Epidemiology
Definitions
- Anaphylactoid Reaction: mechanism involves direct mast cell activation (importantly without prior sensitization)
- However, this is clinically indistinguishable from anaphylaxis
- Anaphylaxis: IgE-mediated mast cell activation (type I hypersensitivity reaction)
Specific Subset of Allergens Account for 90% of Anaphylaxis Cases
- Egg
- Fish/Shellfish
- Milk
- Soy
- Peanuts
- Tree Nuts
- Wheat
Risk Factors for Severe/Fatal Anaphylaxis
- Age-Related Factors
- Infant: inability to describe symptoms
- Adolescent/Young Adult: increased risk-taking behaviors that ay impede ability to obtain prompt medical care, etc
- Labor/Delivery: increased risk from medications
- Elderly: increased risk of fatality from medication or venom-associated anaphylaxis
- Concomitant Disease-Related Factors
- Allergic Rhinitis (see Allergic Rhinitis, [[Allergic Rhinitis]])
- Asthma/Other Respiratory Disease (see Asthma, [[Asthma]])
- Atopic Dermatitis (Eczema) (see Atopic Dermatitis, [[Atopic Dermatitis]])
- Cardiovascular Disease
- Clonal Mast Cell Disorder
- Systemic Mastocytosis (see Systemic Mastocytosis, [[Systemic Mastocytosis]])
- Psychiatric Illness
- Concomitant Medications/Toxins-Related Factors
- Angiotensin Converting Enzyme (ACE) Inhibitors (see Angiotensin Converting Enzyme Inhibitors, [[Angiotensin Converting Enzyme Inhibitors]])
- Antidepressants: use may impair the ability to recognize anaphylaxis triggers and symptoms
- β-Blockers (see β-Adrenergic Receptor Antagonists, [[β-Adrenergic Receptor Antagonists]])
- Ethanol (see Ethanol, [[Ethanol]]): use may impair the ability to recognize anaphylaxis triggers and symptoms
- Recreational Drugs: use may impair the ability to recognize anaphylaxis triggers and symptoms
- Sedatives: use may impair the ability to recognize anaphylaxis triggers and symptoms
- Presence of Physiologic Defect in Mediator Degradation Pathways
- Low Serum ACE Activity: impaired ability to degrade tryptase, histamine, bradykinin
- Low Serum PAF Acetylhydrolase Activity: impaired ability to degrade platelet-activating factor
Risk Factors Which Amplify Anaphylaxis
- Acute Infection
- Disruption of Routine
- Emotional Stress
- Exercise: best characterized amplifying factor
- Commonly Associated with Concomitant Ingestion of a Specific Food Trigger
- Celery
- Omega-5 Gliadin
- Shellfish
- Wheat
- Less Commonly Associated with Concomitant Ingestion of Ethanol or NSAID Drug: these enhance intestinal permeability and allergen absorption
- Premenstrual Status
Etiology
IgE-Mediated Mast Cell Activation (Type I Hypersensitivity) (see Immune Hypersensitivity, [[Immune Hypersensitivity]])
Foods/Food Additives (see Food Allergy, [[Food Allergy]])
- General Comments: specific food triggers vary geographically (due to different foods consumed and methods of preparation)
- North America/Some Countries in Europe and Asia: cow milk, hen’s egg, peanut, tree nuts, shellfish, and fish are common triggers
- European Countries: peach is a common trigger
- Middle East: sesame is common trigger
- Asia: buckwheat, chickpea, rice, and bird’s nest soup are common triggers
- Annatto (see Annatto, [[Annatto]]): yellow food colorant
- Carmine (see Carmine, [[Carmine]]): insect-derived red colorant
- Eggs
- Legumes: beans, lentils, peanuts, peas, soybeans/soy
- Milk: cow milk, goat milk, sheep milk
- Peach
- Red Meat
- Epidemiology: has also been described with lamb and some cuts of pork
- Physiology
- Tick Acquires the Oligosaccharide, Alpha-Gal, After Feasting on a Mammal, Retaining it in its Gastrointestinal Tract Until it Bites a Human: the bite provokes an IgE response in the human
- Alpha-Gal is Found in Red Meats
- Alpha-Gal is Also Found in Cetuximab (Erbitux) (see Cetuximab, [[Cetuximab]])
- Alpha-Gal May Also Be Found in Porcine Products, Such as Heart Valves and Heparin
- Clinical
- Alpha-Gal Related Meat Allergy is Unusual in that it has a Delayed Onset, Occurring 4-6 hrs After Meat Ingestion
- Alpha-Gal Associated Cetuximab (Erbitux) Allergy (see Cetuximab, [[Cetuximab]]): may occur on first exposure and may be severe, resulting in anaphylaxis
- Allergy May Recede Over Months-Years if Red Meat is Avoided
- Seafood: crustaceans, shellfish, finned fish, shrimp
- Sesame
- Spices
- Tree Nuts: almonds, cashews, walnuts
- Vegetable Gums
- Wheat
Stings/Bites/Envenomations
- Phylum Arthropoda -> Class Insecta -> Order Hymenoptera
- Bumble Bee Sting (see Bee Sting, [[Bee Sting]])
- Fire Ant Bite (see Fire Ant Bite, [[Fire Ant Bite]])
- Honey Bee Sting (see Bee Sting, [[Bee Sting]])
- Hornet Sting (see Hornet Sting, [[Hornet Sting]])
- Paper Wasp Sting (see Wasp Sting, [[Wasp Sting]])
- Wood Ant Bite
- Yellowjacket Sting (see Bee Sting, [[Bee Sting]])
- Phylum Arthropoda -> Class Insecta -> Order Hemiptera
- Bed Bug Bite (Cimex) (see Bed Bug Bite, [[Bed Bug Bite]]): may induce an anaphylaxis-like reaction (unknown if IgE-mediated)
- Kissing Bug Bite (Triatoma) (see Kissing Bug Bite, [[Kissing Bug Bite]])
- Phylum Arthropoda -> Class Insecta -> Order Diptera
- Phylum Arthropoda -> Class Insecta -> Order Lepidoptera
- Pine Processionary Caterpillar Envenomation
- Puss Caterpillar Envenomation (see Puss Caterpillar Envenomation, [[Puss Caterpillar Envenomation]]): may induce an anaphylaxis-like reaction (unknown if IgE-mediated)
- Phylum Arthropoda -> Class Arachnida
- Ixodes Holocyclus (Australian Paralysis Tick) Bite (see Tick Bite, [[Tick Bite]])
- Argas Reflexus (Pigeon Tick) Bite (see Tick Bite, [[Tick Bite]])
- Scorpion Sting (see Scorpion Sting, [[Scorpion Sting]]): particularly Centruroides (common striped scorpion)
- Ixodes Pacificus (Western Black-Legged Tick) Bite (see Tick Bite, [[Tick Bite]])
- Phylum Cnidaria
- Box Jellyfish (Carybdea Alata) Sting (see Jellyfish Sting, [[Jellyfish Sting]]): may induce an anaphylaxis-like reaction (unknown if IgE-mediated)
- Portuguese Man-of-War (Physalia Physalis) Sting: may induce an anaphylaxis-like reaction (unknown if IgE-mediated)
- Sea Nettle Sting
- Phylum Chordata -> Class Reptila
- European Viper (Vipera) Snake Bite
- Gila Monster Bite (see Poisonous Lizard Bite, [[Poisonous Lizard Bite]]): may induce an anaphylaxis-like reaction (unknown if IgE-mediated)
- Mexican Beaded Lizard Bite (see Poisonous Lizard Bite, [[Poisonous Lizard Bite]]): may induce an anaphylaxis-like reaction (unknown if IgE-mediated)
- Rattlesnake (Crotalus) Bite (see Rattlesnake Bite, [[Rattlesnake Bite]])
- Phylum Chordata -> Class Mammalia
- Gerbil Bite
- Hamster Bite
- Mouse Bite
- Rat Bite
Drugs
- Abacavir (see Abacavir, [[Abacavir]])
- Acetaminophen (Tylenol) (see Acetaminophen, [[Acetaminophen]])
- Epidemiology: cases of anaphylaxis have been reported
- Allergen Immunotherapy (Subcutaneous) (see Allergen Immunotherapy, [[Allergen Immunotherapy]])
- Alpha-1 Antitrypsin (Aralast, Glassia, Prolastin, Zemaira) (see Alpha-1 Antitrypsin, [[Alpha-1 Antitrypsin]]): occurs in <1% of cases
- Angiotensin Converting Enzyme (ACE) Inhibitors (see Angiotensin Converting Enzyme Inhibitors, [[Angiotensin Converting Enzyme Inhibitors]])
- Acyclovir (Zovirax) (see Acyclovir, [[Acyclovir]])
- Anti-Thymocyte Globulin (ATG) (see Anti-Thymocyte Globulin, [[Anti-Thymocyte Globulin]])
- Antivenoms
- β-Lactam Antibiotics (see β-Lactam Antibiotics, [[β-Lactam Antibiotics]])
- Cephalosporins (see Cephalosporins, [[Cephalosporins]])
- Imipenem (see Imipenem, [[Imipenem]]): cross-reactivity in 50% of patients with allergy to penicillins
- Penicillins (see Penicillins, [[Penicillins]]): occurs in 0.05% of cases, fatal in 5-10% of cases
- Demeclocycline (see Demeclocycline, [[Demeclocycline]])
- Gemcitabine (Gemzar) (see Gemcitabine, [[Gemcitabine]]): cases of laryngeal edema have been reported
- Heparin (see Heparin, [[Heparin]]): anaphylaxis is a manifestation of heparin-induced thrombocytopenia (HIT) (see Heparin-Induced Thrombocytopenia, [[Heparin-Induced Thrombocytopenia]])
- Insulin (see Insulin, [[Insulin]])
- Iodinated Drugs
- See Also Radiographic Contrast Below
- Local Anesthetics
- Lidocaine (see Lidocaine, [[Lidocaine]])
- Procaine (Novocaine, Novocain) (see Procaine, [[Procaine]])
- Monoclonal Antibodies/Biologics
- Cetuximab (Erbitux) (see Cetuximab, [[Cetuximab]])
- Physiology: tick bite-associated alpha-galactosidase sensitization has been found to be a mechanism of allergic sensitization to cetuximab and read meats (J Allergy Clin Immunol, 2015) [MEDLINE]
- Intravenous Immunoglobulin (IVIG) (see Intravenous Immunoglobulin, [[Intravenous Immunoglobulin]])
- Omalizumab (Xolair) (see Omalizumab, [[Omalizumab]]): rare etiology of anaphylaxis
- Rituximab (Rituxan) (see Anti-CD20 Therapy, [[Anti-CD20 Therapy]])
- N-Acetylcysteine (Mucomyst, Acetadote, Fluimucil, Parvolex) (see N-Acetylcysteine, [[N-Acetylcysteine]])
- Epidemiology: associated with intravenous administration
- Physiology: histamine release has been implicated
- Non-Dextran Intravenous Iron
- Ferumoxytol (Feraheme) (see Ferumoxytol, [[Ferumoxytol]])
- Risk of First-Exposure Anaphylaxis (see Anaphylaxis, [[Anaphylaxis]]) [MEDLINE]: 24 per 100k patients
- Iron Gluconate (Ferrous Gluconate, Fergon, Ferralet, Simron) (see Iron Gluconate, [[Iron Gluconate]])
- Risk of First-Exposure Anaphylaxis (see Anaphylaxis, [[Anaphylaxis]]) [MEDLINE]: 24 per 100k patients
- Iron Sucrose (Venofer) (see Iron Sucrose, [[Iron Sucrose]])
- Risk of First-Exposure Anaphylaxis (see Anaphylaxis, [[Anaphylaxis]]) [MEDLINE]: 24 per 100k patients
- Cumulative Risk of Anaphylaxis (Over 12 wk Period) [MEDLINE]: iron sucrose has lowest risk of all of the intravenous iron agents
- Nonsteroidal Anti-Inflammatory Drugs (NSAID’s) (see Nonsteroidal Anti-Inflammatory Drug, [[Nonsteroidal Anti-Inflammatory Drug]])
- Epidemiology: NSAID’s rarely cause allergic reactions via this mechanism
- Platins
- Carboplatin (see Carboplatin, [[Carboplatin]])
- Cisplatin (see Cisplatin, [[Cisplatin]])
- Oxaliplatin (Eloxatin, Oxaliplatin Medac) (see Oxaliplatin, [[Oxaliplatin]]): anaphylaxis occurs in 1.3% of cases
- Progesterone (see Progesterone, [[Progesterone]])
- Protamine (see Protamine, [[Protamine]])
- Radiographic Contrast (see Radiographic Contrast, [[Radiographic Contrast]])
- Epidemiology: although contrast-associated IgE-mediated anaphylaxis was once considered rare, contrast-specific IgE antibodies have been demonstrated in some cases (Am J Roentgenol, 2008) [MEDLINE] (Allerg Immunol, 1993; Paris) [MEDLINE]
- Physiology
- IgE-Mediated: some cases
- Non-IgE-Mediated: most cases
- Activation of Coagulation/Kinin/Complement Cascades
- Direct Mast Cell Activation
- Inhibition of Cholinesterase
- Inhibition of Platelet Aggregation with Increased Serotonin Release
- Sorafenib (Nexavar) (see Sorafenib, [[Sorafenib]])
- Streptomycin (see Streptomycin, [[Streptomycin]])
- Succinylcholine (see Succinylcholine, [[Succinylcholine]])
- Sulfobromophthalein
- Taxanes (see Taxanes, [[Taxanes]])
- Docetaxel (Taxotere) (see Docetaxel, [[Docetaxel]])
- Paclitaxel (Taxol) (see Paclitaxel, [[Paclitaxel]])
- Vaccines: may be due to either egg or gelatin components of the vaccine
- Vitamin K (see Vitamin K, [[Vitamin K]])
Other
- Aeroallergens: rarely involved in angioedema/anaphylaxis
- Cat Dander
- Grass Pollen
- Horse Dander
- Allergen Immunotherapy (see Allergen Immunotherapy, [[Allergen Immunotherapy]])
- Blood Products
- Fluorescein (see Fluorescein, [[Fluorescein]])
- Hemodialysis (see Hemodialysis, [[Hemodialysis]]): due to reaction to dialysis membranes
- Cellulose Membranes: predominant type of membrane associated with anaphylaxis
- Membranes are ethylene oxide sterilized
- Membranes can activate complement
- Polyacrylonitrile AN69 High Flux Membranes: fewer reported cases of anaphylaxis
- Human Seminal Fluid
- Epidemiology: rare etiology of anaphylaxis in females
- Intradermal Allergen Skin Testing
- Natural Rubber Latex (see Latex, [[Latex]])
- Occupational Allergens
- Vaccines
Immunologic Non-IgE-Mediated Mast Cell Activation
- Heparin Contaminated with Oversulfated Chondroitin Sulfate (see Heparin, [[Heparin]])
- Physiology: mediated by coagulation system activation
- Dextrans
- Dextran (see Dextran, [[Dextran]])
- Iron Dextran (Dexferrum, INFeD) (see Iron Dextran, [[Iron Dextran]])
- Risk of First-Exposure Anaphylaxis (see Anaphylaxis, [[Anaphylaxis]] [MEDLINE]): 68 per 100k patients
- Cumulative Risk of Anaphylaxis (Over 12 wk Period) [MEDLINE]: iron dextrose has highest risk of all of the intravenous iron agents
- Idiopathic Histaminergic Angioedema
- Clinical: recurrent angioedema often associated with chronic spontaneous urticaria or inducible (physical) urticaria
- Infliximab (Remicade) (see Infliximab, [[Infliximab]])
- Packed Red Blood Cells (PRBC) (see Packed Red Blood Cells, [[Packed Red Blood Cells]])
- Epidemiology: rare cases of patients with very low levels of IgA and anti-IgA Ab’s, may develop anaphylaxis upon receiving blood with IgA present (these patients need IgA-deficient blood products)
Non-Immunologic Direct Mast Cell/Basophil Activation
- Ethanol (see Ethanol, [[Ethanol]]): rarely induces anaphylaxis by itself, but may augment mast cell activation
- Foods: these “pseudoallergens” may cause urticaria (or contact urticaria) via IgE-mediated or via non-immunologic mechanisms, especially in children
- Neuromuscular Junction Antagonists (see Neuromuscular Junction Antagonists, [[Neuromuscular Junction Antagonists]])
- Relative Incidence (in Australian Study from 2002-2011): Rocuronium (56% of cases) > Succinylcholine (21% of cases) > Vecuronium (11% of cases) (Br J Anaesth, 2013) [MEDLINE])
- Cisatracurium Had the Lowest Prevalence of Cross-Reactivity in Patients with Known Anaphylaxis to Either Rocuronium or Vecuronium
- Atracurium (see Atracurium, [[Atracurium]])
- Cisatracurium (Nimbex) (see Cisatracurium, [[Cisatracurium]])
- Curare (see Curare, [[Curare]])
- Rocuronium (Zemuron) (see Rocuronium, [[Rocuronium]])
- Succinylcholine (see Succinylcholine, [[Succinylcholine]])
- Vecuronium (see Vecuronium, [[Vecuronium]])
- Opiates (see Opiates, [[Opiates]])
- Physical Factors
- Cold
- Heat
- Exercise: usually associated with a co-trigger (such as a food, NSAID, or exposure to cold air or water)
- Sunlight/Ultraviolet Radiation
- Radiographic Contrast (see Radiographic Contrast, [[Radiographic Contrast]])
- Epidemiology: although contrast-associated IgE-mediated anaphylaxis was once considered rare, contrast-specific IgE antibodies have been demonstrated in some cases (Am J Roentgenol, 2008) [MEDLINE] (Allerg Immunol, 1993; Paris) [MEDLINE]
- Physiology
- IgE-Mediated: some cases
- Non-IgE-Mediated: most cases
- Activation of Coagulation/Kinin/Complement Cascades
- Direct Mast Cell Activation
- Inhibition of Cholinesterase
- Inhibition of Platelet Aggregation with Increased Serotonin Release
- Some Non-Steroidal Anti-Inflammatory Drugs (NSAID) (see Non-Steroidal Anti-Inflammatory Drug, [[Non-Steroidal Anti-Inflammatory Drug]])
- Stinging Nettle (Urtica Dioica) (see Stinging Nettle, [[Stinging Nettle]]): urticaria was named after this weed (which is commonly found in North America, South Americam Europe, and parts of Africa
- Physiology: histamine (and pain-causing mediators) contained in the plant
- Vancomycin (see Vancomycin, [[Vancomycin]])
Other
- Clonal Mast Cell Disorder
- Systemic Mastocytosis (see Systemic Mastocytosis, [[Systemic Mastocytosis]])
- Previously Unrecognized Allergen
Physiology
Molecular Mechanism of Anaphylaxis
- Mast Cell/Basophil Activation with Release of Multiple Mediators
- Histamine
- IL-4
- IL-13
- Leukotrienes
- Platelet Activating Factor
- Prostaglandin D2 (PGD2)
- TNFα
- Tryptase
Distributive Shock (Similar to Sepsis) (see Hypotension, [[Hypotension]])
- Variable Cardiac Output (CO)
- Early (Before Volume Resuscitation): hypovolemia predominates -> decreased preload -> normal or decreased CO
- Later (After Volume Resuscitation): high CO with low SVR state
- Myocardial depression (decreased ejection fraction observed on echocardiogram) is frequent, despite increased CO
- Venous and Arterial Vasodilation
- Capillary Leak: due to endothelial cell dysfunction
- Tachycardia: due to hypotension-induced reflexive increase in heart rate
- Hypovolemia (early in course): due to capillary leak and venous/arterial vasodilation
Diagnosis
Mast Cell Serum Tryptase Level (see Serum Tryptase, [[Serum Tryptase]])
- Draw within hours of event to diagnose anaphylaxis
- May not be elevated in some cases
RAST Testing
- Useful for Allergy Testing: detects allergen-specific IgE
Chest X-Ray (CXR) (see Chest X-Ray, [[Chest X-Ray]])
- Normal CXR: most common pattern
- Hyperinflation: may indicate the presence of bronchospasm
- Pulmonary Edema: may occur in severe cases
Diagnostic Criteria (One of Three Following Criteria) [MEDLINE]
Acute Onset of Illness (Within Min-Several Hours) with Skin/Mucosal Tissue Involvement (Flushing/Generalized Erythema, Hives, Pruritus, Swollen Lips/Tongue/Uvula) and At Least One of the Following
- Respiratory Compromise
- Hypotension or Associated End-Organ Dysfunction
Two or More of the Following Occurring Rapidly After Exposure to a Likely Antigen
- Involvement of Skin/Mucosal Tissue
- Respiratory Compromise
- Hypotension or Associated End-Organ Dysfunction
- Persistent Gastrointestinal Symptoms
Hypotension After Exposure to a Known Allergen for a Specific Patient Within Min-Several Hours (see Hypotension, [[Hypotension]])
- Adult: systolic blood pressure 90 mm Hg or >30% in systolic blood pressure from patient’s baseline
- Infant/Children: age-specific hypotension or >30% decrease in systolic blood pressure
Clinical Manifestations
General Comments
- Onset: within min-4 hrs
- Biphasic Reaction: symptoms can recur 10 hrs later -> due to this clinical characteristic, prolonged observation may be required (and corticosteroids are often useful to blunt the development of the second phase)
Cardiovascular Manifestations
- General Comments
- Cardiovascular Manifestations Occur in 45% of Cases
- Sinus Bradycardia (see Sinus Bradycardia, [[Sinus Bradycardia]]): may occur in some cases
- Hypotension/Cardiovascular Collapse (see Hypotension, [[Hypotension]]): common
- Palpitations (see Palpitations, [[Palpitations]])
- Sinus Tachycardia (see Sinus Tachycardia, [[Sinus Tachycardia]]): common
- Syncope (see Syncope, [[Syncope]])
Dermatologic Manifestations
- General Comments
- Dermatologic Manifestations Occur in 80-90% of Cases
- Angioedema (see Angioedema, [[Angioedema]])
- Erythematous Rash/Flushing (see Erythroderma, [[Erythroderma]] or Flushing, [[Flushing]])
- Pruritus (see Pruritus, [[Pruritus]])
- Rash
- Urticaria (see Urticaria, [[Urticaria]])
Gastrointestinal Manifestations
- General Comments
- Gastrointestinal Manifestations Occur in 45% of Cases
- Crampy Abdominal Pain (see Abdominal Pain, [[Abdominal Pain]])
- Diarrhea (see Diarrhea, [[Diarrhea]])
- Nausea/Vomiting (see Nausea and Vomiting, [[Nausea and Vomiting]])
Neurologic Manifestations
- Dizziness (see Dizziness, [[Dizziness]])
- Lightheadedness
- Sense of Impending Doom
Otolaryngologic Manifestations
- Conjunctival Injection
- Lacrimation
- Metallic Taste
- Nasal Congestion
- Ocular Pruritus
- Oropharyngeal Edema/Upper Airway Obstruction (see Obstructive Lung Disease, [[Obstructive Lung Disease]])
- Clinical
- Drooling
- Dysphagia
- Dysphonia
- Hoarseness (see Hoarseness, [[Hoarseness]])
- Inability to Speak
- Lingual Edema (see Lingual Edema, [[Lingual Edema]])
- Stridor (see Stridor, [[Stridor]])
- Peri-Orbital Edema
- Rhinorrhea (see Rhinorrhea, [[Rhinorrhea]])
- Sneezing
Pulmonary Manifestations
- General Comments
- Pulmonary Manifestations Occur in 70% of Cases
- Acute Respiratory Distress Syndrome (ARDS) (see Acute Respiratory Distress Syndrome, [[Acute Respiratory Distress Syndrome]]): may occur in severe cases
- Acute Respiratory Failure (see Respiratory Failure, [[Respiratory Failure]])
- Physiology: high-grade upper airway obstruction or bronchospasm with excessive work of breathing
- Clinical
- Bronchospasm (see Obstructive Lung Disease, [[Obstructive Lung Disease]])
- Clinical
- Dry Cough (see Cough, [[Cough]])
- Dyspnea (see Dyspnea, [[Dyspnea]])
- Wheezing (see Wheezing, [[Wheezing]])
- Tachypnea (see Tachypnea, [[Tachypnea]])
Other Manifestations
- Uterine Contractions: in females
Anaphylactoid Reactions to Contrast Medium
Cutaneous and Mucosal
- Angioedema
- Edema
- Flushing
- Laryngeal Edema
- Pruritus
Smooth Muscle
- Arrhythmia
- Bronchospasm
- Cardiovascular
- GI Spasm
- Uterine Contraction
- Vasodilation/Hypotension/Anaphylactic Shock
Types of Contrast Reactions
Minor
- Flushing
- Nausea
- Pruritus
- Rash
- Urticaria
Major
- Cough
- Dyspnea
- Seizures
- Shock
- Stridor
- Syncope
- Wheezing
Treatment
General Treatment
- Airway Management (see Airway Management, [[Airway Management]])
- Intravenous Fluid Management: as required
- Eliminate Source/Eliminate Contact with Antigen (If Known): crucial
Epinephrine (see Epinephrine, [[Epinephrine]])
- Indications
- Systemic Symptoms (Hypotension, etc)
- Pharmacology
- Bronchodilation
- Vasoconstriction
- Adverse Effects
- Dose: 0.3 mg IM (1:1000) for adults
- Repeat Dosing: may repeat q5-10 min
- Max Single Dose: 1 mg
- Max Total Dose: none
- Preferred Route of Administration
- Non-Code Blue Situation: IM into thigh is preferred over SQ route
- Code Blue Situation: IV route (with 1:10,000 solution) is preferred
Preloaded Epinephrine Injectable Devices
- Advantages
- Patient Can Keep Nearby at Home for Emergency Use: do not store in warm/hot places (such as a car), due to drug stability
- Shelf-Life: 1 year (when stored properly)
- Adult Dose: 0.3 mg IM (1:1000) for adults
- Brands
- Epipen
- Hold like a pen, not like a knife (to avoid inadvertent injection into the thumb)
- Remove blue safety cap -> firmly push orange tip against lateral thigh (don’t need to remove clothes to use), until it clicks -> hold in place for 5-10 sec
- Auvi-Q: provides verbal instructions
- Adrenaclick: pen-like device
Corticosteroids (see Corticosteroids, [[Corticosteroids]])
- Pharmacology
- Administration
- PO: Prednisone (see Prednisone, [[Prednisone]])
- Dose: 40-50 mg qday PO with taper
- IV: Methylprednisolone (Solumedrol) (see Methylprednisolone, [[Methylprednisolone]])
- Dose: 125 mg IV x1, then 60 mg IV q6hrs with taper
H1-Histamine Receptor Antagonists (see (see H1-Histamine Receptor Antagonists, [[H1-Histamine Receptor Antagonists]])
- Indications
- Pharmacology: H1-Histamine Receptor Antagonist
- Agents
- Diphenhydramine (Benadryl) (see Diphenhydramine, [[Diphenhydramine]]): 25-50 mg IV PRN
H2-Histamine Receptor Antagonists (see H2-Histamine Receptor Antagonists, [[H2-Histamine Receptor Antagonists]])
- Pharmacology: H2-Histamine Receptor Antagonist
- Agents
- Cimetidine (Tagamet) (see Cimetidine, [[Cimetidine]])
- Famotidine (Pepcid) (see Famotidine, [[Famotidine]])
- Administration: 20 mg IV q12hrs
- Ranitidine (Zantac) (see Ranitidine, [[Ranitidine]])
References
- Physiologic manifestations of human anaphylaxis. J Clin Invest 1980; 66:1072-1080 [MEDLINE]
- Hemodynamic changes in human anaphylaxis. Am J Med 1984; 77:341-344 [MEDLINE]
- Profound reversible myocardial depression after anaphylaxis. Lancet 1988; 1:386-388 [MEDLINE]
- Anaphylactic shock induced by paracetamol. Eur J Clin Pharmacol. 1990;38(4):389 [MEDLINE]
- Anaphylaxis-induced myocardial depression treated with amrinone. Lancet 1991; 337:682-683 [MEDLINE]
- Anaphylaxis. N Engl J Med 1991; 324:1785-1786 [MEDLINE]
- Histamine decreases left ventricular contractility in normal human subjects. J Appl Physiol 1992; 73:2530-2537 [MEDLINE]
- Paracetamol anaphylaxis. Clin Exp Allergy. 1992;22(9):831 [MEDLINE]
- Case report: recurrent anaphylactic shock to radiographic contrast media. Evidence supporting an exceptional IgE-mediated reaction. Allerg Immunol (Paris). 1993;25(10):425 [MEDLINE]
- Anaphylaxis induced by horsefly bites: identification of a 69 kd IgE-binding salivary gland protein from Chrysops spp. (Diptera, Tabanidae) by western blot analysis. J Allergy Clin Immunol. 1998;101(1 Pt 1):134. [MEDLINE]
- Second symposium on the definition and management of anaphylaxis: summary report–Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network symposium. J Allergy Clin Immunol. 2006 Feb;117(2):391-7 [MEDLINE]
- Anaphylaxis to iodinated contrast material: nonallergic hypersensitivity or IgE-mediated allergy? AJR Am J Roentgenol. 2008;190(3):666 [MEDLINE]
- Anaphylaxis. J Allergy Clin Immunol. 2010;125(2 Suppl 2):S161 [MEDLINE]
- World allergy organization guidelines for the assessment and management of anaphylaxis. World Allergy Organ J. 2011 Feb;4(2):13-37. doi: 10.1097/WOX.0b013e318211496c [MEDLINE]
- The relevance of tick bites to the production of IgE antibodies to the mammalian oligosaccharide galactose-α-1,3-galactose. J Allergy Clin Immunol. 2011;127(5):1286. Epub 2011 Mar 31 [MEDLINE]
- Anaphylaxis to neuromuscular blocking drugs: incidence and cross-reactivity in Western Australia from 2002 to 2011. Br J Anaesth. 2013 Jun;110(6):981-7. doi: 10.1093/bja/aes506. Epub 2013 Jan 18 [MEDLINE]
- Tick bites and red meat allergy. Curr Opin Allergy Clin Immunol. 2013 Aug;13(4):354-9. doi: 10.1097/ACI.0b013e3283624560 [MEDLINE]
- International consensus on (ICON) anaphylaxis. World Allergy Organ J. 2014; 7(1): 9 [MEDLINE]
- The alpha-gal story: lessons learned from connecting the dots. J Allergy Clin Immunol. 2015;135(3):58 [MEDLINE]
- Comparative Risk of Anaphylactic Reactions Associated With Intravenous Iron Products. JAMA. 2015 Nov 17;314(19):2062-2068. doi: 10.1001/jama.2015.15572 [MEDLINE]
- Red meat allergy induced by tick bites: A Norwegian case report. Eur Ann Allergy Clin Immunol. 2017 Jul;49(4):186-188 [MEDLINE]