ZSFG ID report! Anaphylaxis

Ray and Billy presented a fascinating case of a woman with the flu who developed anaphylaxis in the ED.

Top pearls

  • The diagnostic criteria for anaphylaxis, which Mike, our EM intern, pithily summarized as…
    • If A, B, or C, give E (epinephrine)
  • IM epinephrine is ALWAYS the treatment of choice for anaphylaxis, whether in the hospital or outside
  • don’t forget to discharge with an epi auto-injector!

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For those who want to know more:

Anaphylaxis overview

  • 1% of patients die/year of anaphylaxis, and do so quickly. This is thought largely 2/2 misdiagnosis and delays in care. So have a low threshold to treat!
  • Enjoy this adorable pictogram of the diagnostic criteria (attached to the evernote)

anaphylaxis-definition

Management

Start with CAB (just like the new BLS)

  • C – give IM epinephrine 0.3-0.5mg of 1mg/ml. This is lifesaving and emergent!
    •      aggressive IV fluid resuscitation + raise legs if tolerated
  • A – evaluate airway for signs of airway edema and if present, intubate early vs surgical airway.
    •      With airway edema, call anesthesia or ENT emergently to intubate. Consider intubating in the OR if a surgical airway is being considered
  • B – albuterol for bronchospasm and supplemental oxygen
  • Adjunctive therapies
    • Steroids: 125mg methylprednisolone IV q6h – controversial
    •      Antihistamines
    •      H1 – 50mg IV diphenhydramine
    •      H2 – 50mg IV ranitidine (use IV famotidine 40mg here)
  •      Identify and remove underlying cause
  • Refractory symptoms
    •      Repeat epinephrine IM -> epinephrine gtt. Patients on beta blockers may not respond to epinephrine, in which case a glucagon infusion can be helpful.
Fast-forwarding to discharge
  • ALWAYS discharge with an epinephrine auto-injector
  • refer to allergy/immunology for confirmatory testing
  • update the allergy list in your EMR!
  • Consider medic alert jewelry (or this pinterest page of medic alert tattoos)

Evernote: https://www.evernote.com/shard/s192/sh/4e0b6204-eee3-4633-aa10-8af98c493145/a5fd90ffe26a1ca4b4221e590f00919e

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