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discovered that 13 of 25 cases died within 60 minutes. Patients TABLE III Signs and Symptoms of Anaphylaxis 18
taking beta blockers, angiotensin converting enzyme (ACE) in- Signs and Symptoms Percentage
hibitors, or angiotensin receptor blocking medications as well Cutaneous
as those with co-existing medical conditions such as poorly Urticaria and angioedema 62-90
controlled asthma, chronic obstructive pulmonary disease and
cardiovascular disease, were shown to have more severe reac- Flushing 45-55
tions and a higher mortality. 7,8,9 Pruritus without rash 2-5
Respiratory
Dyspnea, wheezing 45-50
Diagnosis of anaphylaxis
Angioedema of upper airway 50-60
Anaphylaxis is an acute, life-threatening emergency requiring Rhinitis 15-20
prompt diagnosis and treatment (see Table II). A medic should Hypotension, dizziness, syncope, diaphoresis 30-35
suspect anaphylaxis and initiate treatment whenever a patient Abdominal
presents with the characteristic signs and symptoms occurring Nausea, vomiting, diarrhea, abdominal pain 25-30
within minutes to hours after the exposure to a known or sus- Miscellaneous
pected allergen. More than 80 percent of anaphylactic reactions
will involve the skin, mucosal tissue or both (e.g., generalized Headache 5-8
hives, pruritus or flushing, swollen lips-tongue-uvula) along Substernal Pain 4-5
with respiratory distress and/or hypotension (see Table III). As Seizure 1-2
many as 20 percent of children with a food or insect sting al-
lergy will not manifest skin symptoms and can be identified by Treatment of anaphylaxis
signs of gastrointestinal distress in association with shock, re- The initial treatment of anaphylaxis begins with the intramus-
spiratory distress, and/or skin and mucosal signs. In rare cases, cular (IM) administration of epinephrine into the mid-outer
some patients will exhibit only signs of shock following the thigh and removal of the patient from the inciting allergen,
exposure to a known allergen. Anaphylaxis in this instance, of when possible. As with any critically ill patient, next steps in-
shock in the absence of skin and mucosal involvement, respira- clude a rapid assessment and support of the airway, breath-
tory distress and/or gastrointestinal distress, is a diagnosis of ing and circulation, including the administration of oxygen
exclusion and should result in a medic considering alternative for known or suspected hypoxemia and intravenous fluids for
causes of shock such as sepsis and occult hemorrhage. hypotension. The ABCs of treating anaphylaxis are: adrenalin,
airway, breathing and circulation.
TABLE II Clinical Criteria for Diagnosing Anaphylaxis
Anaphylaxis is highly likely when patients meet any one of the Epinephrine is the primary treatment for anaphylaxis and
following three criteria: should be administered without delay whenever anaphylaxis
is suspected and the patient exhibits the signs and symptoms
1. Acute onset of an illness (within minutes to several hours)
involving the skin, mucosal tissue, or both (e.g., generalized hives, outlined in Table I. The early administration of epinephrine
pruritus or flushing, swollen lips-tongue-uvula) and at least one of prior to meeting the diagnostic criteria is justified for symp-
the following: tomatic patients with a prior history of near- fatal anaphy-
a. Respiratory distress (e.g., dyspnea, wheeze-bronchospasm, laxis. There are no absolute contraindications to epinephrine
stridor, reduced PEF, hypoxemia)
b. Hypotension or symptoms of end-organ dysfunction (e.g., and its benefits in treating anaphylaxis generally outweigh any
hypotonia [collapse], syncope, incontinence) risks associated with using this drug in patients with cardio-
2. Two or more of the following findings occurring rapidly after vascular disease, including acute coronary syndrome. 12
exposure (i.e. within minutes to several hours) to a patient’s
known or suspected allergen: If respiratory symptoms fail to respond to epinephrine, then
a. Involvement of the skin-mucosal tissue (e.g., generalized hives, administer nebulized beta-agonists such as albuterol. The ad-
itch-flush, swollen lips-tongue-uvula)
b. Respiratory distress (e.g., dyspnea, wheeze-bronchospasm, ministration of antihistamines and steroids are not beneficial
stridor, reduced PEF, hypoxemia) in the early treatment of anaphylaxis, but continue to have
c. Hypotension or symptoms of shock (e.g., hypotonia [collapse], a secondary role in potentially mitigating the cutaneous and
syncope, incontinence) biphasic reactions, respectively. Administering these drugs in
d. Persistent gastrointestinal symptoms (e.g., crampy abdominal addition to epinephrine is not indicated initially, as the onset
pain, vomiting)
3. Hypotension after exposure to a known allergen (minutes to of their effects is delayed and their early administration were
several hours): not shown to affect mortality.
a. Infants and children: low systolic BP (age specific) or greater
than 30 percent decrease in systolic BP The initial dose of epinephrine is 0.01 mg/kg to a maximum
b. Adults: systolic BP of less than 90 mm Hg or greater than 30 dose of 0.5 mg (1:1000 adrenalin: 0.5 mg = 0.5 ml) for teen-
percent decrease from that person’s baseline agers and adults. Children weighing between 7 kg and 25 kg
should receive 0.15 mg, and the dose for a prepubescent child
Other conditions that may appear similar to anaphylaxis is 0.3 mg. This dose can be repeated every five to 15 minutes
include vasomotor syncope (vasovagal/neurocardiogenic), until symptoms and blood pressure are controlled. More fre-
characterized by hypotension, pallor, bradycardia, weakness, quent dosing sometimes is required in severe cases for symptom
nausea and vomiting; acute respiratory decompensation from control. The epinephrine should be administered intramuscu-
severe asthma attacks, foreign body aspiration and pulmonary larly (IM) into the mid-outer thigh. This site has been shown to
embolism; vocal cord dysfunction; acute anxiety (e.g., panic produce higher circulating drug levels than when epinephrine is
attack or hyperventilation syndrome); myocardial dysfunc- administered into the deltoid muscle or subcutaneously. The
13
tion, acute poisoning; hypoglycemia; and seizure disorders. 10,11 IM administration of epinephrine results in an increased serum
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