi.org/10.1097/SMJ.0b013e3181f8c56f

4. Zhang, Z., Su, X., & Liu, C. (2015). Cardiac arrest with anaphylactic shock: a successful resuscitation using extracorporeal membrane oxygenation. The American Journal of Emergency Medicine, 33(1), 130.e3-4. https://doi.org/10.1016/j.ajem.2014.06.034

5. Jang, D. H., Nelson, L. S., & Hoffman, R. S. (2013). Methylene Blue for Distributive Shock: A Potential New Use of an Old Antidote. Journal of Medical Toxicology, 9(3), 242–249. https://doi.org/10.1007/s13181-013-0298-7

6. Weissgerber, A. J. (2008). Methylene blue for refractory hypotension: A case report. AANA Journal, 76(4), 271–274.

7. Evora, P. R. B. (2013). Methylene blue for the treatment of refractory anaphylaxis without hypotension. American Journal of Emergency Medicine. https://doi.org/10.1016/j.ajem.2013.01.033

8. Evora, P. R. B., & Simon, M. R. (2007). Role of nitric oxide production in anaphylaxis and its relevance for the treatment of anaphylactic hypotension with methylene blue. Annals of Allergy, Asthma and Immunology. https://doi.org/10.1016/S1081-1206(10)60545-5

9. Zheng, F., Barthel, G., Collange, O., Montémont, C., Thornton, S. N., Longrois, D., … Mertes, P. M. (2013). Methylene blue and epinephrine: A synergetic association for anaphylactic shock treatment. Critical Care Medicine, 41(1), 195–204. https://doi.org/10.1097/CCM.0b013e318267667b

10. Kounis, N. G. (2013). Coronary hypersensitivity disorder: The kounis syndrome. Clinical Therapeutics. https://doi.org/10.1016/j.clinthera.2013.02.022

11. Reber, L. L., Hernandez, J. D., & Galli, S. J. (2017). The pathophysiology of anaphylaxis. Journal of Allergy and Clinical Immunology, 140(2), 335–348. https://doi.org/10.1016/j.jaci.2017.06.003

12. Hanamoto, H., Kozu, F., Oyamaguchi, A., Inoue, M., Yokoe, C., & Niwa, H. (2017). Anaphylaxis with delayed appearance of skin manifestations during general anesthesia: Two case reports. BMC Research Notes, 10(1), 1–6. https://doi.org/10.1186/s13104-017-2624-7

13. Campbell, R. L., Li, J. T. C., Nicklas, R. A., & Sadosty, A. T. (2014). Emergency department diagnosis and treatment of anaphylaxis: A practice parameter. Annals of Allergy, Asthma and Immunology, 113(6), 599–608. https://doi.org/10.1016/j.anai.2014.10.007

14. Anaphylaxis: assessment and referral after emergency treatment. (2011), (December 2011). https://www.nice.org.uk/guidance/cg134

15. Simons, F. E. R. (2004). First-aid treatment of anaphylaxis to food: Focus on epinephrine. Journal of Allergy and Clinical Immunology, 113(5), 837–844. https://doi.org/10.1016/j.jaci.2004.01.769