4. Criteria for diagnosing anaphylaxis 1
Anaphylaxis is highly likely when any one of the following 3 criteria are fulfilled:
1. Acute onset of an illness (minutes to several hours) with involvement of the skin, mucosal tissue, or
both (eg, generalized hives, pruritus or
(eg,
flushing, swollen lips-tongue-uvula)
lips-tongueAND AT LEAST ONE OF THE FOLLOWING
a. Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, reduced PEF, hypoxemia)
(eg, dyspnea, wheeze-bronchospasm, stridor,
b. Reduced BP or associated symptoms of end-organ dysfunction (eg, hypotonia [collapse], syncope,
end(eg,
incontinence)
2. Two or more of the following that occur rapidly after exposure to a likely allergen for that patient
(minutes to several hours):
a. Involvement of the skin-mucosal tissue (eg, generalized hives, itch-flush, swollen lips-tongue-uvula)
skin(eg,
itchlips-tongueb. Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, reduced PEF, hypoxemia)
(eg, dyspnea, wheeze-bronchospasm, stridor,
c. Reduced BP or associated symptoms (eg, hypotonia [collapse], syncope, incontinence)
(eg,
d. Persistent gastrointestinal symptoms (eg, crampy abdominal pain, vomiting)
(eg,
3. Reduced BP after exposure to known allergen for that patient (minutes to several hours):
a. Infants and children: low systolic BP (age specific) or greater than 30% decrease in systolic BP*
b. Adults: systolic BP of less than 90 mm Hg or greater than 30% decrease from that person’s baseline
Sampson HA et al. J Allergy Clin Immunol 2006; 117:391 - 397
2006; 117:
5. Criteria for diagnosing anaphylaxis 2
Anaphylaxis is highly likely when any one of the following 3 criteria
are fulfilled:
1. Acute onset of an illness (minutes to several hours) with involvement of
the skin, mucosal tissue, or both (eg, generalized hives, pruritus or
(eg,
flushing, swollen lips-tongue-uvula)
lips-tongueAND AT LEAST ONE OF THE FOLLOWING
a. Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor,
(eg, dyspnea, wheeze-bronchospasm, stridor,
reduced PEF, hypoxemia)
b. Reduced BP or associated symptoms of end-organ dysfunction (eg,
end(eg,
hypotonia [collapse], syncope, incontinence)
Sampson HA et al. J Allergy Clin Immunol 2006; 117:391 - 397
2006; 117:
6. Criteria for diagnosing anaphylaxis 3
Anaphylaxis is highly likely when any one of the following 3 criteria
are fulfilled:
2. Two or more of the following that occur rapidly after exposure to a likely
allergen for that patient (minutes to several hours):
a. Involvement of the skin-mucosal tissue (eg, generalized hives, itch-flush,
skin(eg,
itchswollen lips-tongue-uvula)
lips-tongueb. Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor,
(eg, dyspnea, wheeze-bronchospasm, stridor,
reduced PEF, hypoxemia)
c. Reduced BP or associated symptoms (eg, hypotonia [collapse], syncope,
(eg,
incontinence)
d. Persistent gastrointestinal symptoms (eg, crampy abdominal pain,
(eg,
vomiting)
Sampson HA et al. J Allergy Clin Immunol 2006; 117:391 - 397
2006; 117:
7. Criteria for diagnosing anaphylaxis 4
Anaphylaxis is highly likely when any one of the following 3 criteria
are fulfilled:
3. Reduced BP after exposure to known allergen for that patient (minutes to
several hours):
a. Infants and children: low systolic BP (age specific) or greater than 30%
decrease in systolic BP*
b. Adults: systolic BP of less than 90 mm Hg or greater than 30% decrease
from that person’s baseline
PEF, Peak expiratory flow; BP, blood pressure.
*Low systolic blood pressure for children is defined as less than 70 mm Hg from 1
month to 1 year, less than (70 mm Hg + [2 x age]) from 1 to 10 years,
(70
and less than 90 mm Hg from 11 to 17 years.
Sampson HA et al. J Allergy Clin Immunol 2006; 117:391 - 397
2006; 117:
8. Incidence of anaphylaxis
No exact incidence.
incidence.
Increased from 0.26 per10,000 persons
per10,
in 1992 to 4.6 per 10,000 persons in
10,
2001.
2001.
Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1027-49
2009.
1027Techapornroong M et al. Asian Pac J Allergy Immunol 2010;28:262-9
2010;28:262-
9. Incidence of Anaphylaxis to Specific Agents 1
Antibiotics
Most common cause of drug induced
anaphylaxis.
Latex
Increased incidence last decade.
Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1027-49
1027-
10. Incidence of Anaphylaxis to Specific Agents 2
Radiocontrast media
Introduction of lower osmolarity agents
reduced reaction rate.
Hymenoptera stings
Incidence ranges from 0.4-0.8% of
children and 3% of adults.
Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1027-49
2009.
1027-
11. Incidence of Anaphylaxis to Specific Agents 3
Food
0.0004% of US population per year.
0004%
Shellfish most common in adults, and
peanuts in children.
Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1027-49
1027-
12. Incidence of Anaphylaxis to Specific Agents 4
Perioperative anaphylaxis
Most common agents are muscle relaxants,
which account for 62% of reactions.
62%
Non Steroidal Anti-Inflammatory Drugs
Anti(NSAIDs)
Probably second most common offending
drug next to antibiotics.
Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1027-49
2009.
1027-
13. Incidence of Anaphylaxis to Specific Agents 5
Antisera
Incidence for antilymphocyte globulin as
high as 2% and incidence to antivenom
4.6-10%
10%
Idiopathic
Estimated between 20,592 - 47,024
20,
47,
cases in USA
Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1027-49
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14. Factors affecting the incidence
and/or severity of anaphylaxis
Age
Comorbidities
Concurrent medication/chemical use
Other factors
Simons FE, JACI 2010;125:161-81
2010;125:161-
15. Pathophysiology 1
Anaphylaxis : allergic
IgE mediated
Foods,
Drugs
Insect stings and bites
Exercise (food dependent)
dependent)
NonNon-IgE mediated
Immune aggregates
IgG anti-IgA
antiCytotoxic
Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1027-49
2009.
1027-
16. Pathophysology 2
Anaphylaxis : non-allergic
nonDirect mediator release from mast cells and
basophils
Drugs such as opiates
Physical factors : Cold, Sunlight
Idiopathic
Exercise
Activation of contact system
Dialysis membranes
Radiocontrast media
Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1027-49
1027-
17. Pathophysiology 3
Anaphylaxis : non-allergic
nonDisturbances in arachidonic acid metabolism
Aspirin
Other non-steroidal antiinflammatory drugs
nonMultimediator recruitment Complement
Clotting
Clot lysis
Contact system
Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1027-49
2009.
1027-
19. Dynamics of cardiovascular abnormality
At onset of
reaction
Blood pressure
↓
Early stage
(minutes)
with no
treatment
Prolonged
shock
↓↓
↓↓↓
↓
↓↓
→↓
→ ↓
Pulse
Cardiac output
Peripheral
vascular
resistance
↓
→↓
↓
↓↓↓
Intravascular
Lieberman In: Allergy: Principles and Practice. Mosby, 2003
volume
Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1027-49
1027-
20. Signs and Symptoms of Anaphylaxis 1
Signs and symptoms
Cutaneous
Percentage
>90
Urticaria and angioedema
85-90
85-
Flush
4545-55
Pruritus without rash
2-5
2-
Respiratory
40-60
40-
Dyspnea,
Dyspnea, wheeze
45-50
45-
Upper airway angioedema
50-60
50-
Rhinitis
1515-20
Dizziness, syncope, hypotension
3030-35
Abdominal
Nausea, vomiting, diarrhea, cramping pain
2525-30
Miscellaneous
Headache
55-8
Substernal pain
4-6
4-
Seizure
11-2
Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1027-49
2009.
1027-
21. Signs and Symptoms of Anaphylaxis 2
Biphasic anaphylaxis
Uniphasic anaphylaxis
Protracted anaphylaxis
Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1027-49
2009.
1027-
22. Severity of anaphylaxis reaction
Grade
Skin
GI tract
Res.
CVS
Neuro
1 Mild
Sudden itching
of eyes and
nose,
generalized
prurituis,
prurituis,
flushing,
urticaria,
urticaria,
angioedema,
angioedema,
Oral pruritus,
pruritus,
oral tingling,
mild lip
swelling,
nausea
or emesis, mild
abdominal pain
Nasal
congestion
and/or
sneezing,
rhinorrhoea,
rhinorrhoea,
throat pruritis,
pruritis,
throat
tightness, mild
wheezing
Tachycardia
(increase
>15
beats/min)
Change in
activity level
plus anxiety
2 Moderate
Any of the
above
Any of the
above, crampy
abdominal
pain,
diarrhoea,
diarrhoea,
recurrent
vomiting
Any of above,
hoarseness,bar
ky
cough,
difficulty
swallowing,
stridor,
stridor,
dyspnoea,
dyspnoea,
moderate
wheezing
As above
Light
headedness
feeling of
pending doom
3 Severe
Any of the
above,
Any of the
above loss of
bowel control
Any of the
above,
cyanosis or
Saturation
<92%,
respiratory
arrest
Hypotension*
and/or
collapse,
dysrhythmia,
dysrhythmia,
severe
bradycardia
and/or cardiac
arrest
Confusion, loss
of
consciousness
* Hypotension defined as systolic blood pressure: 1 month to 1 year <70 mmHg; 1–10 years< [70 mmHg +
<70
[70
(2 x age)]; 11–17 years <90 mmHg.
11–
<90
Muraro et al. Allergy 2007: 62: 857–871
2007: 62: 857–
23. Differential diagnosis of anaphylaxis 1
Vasodepressor reactions
Flush syndromes
Carcinoid
Menopause
Chlorpropamide–alcohol
Medullary carcinoma thyroid
Autonomic epilepsy
Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1027-49
2009.
1027-
24. Differential diagnosis of anaphylaxis 2
‘Restaurant syndromes’
Monosodium glutamate (MSG)
Sulfites
Scrombroidosis
Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1027-49
1027-
25. Differential diagnosis of anaphylaxis 3
Excess endogenous production of
histamine syndromes
Systemic mastocytosis
Urticaria pigmentosa
Basophilic leukemia
Acute promyelocytic leukemia (tretinoin
Hydatid cyst
treatment)
Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1027-49
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26. Differential diagnosis of anaphylaxis 4
Other forms of shock
Hemorrhagic
Cardiogenic
Endotoxic
Non-organic disease
Panic attacks
Vocal cord dysfunction syndrome
Undifferentiated somatoform anaphylaxis
Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1027-49
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27. Differential diagnosis of anaphylaxis 5
Miscellaneous
Hereditary angioedema
‘Progesterone’ anaphylaxis
Urticarial vasculitis
Hyperimmunoglobulin E, urticaria syndrome
Neurologic (seizure, stroke)
Pseudoanaphylaxis
Red man syndrome (vancomycin)
Capillary leak syndrome
Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1027-49
2009.
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28. Laboratory 1
Histamine
Plasma histamine rise within 5- 10 min.
and remain 30-60 min.
30Urinary histamine metabolites elevated
longer period of time.
Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1027-49
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29. Laboratory 2
Serum tryptases
Peak 60-90 min.
60Persist longer than plasma histamine
levels but not as long as 5 hours.
Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1027-49
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33. Medication
Epinephrine
Antihistamines ( H1, H2 )
β-Adrenergic agonist
Glucocorticoid
Volume expanders
Atropine
Glucagon
Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1027-49
2009.
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34. PhysicianPhysician-Supervised Management of Anaphylaxis 1
I. Immediate Intervention
a) Assessment of airway, breathing,
circulation, and mentation.
mentation.
b) Administer EPI, 1:1000 dilution, 0.3 - 0.5
ml (0.01 mg/kg in children, max 0.3 mg
dosage) IM, to control Symptoms and BP
Repeat as necessary.
Stephen F. Kemp et al.JACI 2002
35. PhysicianPhysician-Supervised Management of Anaphylaxis 2
II. General measures
a) Place in recumbent position and elevate lower
extremities.
b) Maintain airway
c) O2 6 - 8 L/minute.
d) NSS IV If severe hypotension, give volume
expanders.
e) Venous tourniquet above reaction site
might decreases absorption of allergen.
Stephen F. Kemp et al.JACI 2002
36. PhysicianPhysician-Supervised Management of Anaphylaxis 3
III. Specific Measures that Depend on Clinical
Scenario
a) Aqueous EPI 1:1,000, ½ dose (0.1- 0.2 mg) at
000,
(0
reaction site.
b) Diphenhydramine, 50 mg or more in divided
Diphenhydramine,
doses orally or IV, maximum daily dose 200 mg
(5 mg/kg) for children and 400 mg for adults.
c) Ranitidine, 50 mg in adults and 12.5 - 50 mg
12.
(1 mg/kg) in children inject IV (Cimetidine 4mg/kg
(Cimetidine
for adults, not established for pediatrics).
Stephen F. Kemp et al.JACI 2002
37. PhysicianPhysician-Supervised Management of Anaphylaxis 4
III. Specific Measures that Depend on
Clinical Scenario continued
d) Bronchospasm, nebulized salbutamol
Bronchospasm,
e) Aminophylline, 5mg/kg over 30 min IV may be
Aminophylline,
helpful if no response to inhaled β-agonist.
βf) Refractory hypotension, give dopamine.
Stephen F. Kemp et al.JACI 2002
38. PhysicianPhysician-Supervised Management of Anaphylaxis 4
III. Specific Measures that Depend on
Clinical Scenario continued
g) Glucagon, 1- 5 mg (20 - 30 µg/kg [max
(20
1 mg] in children) IV
h) Methylprednisolone 1- 2 mg/kg/day might
prevents prolonged reactions and relapses.
Stephen F. Kemp et al.JACI 2002
39. Clinical practice guidelines for management anaphylaxis
http://www.allergythai.org/modules/anaphylaxis/CPG070911full.pdf
http://www.allergythai.org/modules/anaphylaxis/CPG070911full.pdf
40. Clinical practice guidelines for management anaphylaxis
Available from :
http://www.allergythai.org/modules/anaphylaxis/CPG070911full.pdf
http://www.allergythai.org/modules/anaphylaxis/CPG070911full.pdf
41. Prevention 1
General
Obtain history for drug allergy.
Avoid drugs (immunologic or biochemical
cross-reactivity)
cross-reactivity).
Orally rather than parenterally.
parenterally.
Proper labeling.
Observe patients 20-30 min. after
20injections.
Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1027-49
2009.
1027-
42. Prevention 2
For patients at risk
Wear and carry warning identification tags.
Teach self-injection of epinephrine and
selfkeep epinephrine auto-injector.
autoDiscontinue β -adrenergic blocking agents,
angiotensinangiotensin-converting enzyme (ACE)
inhibitors, ACE blockers, monoamine
oxidase inhibitors, and certain tricyclic
antidepressants.
Use preventive techniques.
Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1027-49
2009.
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43.
44. Ousama Rachid et al. The Journal of Allergy and Clinical Immunology 2013; 131 : 236-238
236-
45. Ousama Rachid et al. The Journal of Allergy and Clinical Immunology 2013; 131 : 236-238
2013;
236-
46. Take Home Message
Anaphylaxis is defined as a serious allergic
reaction.
Prompt recognition and treatment are
critical in anaphylaxis.
Epinephrine is the drug of choice for
anaphylaxis.