Anaphylaxis

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Anaphylaxis   is   a   severe,   life-threatening,  generalised   or   systemic   hypersensitivity  reaction characterised by rapidly developing life-threatening airway (pharyngeal or laryngeal edema) and/or  breathing (bronchospasm  and  tachypnea)  and/or  circulation  (hypotension  and  tachycardia)  problems usually associated with skin and mucosal changes. 

Clinical presentation 

  • Hives
  • Angioedema
  • Wheezes
  • Difficult breathing
  • Diarrhoea
  • Hypotension

Anaphylaxis is a clinical diagnosis and should be suspected when: 

  • Acute onset involving skin, mucosal tissue with either respiratory compromization or blood pressure reduction (or syncope)
  • Hypotension after exposure to a known allergy for the patient (SBP <90mmHg or >30% from baseline)
  • Respiratory compromise (i.e dyspnoea, stridor, wheeze, hypoxemia)
  • Exposure  to  a  likely  allergen  causing  involvement  of  the  skin,  mucosal,  respiratory compromization or blood pressure reduction

Investigations 

Blood gases, Serum Electrolytes, POC ECG, Troponin, CXR and/or POC USS 

Non pharmacological management 

  • Perform both primary and secondary assessment. If patient has signs of severe respiratory distress perform early intubation/surgical airway
  • Give oxygen if hypoxic (spO2 below 95%) or severe respiratory distress
  • Insert TWO large bore IV cannulas or obtain intraoseous access

Pharmacological Management 

A: adrenaline (IM): Adult 0.3-0.5mg (maximum 0.5mg) every 5-15min as soon as possible. If  inadequate  response,  start  adrenaline  (IV)  2-10mcg/min  in  0.9%  sodium  chloride  (IV)  OR  Ringer lactate (IV) 1-2 litres. If hypotensive. Repeat IV fluids as needed; Paediatric 0.01mg/kg,  every  5-15min  as  soon  as  possible.    If  inadequate  response,  start  adrenaline  (IV)  0.05- 1mcg/kg/min  in  0.9%  sodium  chloride  (IV)ORcompound  sodium  lactate  (IV)  20mls/kg  if  hypotensive. Repeat IV fluids as needed 

OR 

A: hydrocortisone (IV)200mg stat 

OR 

B: salbutamol (nebulisation) 10mg and equal volume of water for injection (This is useful to 

patients with refractory bronchospasm).   

OR  

D: methylprednisolone (IV) 1-2mg/kg/day 

Disposition 

All  patient  with  severe  and  moderate  symptoms  which  required  repeated  doses  of  adrenaline  or  didn’t respond to treatment must be admitted or referred to higher health facility. Those with mild  response which responded to IM adrenaline may be discharged after 4 hours’ observation at the  health facility.