Anaphylaxis Management

🍁Why not discuss today a case scenario of Anaphylaxis?

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🌹Dr Padmanabh Keskar

EMS Instructor,  Ruby Hall Clinic, Pune 

Mobile - 9762258650 

Case - COVID 19 Vaccination च्या दरम्यान एका पेशंटला Anaphylaxis चा त्रास झाला ( Imaginary case ) ....

Though it's a rare event but one of the participants of COVID Vaccination developes allergic reaction after 15 to 20 minutes of vaccine.  He is still in observation area of center .

He is immediately transferred to Emergency room ... 

O/E he have developed rash all over his body , itching ++ , slight  difficulty in breathing with Bilateral wheezing , giddiness and blackout in front of eyes ... extremities are slightly cold with  delayed capillary refill time of 3 to 4 seconds 

BP - 80 / 60 mm of Hg 

Pulse - 110 / min , thready and fast 

SPO2 - 88 %

BSL ( R ) - 200 mg/dl 

How will you proceed with this case ?

🍁Management of Anaphylaxis

🌸Dr Padmanabh Keskar

EMS Instructor,  Ruby Hall Clinic, Pune 

Mobile  - 9762258650 

What we will do , we will discuss Anaphylaxis Management in general and then we will discuss a case specific variation afterwards. 

🍁How to differentiate Anaphylaxis  from general hypersensitivity reactions?

Criterias -

✅ Acute onset of an illness (minutes to hours), with involvement of the skin, mucosal tissues

 AND 

✅ At least one of the following:

1) Respiratory compromise

2) Reduced blood pressure ( Hypotension)

🌸NB - Isolated Hypotension* after exposure of known allergen to that patient is *treated as Anaphylaxis though no skin rashes and other allergic signs are absent.

✅ When we say Anaphylactic Shock - Hypotension is must with other signs of Anaphylaxis. 

©️ Dr Padmanabh Keskar 

🌸Emergency Management🌸

1) Give Shock position - It is the position of a person who is lying flat on their back with the legs elevated approximately 8-12 inches.

In case of pregnant lady left lateral position can be considered. 

2) Check Response - If patient is collapsed tap on his shoulder and ask him a question - Are you alright? 

3) If Unresponsive  Immediately activate EMS system* Call 108 or any Cardiac Ambulance which has AED inside. 

4) Check for Carotid pulse and breathing - If patient is pulse less and not breathing start with CPR

🌸Don't forget ABC Management along with early administration of IM Epinephrine

🌸Maintain Airway initially with OPA / NPA as per consciousness of patient. 

🌸If Angioedema then early intubation is indicated. 

©️ Dr Padmanabh Keskar 

🌸Start with high flow oxygen.

🌸If severe bronchial spasm start  Nebulisation with Salbutamol and Budecort. You can use Adrenalin also for Nebulisation for upper Airway vasoconstriction and Laryngeal  oedema.

🌸Bag mask ventilation if patient is not adequately breathing and maintaining oxygen saturation. 

🌸 Take IV access with large bore needle and start fast fluid replacement if patient is in Hypotension and shock . Choice of fluid will be Normal Saline ( NS 0.9% )

🌸Give 1 to 2 litres of NS fast through bilateral venous access immediately if patient is in shock . In children also give IV fluid in large doses ( 20 ml / kg or even higher doses ) 

©️ Dr Padmanabh Keskar 

🌸 Early adminstration of IM Adrenalin is life saving in confirmed Anaphylaxis

All patient who fulfill the criteria for anaphylaxis require the administration of epinephrine. Epinephrine is the only drug to show a mortality benefit in the management of anaphylaxis.

✅Adrenalin ( Timing - Route - Location - Dose )

©️ Dr Padmanabh Keskar 

Timing- Epinephrine should be administered as soon as the diagnosis of anaphylaxis is confirmed. 

Route - Always initial first 2 doses through intramuscular route. Adrenalin ( 1:1000 )

As there is no adequate capillary refill during shock-  subcutaneous route has no absorption or very poor delayed  absorption.

While IV Adrenalin will cause arrhythmias and other untoward side effects. 

Location- Intramuscular administration of epinephrine in the anterolateral thigh reaches the maximal epinephrine serum concentration  approximately 7 times faster compared to the arm ( deltoid ). So no deltoid

©️ Dr Padmanabh Keskar 

Dose - correct dose of epinephrine for the treatment of anaphylaxis is 0.01mg/kg (to a max of 0.5mg) IM, repeated after 5 mins if there’s no clinical improvement. 

So in adults give 1st dose of 0.5 ml IM - wait for 5 minutes look for any improvement in Hypotension or other signs of shock - if no improvement then give 2nd dose of 0.5 ml Adrenalin ( 1:1000 )

Any patient weighing 50Kg or more should receive 0.5mg of epinephrine IM

©️ Dr Padmanabh Keskar 

🌸The most common cause of death in anaphylaxis is not giving epinephrine at the right time at the correct dose

🌸For quick adminstration Adrenalin epipen available in prefilled form with 0.3 mg Adrenalin

🌸 If patient is not responding to 2 IM doses of Adrenalin and still remains in Hypotension and other signs are not relieved then give IV 0.1 mg Adrenalin in 1:10,000 concentration.

IV Adrenalin- slow push of 0.5 to 1 mL of 0.1 mg/mL (1:10,000) epinephrine solution ("cardiac" epinephrine ) available in 10 mL prefilled syringes, containing 1 mg of epinephrine, and stocked on resuscitation crash cart. 

©️ Dr Padmanabh Keskar 

🌸 2nd line treatment in Anaphylaxis

🌸 Antihistamines ( H1 receptor blockers ) - Give Diphenhydramine ( Benadryl) - 25 - 50 mg IV 

🌸 H2 receptor blocker like Ranitidine - 50 mg IV every 5 minutes. 

🌸Steroids ??? Are they really helpful?

Remember that steroids take 4-6hrs to become effective, so (in contradistinction to epinephrine) there is no rush to administer them.

Generally in acute event in first 30 minutes Steroids are not helpful but in biphasic reaction or late manifestations Steroids will be helpful. 

Inj Hydrocort - 200 mg IV

OR 

Inj Dexamethasone 8 mg IV ( comparatively delayed onset but long acting) 

The onset of action of glucocorticoids takes several hours. Therefore, these medications do not relieve the initial symptoms and signs of anaphylaxis. 

©️ Dr Padmanabh Keskar 

IV Vasopressin is indicated if patient remains in Hypotension despite Adrenalin adminstration

If patient is on Beta blockers then more severe Anaphylaxis will occur - in such cases additional Inj Glucagon - 1 to 5 mg IV slow bolus indicated

©️ Dr Padmanabh Keskar 

To make it simple Emergency Management of Anaphylaxis will consist of -  

✅Airway Management,  

✅Oxygenation / Bag mask ventilation , Nebulisation

✅IV fluid Management with NS 1 to 2 lit 

✅Early 2 doses of 0.5 mg Intramuscular Adrenalin  

✅Antihistamines - ( H1 ) Diphenhydramine 50mg IV , ( H2 ) Ranitidine 50mg IV

✅Steroids- Inj Hydrocort 200 mg IV / Inj Dexamethasone 8 mg 

🌸Dr Padmanabh Keskar

EMS Instructor,  Ruby Hall Clinic, Pune.

Mobile 9762258650

______________________________

Angioedema ....Laryngeal spasm .... upper Airway closure is so fast  in Anaphylactic shock .

You require a team to manage such emergencies....

At Family Physician level at least you should give 1 to 2 shots of Adrenalin IM before referring patient....

If patient is unconscious you may not intubate him in your opd but you can put Laryngeal mask airway ( LMA ) which does not require much skill and can start bag mask ventilation....

CPR in pulseless patient is of prime importance...

Due to this kind of interaction now everybody must have understood importance of Adrenalin in Anaphylaxis and essentially it should be in IM route ( before this many doctors were of opinion of subcute )

©️ Dr Padmanabh Keskar 

______________________________

Inj Adrenalin ampoule is 1mg/ml .

1 ampoule is of 1 ml and concentration is 1:1000 

You can use it for IM / SC 

If you want to use it for IV route then you have to make concentration of 1:10,000

For that purpose-  mix 1 ampoule of 1:1000 in 10 ml Normal saline so now dilution is 1:10,000 - niw you can use this for iv route

©️ Dr Padmanabh Keskar 

___________________________

*Can isolated Hypotension without any skin reaction after confirmed exposure to allergen will be termed as Anaphylaxis ?*

*पेशंट ला एखाद्या घटकाची ( Allergen ) allergy आहे व तो त्या Allergen ला Expose झाला ... त्यानंतर त्याला कोणतेही skin rashes किंवा अन्य काही लक्षणे उत्पन्न झाली नाहीत फक्त - Hypotension झाले - तर या घटनेला Anaphylaxis म्हणायचे का ?*

उत्तर - हो 

©️ You can forward my posts with my name and without editing any content of it

🌹Dr Padmanabh Keskar

EMS Instructor,  Ruby Hall Clinic,  Pune 

Mobile  - 9762258650