Rise of the killer peanuts

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1 Rise of the killer peanuts Epi Then, Epi Now Taher Vohra, MD Henry Ford Hospital Department of Emergency Medicine

2 ObjecCves To define anaphylaxis To review the epidemiology of anaphylaxis To discuss treatments for anaphylaccc shock

3 What is Anaphylaxis?

4 Ana Phylax Against ProtecCon Richet and PorCer 1902 Dog tolerated jelly fish once and then died with second exposure

5 Anaphylaxis is a serious allergic reaccon that is rapid in onset and may cause death Sampson HA et al. Second Symposium on the definicon and management of anaphylaxis: summary report- Second NaConal InsCtute of Allergy and InfecCous Disease/Food Allergy Anaphylaxis Network symposium. J Allergy Clin Immunol 2006;117:391-7.

6 No known allergen exposure and Acute skin or mucosal.ssue involvement with EITHER respiratory compromise or reduced BP Likely exposure to allergen for this pacent and rapid development of two or more of Involvement of skin- mucosal Cssue Respiratory compromise Reduced BP or associated symptoms Persistent GI symptoms Known exposure to allergen for this pacent and reduced BP Sampson HA et al. Second Symposium on the definicon and management of anaphylaxis: summary report- Second NaConal InsCtute of Allergy and InfecCous Disease/Food Allergy Anaphylaxis Network symposium. J Allergy Clin Immunol 2006;117:391-7.

7 Acute onset of an illness (minutes to several hours) with involvement of the skin, mucosal.ssue, or both (e.g. generalized hives, pruritus or flushing, swollen lips- tongue- uvula) and at least ONE of the following: Respiratory compromise Reduced BP or associated symptoms of end- organ dysfunccon (hypotonia, syncope, inconcnence) Sampson HA et al. Second Symposium on the definicon and management of anaphylaxis: summary report- Second NaConal InsCtute of Allergy and InfecCous Disease/Food Allergy Anaphylaxis Network symposium. J Allergy Clin Immunol 2006;117:391-7.

8 Two or more of the following that occur rapidly a_er exposure to a likely allergen for that pacent (minutes to several hours): Involvement of skin- mucosal Cssue Respiratory compromise Reduced BP or associated symptoms Persistent GI symptoms Sampson HA et al. Second Symposium on the definicon and management of anaphylaxis: summary report- Second NaConal InsCtute of Allergy and InfecCous Disease/Food Allergy Anaphylaxis Network symposium. J Allergy Clin Immunol 2006;117:391-7.

9 Reduced BP a_er exposure to known allergen for that pacent (minutes to several hours): Infants and children Low systolic BP or greater than 30% decrease Adults SBP less than 90 or greater than 30% decrease from person s baseline Sampson HA et al. Second Symposium on the definicon and management of anaphylaxis: summary report- Second NaConal InsCtute of Allergy and InfecCous Disease/Food Allergy Anaphylaxis Network symposium. J Allergy Clin Immunol 2006;117:391-7.

10 How Common is Anaphylaxis?

11 Prevalence ranges from % The rate seems to be increasing especially in young people Incidence of fatal anaphylaxis is rare Ranges from 0.33 to 0.64 deaths per year per million (UK and Australia) Tang MLK et al. Epidemiology of anaphylaxis. Curr Opin Allergy Clin Immunol 2009; 9:

12 How does it happen?

13

14 Foods are most common cause of anaphylaxis in children MedicaCon and insect scngs are most common in adults Less common causes include: Latex Immunotherapy Exercise Cold Idiopathic

15 Fatal anaphylaxis usually occurs soon a_er trigger Case series data: Food typically min Insect scngs min IV medicacons 5 min

16 How to treat? Image from academiclifeinem.com

17 IniCal Steps Remove triggering agent PosiCon pacent Assess ABCs Epinephrine IV fluids

18 IniCal Steps? Remove triggering agent PosiCon pacent Epinephrine Assess ABCs IV fluids

19 Epinephrine

20 Epinephrine Mainstay of anaphylaxis therapy and should be first line therapy α and β effects counter act allergic reaccon

21 Dosing Challenges

22 Dose dependant on route of delivery Two concentracons available 1:1000 and 1:10,000 Nomenclature is ancquated and confusing PotenCal for errors

23 1: micrograms/ml or 1 mg/ml 1: micrograms/ml or 0.1 mg/ml

24 Delivery Routes

25 Inhalers Studies comparing inhaled epinephrine versus subcutaneous epinephrine Wide variability noted Not recommended for acute anaphylaxis

26 Subcutaneous Dosing same as intramuscular Wide variability in absorpcon Not recommended for acute anaphylaxis

27 Intramuscular Adult dose 0.3 to 0.5 mg IM mcg ml of the 1:1000 concentracon Pediatric dosing 0.01 mg/kg to a max of 0.3 mg

28 Auto- injectors

29 EpiPen

30 Auvi- Q

31 Intravenous Use with caucon Make sure use the proper concentracon 1:10000 Guidelines vary dramaccally

32 Bolus of 100 mcg given over 5-10 min Infusion started at 1mcg/min and increased to 4mcg/min as needed to prevent need for repeat injeccons Pediatric dosing Bolus as small as 1mcg/kg Might just start infusion of 0.1mcg/kg/min and Ctrate to a max of 1.5mcg/kg/min Barach, E. M., R. M. Nowak, et al. (1984). "Epinephrine for treatment of anaphylaccc shock." JAMA 251(16):

33 Titrate 50mcg boluses based on response If repeated dose needed then start infusion Pediatrics May respond to doses as small as 1mcg/kg Soar, J., R. Pumphrey, et al. (2008). "Emergency treatment of anaphylaccc reaccons- - guidelines for healthcare providers." ResuscitaCon 77(2):

34 5-15 mcg/min depending on severity Titrate to response and side effects Tachycardia, tremor, and pallor in the seqng of normal or raised BP considered toxicity and consider reducing rate Stop infusion 30 min post symptoms Normal Saline 1 Liter infused over 1-3 min Give if hypotension severe or doesn t respond to epinephrine Brown, S. G., K. E. Blackman, et al. (2004). "Insect scng anaphylaxis; prospeccve evaluacon of treatment with intravenous adrenaline and volume resuscitacon." Emerg Med J 21(2):

35 Don t fear Epi Reluctance to give epinephrine to middle aged or older pacents Use requires caucon but untreated anaphylaxis also targets the heart Dosing and monitoring are important

36 Special SituaCons

37 Beta Blocker Use Concurrent beta blocker use can cause a paradoxical reaccon to epinephrine Consider glucagon in these pacents 1-2mg IV repeat every 5 min if needed

38 Bradycardia RelaCve bradycardia can occur during anaphylaxis This may be due to a neurocardiogenic response These pacents may benefit from atropine

39 Hypotension Refractory hypotension a_er epinephrine and fluids Case reports suggest that vasopressin Could also consider norepinephrine

40 Cardiac Arrest Usually a PEA or Asytole arrest Special consideracons Aggressive large volume resuscitacon High Dose Epinephrine Prolonged CPR 2005 AHA Guidelines For Cardiopulmonary ResuscitaCon and Emergency Cardiovascular Care: Part 10.6: Anaphylaxis. CirculaCon 2005; 112; IV IV- 145.

41 AddiConal Treatments

42 AnChistamines H1 anchistamines Useful adjunct in allergic reaccons Oral doses take 1 3 hours to work Should not be first line in true anaphylaxis H2 anchistamines May provide addicve effect when used with H1 anchistamine Should not use alone in anaphylaxis

43 Steroids Decrease late phase allergic response No benefit in the acute phase of anaphylaxis

44 DisposiCon

45 MulCphasic ReacCons Common Up to 20% pacents Occur up to 72 hours No clear prediccve clinical features Decreased possibly associated with Rapid epinephrine administracon Adequate inical epinephrine dosing Early and higher doses of steroids Lieberman P. Biphasic anaphylaccc reaccons. Ann Allergy Asthma Immunol 2005;95:

46 ObservaCon Period Observe for 4-6 hours to monitor for biphasic reaccon and treatment effect Consider admission for extended observacon More severe cases Longer duracon to inical resolucon Poor social support

47 Discharge Planning Explain risk of subsequent reaccon and recommend they call an ambulance immediately Try to idencfy allergen and avoid Follow up with an allergist Provide pacent with prescripcon for epinephrine auto- injector Discharge with anchistamines and steroids for 72 hours Lieberman P et al. SAFE: a mulcdisciplinary approach to anaphylaxis educacon in the emergency department. Ann Allergy Asthma Immunol 2007;98:

48 Key Points Early and aggressive intervencon is important Epinephrine is mainstay of therapy 0.3 mg of Epinephrine IM Be caucous with dosing and routes of administracon of epinephrine Consider epinephrine auto- injector prescripcon and Allergist referral with all mild allergic reaccons

49

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