Fennessy adds an unexpected high note to the topic of managing the anaphylactic patient.

1. Anaphylaxis
The Dying Breaths
Dr Gerard Fennessy
ICU Registrar
The Royal Melbourne Hospital
Victoria, Australia

3. Anaphylaxis

Definition and Causes

Clinical Aspects

Investigations and Treatment

Reprise
 Starring a famous movie star

4. About me…

NZ trained
◦

Joint ICU and ED training
Royal Melbourne Hospital

6. Mt Ruapehu

7. Mt Ruapehu

10. …and it was a quiet day on the MV Pacific
Carnival Princess Cruise Liner…

11. …and it was a quiet day on the MV Pacific
Carnival Princess Cruise Liner…

A – no stridor, able to talk

B – no wheeze, sats 100%
 RR 14

C – PR 100
 BP 140/100

Would you give her adrenaline?

12. Anaphylaxis: the last slide…
 Adrenaline
 Adrenaline
 Adrenaline
 Epinephrine

13. Presentation is
VARIABLE

14. Diagnosis is CLINICAL

15. Requires URGENT
treatment

16. No consensus on
definition

17. ERC Resuscitation 2010

hypersensitivity reaction

severe, life-threatening

generalised or systemic

may have skin and mucosal changes
European Resuscitation Council Guidelines for Resuscitation 2010. Resuscitation 81 (2010) 1219–1276

18. Compromise to…

19. Incidence

20. Incidence

21. Incidence
Adults
1:3400 per year
1:500 – 1:1000 ED presentations

24. Fatalities
 <1

in 1,000,000
Within 5-30 minutes of exposure

25. Highly Popular Disease

29. IgE
http://www.ifr.ac.uk/

30. Non-allergic anaphylaxis

“anaphylactoid reaction”

identical presentation and treatment

31. Causes

32. Food

33. Hymenoptera

34. Drugs

35. Cephalosporin and Penicillin
Cross-Reactivity

36. The Journal of Emergency Medicine, Vol. 42, No. 5, pp. 612–620, 2012

37.  Β-lactam
R
ring
≈ side chain
The Journal of Emergency Medicine, Vol. 42, No. 5,
pp. 612–620, 2012

38. 
Penicillin allergic patients
 more allergic to EVERYTHING

Until mid-1980s
 penicillins and cephalorsporins made
using the same mold
The Journal of Emergency Medicine, Vol. 42, No. 5,
pp. 612–620, 2012

39. 
Cross reactivity:

1% who state penicillin allergy

2% with confirmed penicillin allergy

1st and 2nd generation only
The Journal of Emergency Medicine, Vol. 42, No. 5,
pp. 612–620, 2012

40. Negligible cross-reactivity with
3rd and 4th generation
cephalosporins
The Journal of Emergency Medicine, Vol. 42, No. 5,
pp. 612–620, 2012

41. Cephalosporins and Penicillin
Negligible Cross-reactivity

MOST 1st and 2nd generation
(cefaclor, cefalexin etc)
and

ALL 3rd and 4th generation
(ceftriaxone)

42. Clinical findings

Mild
◦

Moderate
◦

Skin, angioedema
Dyspnoea, stridor, wheeze, GI upset
Severe
◦
Cyanosis, hypotension, collapse

43. Clinical – Cutaneous 80-90%

Urticaria

Pruritis

Erythema

Angioedema

44. Respiratory

Hoarseness

Stridor

Wheeze

Bronchospasm

Hypoxia
Patrick J. Lynch, medical illustrator; C. Carl Jaffe, MD, cardiologist

45. Cardiovascular

Hypotension

Tachycardia

Arrythmia

Syncope

Myocardial Depression

46. Investigations

47. Tryptase

Mast cell tryptase
◦
1-6 hours after event
◦
not sensitive or specific
◦
serial measurements may be useful

48. Treatment

49.  Adrenaline
 Adrenaline
 Adrenaline
 Epinephrine

50. Adrenaline

Airway swelling

Bronchospasm

Hypotension

51. 
Give it EARLY

IM
◦
0.3-0.5mg
 Repeat PRN

IV
◦

10-20 mcg/min
Nebulised

52. 
http://www.firstaidforlife.org.uk/courses/acute-allergic-reaction-and-how-to-use-and-epipen/

54. Uncertain Benefit
 Antihistamines
 Steroids
 Glucagon

55. A bit of light entertainment…

56. References and
Acknowledgements

Brown A. Current management of anaphylaxis. Emergencias 2009; 21: 213-223.

Campagna JD, Bond MC, Schabelman E, Hayes BD. The use of cephalosprins in
penicillin allergic patients: a literature review. Journal of Emergency Medicine 2012.
42(5); 612–620.

deShazo R. Anaphylaxis: My “Top 10′′ List. Southern Medical Journal 2007: 100(3),
233­234.

Dewachter P, Mouton-Faivre C, Emala CW. Anaphylaxis and Anesthesia,
Controversies and New Insights. Anesthesiology 2009; 111:1141–50.

Worth A, Soar J, Sheikh A. Management of anaphylaxis in the emergency setting.
Expert Rev. Clin. Immunol; 2010. 6(1), 89–100.

Not sponsored by Epipen nor Zovirax nor Seasame Street

Thanks to Stephen Odgers (backing vocals and guitar) and Jim Henson