Anaphylaxis

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
    • Travel
  • 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]])
    • Physiology: IgG-mediated
  • 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
    • Strawberries
    • Tomatoes
  • 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
    • Interstitial edema
  • 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

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
    • Skin Symptoms
  • 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]
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