Anaphylaxis

ANAPHYLAXIS
CHULEEPORN KONGMEESOOK ,MD

Outline
Terminology
Pathophysiology
Signs and symptoms
Prevention and management
Take home messages

Anaphylaxis
Severe, life threatening, generalized
or systemic hypersensitivity reaction.
reaction.

WAO Nomenclature Review Committee JACI 2006

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)
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:

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)
b. Reduced BP or associated symptoms of end-organ dysfunction (eg,
end(eg,
hypotonia [collapse], syncope, incontinence)

2006; 117:

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,
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)

2006; 117:

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.

2006; 117:

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-

Incidence of Anaphylaxis to Specific Agents 1
Antibiotics
Most common cause of drug induced
anaphylaxis.
Latex
Increased incidence last decade.

1027-

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.

2009.
1027-

Food
0.0004% of US population per year.
0004%
Shellfish most common in adults, and
peanuts in children.

1027-

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.
2009.
1027-

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

1027-

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-

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
2009.
1027-

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
1027-

Pathophysiology 3
Anaphylaxis : non-allergic
nonDisturbances in arachidonic acid metabolism
Aspirin
Other non-steroidal antiinflammatory drugs
nonMultimediator recruitment Complement
Clotting
Clot lysis
Contact system
2009.
1027-

Nitric oxide
Potentially detrimental
Vasodilation (peripheral vascular bed)
Increased vascular permeability
Potentially beneficial
Bronchodilation
Vasodilation (coronary arteries)
Decreased mast cell degranulation
1027-

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
1027-

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
2009.
1027-

Signs and Symptoms of Anaphylaxis 2
Biphasic anaphylaxis
Uniphasic anaphylaxis
Protracted anaphylaxis

2009.
1027-

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–

Differential diagnosis of anaphylaxis 1
Vasodepressor reactions
Flush syndromes
Carcinoid
Menopause
Chlorpropamide–alcohol
Medullary carcinoma thyroid
Autonomic epilepsy

2009.
1027-

‘Restaurant syndromes’
Monosodium glutamate (MSG)
Sulfites
Scrombroidosis

1027-

Excess endogenous production of
histamine syndromes
Systemic mastocytosis
Urticaria pigmentosa
Basophilic leukemia
Acute promyelocytic leukemia (tretinoin
Hydatid cyst

treatment)

1027-

Other forms of shock
Hemorrhagic
Cardiogenic
Endotoxic
Non-organic disease
Panic attacks
Vocal cord dysfunction syndrome
Undifferentiated somatoform anaphylaxis
1027-

Miscellaneous
Hereditary angioedema
‘Progesterone’ anaphylaxis
Urticarial vasculitis
Hyperimmunoglobulin E, urticaria syndrome
Neurologic (seizure, stroke)
Pseudoanaphylaxis
Red man syndrome (vancomycin)
Capillary leak syndrome

2009.
1027-

Laboratory 1
Histamine
Plasma histamine rise within 5- 10 min.
and remain 30-60 min.
30Urinary histamine metabolites elevated
longer period of time.

2009.
1027-

Laboratory 2
Serum tryptases
Peak 60-90 min.
60Persist longer than plasma histamine
levels but not as long as 5 hours.

2009.
1027-

SalaSala-Cunill et al. Int Arch Allergy Immunol 2013;160:192–199
2013;160:192–

Medication
Epinephrine
Antihistamines ( H1, H2 )
β-Adrenergic agonist
Glucocorticoid
Volume expanders
Atropine
Glucagon

2009.
1027-

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

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.

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).


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.


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.


Clinical practice guidelines for management anaphylaxis

http://www.allergythai.org/modules/anaphylaxis/CPG070911full.pdf

Clinical practice guidelines for management anaphylaxis

Available from :

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.

2009.
1027-

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.
2009.
1027-

Ousama Rachid et al. The Journal of Allergy and Clinical Immunology 2013; 131 : 236-238
236-

Ousama Rachid et al. The Journal of Allergy and Clinical Immunology 2013; 131 : 236-238
2013;
236-

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.

Anaphylaxis

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