Primer Primer

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Anaphylaxis

Dr. Mahadev Desai, MD

plexusmd.com/drmahadevdesai
June, 2015

www.plexusmd.com • editor@plexusmd.com
Added by Dr. Mahadev Desai on plexusmd.com, June 2015 1
Disclaimer Primer
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This presentation is prepared by leading medical experts solely for academic purposes
and intended for reading only by qualified Medical doctors. The objective is to spread
awareness and make clinical management-related information handy for consultants
across specialties and setups. The reader is advised to use own discretion while
relying upon information provided in this presentation and refer more comprehensive
sources if required in a given set of circumstances. This is not a comprehensive note
on the subject – various information may be concised, abbreviated or curtailed to
highlight only the most important aspects in the author’s opinion. PlexusMD and the
author expressly disclaim any liability arising out of the use of the information
provided here.

Added by Dr. Mahadev Desai on plexusmd.com, June 2015 2

Agenda Primer
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• Definition and cascade of events

• Known allergens
• Clinical Manifestations
• Diagnosis
• Treatment
• Discharge

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Anaphylaxis Primer
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Definition:
Life-threatening hypersensitivity response that usually appears within minutes
after administration (injection/ingestion or inhalation) of specific antigen

Greek words ana (against) and phylaxis (protection)

Key points: Anaphylactoid

• An acute systemic allergic reaction
• The result of a re-exposure to an
antigen that elicits an IgE mediated
response
• It is a Type I hypersensitivity
(Pseudoanaphylaxis)
• Similar s/s and Mediators
• Non-IgE mediated reaction
• Treatment is essentially similar

Added by Dr. Mahadev Desai on plexusmd.com, June 2015 4

Cascade of events in Anaphylaxis Primer
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An antigen (allergen) crosses an epithelial

or endothelial barrier

Interacts with allergen-specific IgE

antibodies on mast cells (in tissues) or
basophils (in blood) which are already
sensitized from previous (first) exposure

Cellular mediators (histamine, tryptase,

protease, Leukotrienes, PG-D2 etc.) are
released

End-organ responses in the Skin, RS, CVS,

GIT, possibly the Nervous System

Onset of severe symptoms is dependent on

the causative factor

Added by Dr. Mahadev Desai on plexusmd.com, June 2015 5

 Primer
Tissue Effects of Mediators by

Cardiovascular
 Vasodilatation  Decreased blood pressure
 Tachycardia
 Edema (separation of endothelial cells & increased permeability)

Respiratory
 Broncho-constriction & Bronchial secretions

Gastrointestinal
 Smooth muscle contraction and diarrhoea

Skin
 Urticaria, Non-pitting edema

Added by Dr. Mahadev Desai on plexusmd.com, June 2015 6

Known allergens eliciting Anaphylaxis Primer
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1. Food: milk, eggs, seafood, pea nuts, beans, gelatin in capsule

2. Drugs: Antibiotics (penicillins, cephalosporins, NFT), Amphotericin-B, Vitamins
(thiamine, folic acid), Monoclonal Ab
3. Enzymes: Streptokinase
4. Pollen extracts: grass, trees
5. Antiserum: horse antisera for Tetanus, Diphtheria, AGGS
6. Occupation-related proteins: latex rubber products
7. Bee sting; Insect bite
8. Diagnostic agents: radio-contrast study

Added by Dr. Mahadev Desai on plexusmd.com, June 2015 7

Clinical Manifestations - 1 Primer
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Respiratory: Upper or lower airway obstruction (present in 70%)

• Laryngeal edema - experienced as a "lump" in the throat, hoarseness or stridor
• Bronchial obstruction is associated with a feeling of tightness in the chest and/or
audible wheezing

Skin and mucous membranes (present in 90%)

• Urticaria: pruritic, well-circumscribed, discrete cutaneous wheals with
erythematous, raised, serpiginous borders and blanched centers
• Angioedema: localized, nonpruritic, nonpitting, deeper
edematous cutaneous involvement
• Flushing, swollen lips-tongue-uvula, periorbital edema,
conjunctival swelling

Added by Dr. Mahadev Desai on plexusmd.com, June 2015 8

Clinical Manifestations - 2 Primer
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Gastro-intestinal: (present in 45%)

• Nausea, vomiting, crampy abdominal pain, diarrhea

Cardiovascular (present in 45%)

• Tachycardia, hypotension, syncope, dizziness

Onset may be within seconds to min. (earlier for injection route)

Death from anaphylaxis usually results from asphyxiation due to

upper or lower airway obstruction or to cardiovascular collapse.

Added by Dr. Mahadev Desai on plexusmd.com, June 2015 9

Diagnosis Primer
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Clinical diagnosis
• Tachycardia, hypotension, cold limbs, cyanosis
• Urticaria, bronchospasm (rhonchi), dermographism
• Mental obtundation, confusion, drowsiness

No investigations required

No time for investigations to be wasted

Added by Dr. Mahadev Desai on plexusmd.com, June 2015 10

Differential Diagnosis Primer
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• Vasovagal reaction
• Bronchial Asthma
• Acute Left Ventricular Failure (Pulmonary Edema)
• Tension Pneumothorax
• Foreign Body Obstruction

Definitive investigation
Mast Cell Tryptase Assay
• Highly sensitive indicator of anaphylaxis
• Serum levels parallel histamine (half-life of minutes)
• Peaks in an hour following the reaction
• Elevated for 4 hours (half-life of 2 hours)
• Used more in post-mortem diagnosis of anaphylaxis
Plasma Histamine assay

Added by Dr. Mahadev Desai on plexusmd.com, June 2015 11

Treatment: 3I – Identify, Inject, Inquire Primer
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1. Secure Airways, ABC of Resuscitation

• Intubation (if required); Oxygen (8-10 L /min)
• Removal of inciting antigen, if possible (e.g. stopping infusion)
2. Inj. Adrenaline 0.5 to 1.0 ml (1 mg/ml, 1:1000 dilution)
• IM outer thigh, can be repeated every 5-10 min
• No absolute Contraindications
3. IV access with two wide-bored needles to (if required)
• Transfuse fluids for hypovolemia/hypotension – rapid bolus of 1-2 L NS
• Give Adrenaline infusion(1:10,000 dilution, 2 -10 mcg/min)

Goal of Therapy
Goal of therapy should be early recognition & treatment with
Adrenaline to prevent progression to life-threatening respiratory
and/or cardiovascular symptoms and signs, including shock

Added by Dr. Mahadev Desai on plexusmd.com, June 2015 12

Treatment: 3I – Identify, Inject, Inquire Primer
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4. Antihistaminic: relieve hives and pruritus, No proven mortality benefit.

• H1 antihistamine: Inj. Pheniramine maleate (2 ml; 22.75 mg/ml) or IV Inj.
Diphenhydramine (25 to 50 mg)
• H2 antihistamine: IV Inj. Ranitidine 50 mg
5. Bronchodilator therapy: Nebulized Salbutamol (2.5-5 mg in 3 ml saline) or
Inj. Aminophylline or Theophylline if bronchospasm, secretions
6. Steroids: Methylprednisolone (125 to 250 mg) IV or Hydrocortisone (200 mg)
or Dexamethasone (8 mg)
• Steroids mainly to prevent recurrence of urticaria, angioedema in few cases of
biphasic anaphylaxis where in s/s appear after 8 to 10 hours
• Not proven helpful in initial resuscitation as commonly perceived

Role of Antihistaminics and Steroids

• Anti-Histaminics have no proven mortality benefit
• Steroids have not proven helpful in initial resuscitation, as
commonly perceived

Added by Dr. Mahadev Desai on plexusmd.com, June 2015 13

Treatment of Anaphylaxis in patients with beta-blockers Primer
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1. Give Adrenaline initially

2. If patient does not respond to adrenaline and other usual therapy:
• Isoprenaline (Isoproterenol in USA) (a pure beta-agonist) 1 mg in 500 ml
D5W starting at 0.1 mcg/kg/min
• Glucagon 1 – 5 mg IV over 5 minutes followed by infusion of 5 – 15
mcg/min

Glucagon has inotropic and chronotropic effects

that are not mediated through beta-receptors

Added by Dr. Mahadev Desai on plexusmd.com, June 2015 14

Discharge protocol Primer
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1. Observe the patient for 8 to 12 hours

2. Discharge orders: All patients who have experienced anaphylaxis
should be sent home with an anaphylaxis emergency action plan,
one or more epinephrine auto-injectors, a plan for arranging further
evaluation, and printed information about anaphylaxis and its
treatment
3. Identity Card showing list of Allergens (to be carry always by the
patient)

Added by Dr. Mahadev Desai on plexusmd.com, June 2015 15

 T h a n k Yo u

About the Author:

Dr. Desai, an Editorial Board Member at PlexusMD, is a senior Physician with over 30 years of
teaching experience. He has been the Editor of Gujarat Medical Journal and chaired numerous
Scientific sessions. He is currently HOD of Medicine at Ahmedabad Dental College.
Dr. Mahadev T. Desai, MD
Consultant Physician
Ahmedabad
Connect at: plexusmd.com/drmahadevdesai
Email: mahadevdesai@yahoo.com
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