Anaphylaxis Treatment & Management
- Author: S Shahzad Mustafa, MD; Chief Editor: Michael A Kaliner, MD more...
Anaphylaxis is a medical emergency that requires immediate recognition and intervention. Basic equipment and medication should be readily available in the physician’s office. Lieberman et al have described this in great detail.[26, 47, 67, 68, 69]
Prehospital patients with symptoms of severe anaphylaxis should first receive standard interventions. Interventions include high-flow oxygen, cardiac monitoring, and intravenous (IV) access. These measures are appropriate for an asymptomatic patient who has a history of serious reaction and has been re-exposed to the inciting agent. Measures beyond basic life support (BLS) are not necessary for patients with purely local reactions.
Disposition of patients with anaphylaxis depends on the severity of the initial reaction and the response to treatment. Patients with non–life-threatening symptoms may be observed for 4-6 hours after successful treatment and then discharged. Patients who have refractory or very severe anaphylaxis (with cardiovascular and/or severe respiratory symptoms) should be admitted or treated and observed for a longer period in the emergency department (ED) or an observation area.
Diagnosis and management guidelines are available from the American Academy of Allergy, Asthma, and Immunology; the American College of Allergy, Asthma, and Immunology; and the Joint Council of Allergy, Asthma, and Immunology.
Initial Emergency Department Interventions
The 2010 Joint Task Force anaphylaxis parameter update, the 2011 World Allergy Organization anaphylaxis guidelines, the 2010 NIAID-sponsored expert panel report , and the 2014 practice parameters from the American Academy of Allergy, Asthma and Immunology, the American College of Allergy, Asthma and Immunology, and the Joint Council of Allergy Asthma and Immunology[70, 71] have similar recommendations for immediate treatment in the ED. It should begin with monitoring and treatment, including oxygen, cardiac monitoring, breathing, mental status, skin, and a large-bore IV with isotonic crystalloid solution. At the same time, where appropriate, the ED team should call for specialized help, particularly a resuscitation team. Further intervention depends on severity of reaction and affected organ system(s), but the guidelines recommend the injection of epinephrine and placing the patient in a supine position (or position of comfort if dyspneic or vomiting) with the legs elevated.
For the initial assessment, check the airway closely. If needed, establish and maintain an airway and/or provide ventilatory assistance. Assess the level of consciousness and obtain blood pressure, pulse, and oximetry values. Place the patient in the supine position with legs elevated, and begin supplemental oxygen.
Establishing and maintaining an airway or providing ventilatory assistance may be necessary. One of the quickest, easiest, and most effective ways to support ventilation involves a 1-way valve facemask with oxygen inlet port (eg, Pocket-Mask [Laerdal Medical Corporation, Gatesville, Tex] or similar device). Artificial ventilation via the mouth-to-mask technique with oxygen attached to the inlet port has provided oxygen saturations comparable to endotracheal intubation. Patients with adequate spontaneous respirations may breathe through the mask.
Standard rapid sequence induction (RSI) techniques can be used but may cause loss of the airway in a patient whose airway anatomy is altered by edema. Severe laryngeal edema may occur so rapidly during anaphylaxis that endotracheal intubation becomes impossible. Epinephrine may rapidly reverse airway compromise. If the edema does not reverse promptly with epinephrine, an endotracheal tube should be inserted promptly. Alternatively, it may be preferable to defer intubation and instead ventilate with a bag/valve/mask apparatus in the interim.
In extreme circumstances, cricothyrotomy or catheter jet ventilation may be lifesaving when orotracheal intubation or bag/valve/mask ventilation is not effective. Cricothyrotomy probably should be attempted rather than an emergency tracheostomy because it is easier to perform.
Wheezing or stridor indicates bronchospasm or mucosal edema. Treatment with epinephrine and inhaled beta-agonists is effective for these indications. Inhaled beta-agonists are used to counteract bronchospasm and should be administered to patients who are wheezing.
Recommendations to treat refractory bronchospasm with corticosteroids have been made because of their effectiveness in reactive airway disease. As in asthma therapy, onset of action is delayed for several hours. Aminophylline also has been recommended for bronchospasm in anaphylaxis and may be more rapidly effective than corticosteroids.
For bradykinin-mediated angioedema (including angioedema due to angiotensin-converting enzyme [ACE] inhibitors), antihistamines and corticosteroids are probably not effective. Epinephrine may be tried in severe cases, but airway intervention may be needed.
Cardiac monitoring in patients with severe reactions and in those with underlying cardiovascular disease is important, particularly when adrenergic agonists are used in treatment. Pulse oximetry is also useful.
The IV line should be of large caliber due to the potential requirement for large-volume IV fluid resuscitation. Isotonic crystalloid solutions (ie, normal saline, Ringer lactate) are preferred. A keep-vein-open (KVO) rate is appropriate for patients with stable vital signs and only cutaneous manifestations. If hypotension or tachycardia is present, administer a fluid bolus of 20 mg/kg for children and 1 L for adults. Further fluid therapy depends on patient response. Large volumes may be required in the profoundly hypotensive patient.
Administration of Epinephrine
Epinephrine maintains blood pressure, antagonizes the effects of the released mediators, and inhibits further release of mediators. Health care professionals are sometimes reluctant to administer epinephrine for fear of adverse effects. However, the use of epinephrine for anaphylaxis has no absolute contraindications. It is the drug of choice and it is usually well tolerated and potentially lifesaving.[48, 69, 72] Anaphylactic deaths correlate with delayed administration of epinephrine. The initial dose can be repeated as necessary, depending on the response. Data are limited concerning the frequency with which patients might require repeated doses of epinephrine to treat anaphylaxis (reports range from 16-36%) and multiple cofactors might be involved.[48, 69]
Administer intramuscular (IM) epinephrine immediately.[37, 67] IM administration of epinephrine in the thigh (vastus lateralis) results in higher and more rapid maximum plasma concentrations of epinephrine than IM or subcutaneous (SC) administration in the arm (deltoid) of asymptomatic children and adults (see Medication). However, similar studies comparing IM injections to SC injections in the thigh have not yet been done. Obesity or other conditions that enlarge the subcutaneous fat pad may prevent intramuscular access.
Remove the source of the antigen if possible (eg, remove stinger after honeybee sting or stop drug infusion). If anaphylaxis occurs after injection of allergen-specific subcutaneous immunotherapy (SCIT), a large local reaction often occurs. Place a tourniquet above the injection site and, after IM epinephrine is administered, inject up to 0.1 mL of epinephrine into the large local reaction site to slow absorption.
Racemic epinephrine via a nebulizer can be used to reduce laryngeal swelling, but it does not replace IM administration of epinephrine. Treat bronchospasm that has not responded to IM epinephrine with inhaled beta2 -adrenergic agonists such as albuterol.
Administration of Antihistamines and Corticosteroids
The standard treatment of anaphylaxis should also include antihistamines and corticosteroids. However, antihistamines have a much slower onset of action than epinephrine, they exert minimal effect on blood pressure, and they should not be administered alone as treatment. Antihistamine therapy thus is considered adjunctive to epinephrine.
Administer an H1 blocker and an H2 blocker, because studies have shown the combination to be superior to an H1 blocker alone in relieving the histamine-mediated symptoms. Diphenhydramine and ranitidine are an appropriate combination. IV administration ensures that effective dosing is not impaired by hemodynamic compromise, which adversely affects gastrointestinal (GI) or IM absorption. However, oral or IM administration of antihistamines may suffice for milder anaphylaxis.
Corticosteroids have no immediate effect on anaphylaxis. However, administer them early to try to prevent a potential late-phase reaction (biphasic anaphylaxis). Patients with asthma or other conditions recently treated with a corticosteroid may be at increased risk for severe or fatal anaphylaxis and may receive additional benefit if corticosteroids are administered to them during anaphylaxis. The authors recommend corticosteroid treatment for all patients with anaphylaxis. If absorption is a concern, IV preparations should be used.
Most patients treated with antihistamines and steroids have complete remission following tapering of steroids. Others require long-term prophylaxis with high doses of H1 antihistamines.
Outpatient medications are the oral forms of antihistamines and corticosteroids that should be continued for a short time (a few days) following an episode. The benefit of these drugs is more theoretical because no studies exist that prove their benefit in this setting.
A convenient oral corticosteroid is prednisone. No proven best dose exists. In adults, a dose of 1 mg/kg/d in divided doses is probably adequate; in children, a dose of 0.5-1 mg/kg/d in divided doses is appropriate. Tapering is not necessary unless the patient has been taking steroids chronically.
The following regimens are used commonly by clinicians, though very little hard data concerning the natural history of anaphylaxis treated in the ED exists. In light of this, do not construe the following as an unqualified recommendation or as a standard of care. Evidence for efficacy of H2 -blocker antihistamines is particularly sparse.
H1 -blocker antihistamine treatment is as follows:
Diphenhydramine (Benadryl) - Adults: 25 mg PO q6h for 2-5 d; Children: 1 mg/kg PO q6h for 2-5 d
Hydroxyzine (Atarax) - Adults: 25 mg PO q8h for 2-5 d; Children: 1 mg/kg PO q8h for 2-5 d
Corticosteroid treatment is as follows:
Prednisone - Adults: 20-80 mg PO daily for 2-5 d; Children: 0.5-1 mg/kg PO daily for 2-5 d
Many other glucocorticoid preparations may be used.
H2 -blocker antihistamine treatment is as follows:
Cimetidine - 300 mg PO qid for 2-5 d; Children: Not recommended
Patients with frequent idiopathic anaphylaxis may benefit from daily antihistamine therapy (both H1 antagonists and H2 antagonists) or, in rare circumstances, daily corticosteroid therapy.
For daily antihistamine therapy, diphenhydramine or hydroxyzine is often used first. Second-generation, less-sedating agents may be preferable because of decreased adverse effects. In their adult doses, these include fexofenadine (Allegra) at 180 mg/d, loratadine (Claritin) at 10 mg/d, cetirizine (Zyrtec) at 10 mg/d, desloratadine (Clarinex) at 5 mg/d, and levocetirizine (Xyzal) at 5 mg/d. However, none has been specifically evaluated in anaphylaxis prevention. Some specialists prescribe extra doses of antihistamines as needed and as tolerated to control symptoms.
Management of Blood Pressure
Maintaining proper blood pressure is important in the treatment of anaphylactic reactions. Hypotension is often the most difficult manifestation of anaphylaxis to treat. Persons with protracted hypotension must be monitored in an intensive care unit (ICU) setting.
Because hypotension in anaphylaxis is due to a dramatic shift of intravascular volume, the fundamental treatment intervention after epinephrine is aggressive IV fluid administration. Large volumes of crystalloid may be required, potentially exceeding 5 L. The exact amount should be individualized and based on blood pressure and urine output. Depending on its severity, refractory hypotension may require placement of an invasive cardiovascular monitor (central venous catheter) and arterial line.
In patients with preexisting heart disease, ischemic myocardial dysfunction may occur due to hypotension and hypoxia. Epinephrine still may be necessary in patients with severe anaphylaxis, but remember the potential for exacerbating ischemia. If pulmonary congestion or evidence of cardiac ischemia is present, fluid resuscitation should be approached more cautiously.
Vasopressors may also be needed to support blood pressure. Intravenous epinephrine (1:10,000 v/v preparation) can be administered as a continuous infusion, especially when the response to intramuscular epinephrine (1:1000 v/v) is poor. Dopamine infusion can also be used.
Patients with anaphylaxis who are taking a beta-adrenergic blocking agent (eg, for hypertension, migraine prophylaxis) can have refractory anaphylaxis that is poorly responsive to standard measures. Data are limited to case reports, but glucagon might be effective in this situation. It has both inotropic effects and chronotropic effects on the heart by increasing intracellular levels of cyclic adenosine 3,’5’-monophosphate, independent of the beta-adrenergic receptors. Glucagon can also reverse bronchospasm.
Treatment of Gastrointestinal Symptoms
GI symptoms in anaphylaxis may respond to H1 antihistamines and epinephrine.
Short-Term Desensitization Procedures
Short-term desensitization procedures can be used for medication allergy in some circumstances in which no therapeutic alternative exists.
Published protocols exist for short-term desensitization and are available for various medications. Consult an allergist-immunologist skilled in desensitization procedures to perform these protocols. Most protocols require the patient to be in an ICU setting throughout the procedure and to have established IV access and epinephrine at the bedside before the procedure starts. Obtain informed consent prior to the procedure. Anaphylaxis is a potential complication of this procedure.
A typical desensitization protocol for beta-lactam antibiotics provides the patient a starting dose that is 6-7 logs below the usual therapeutic dose and increases the dose by 1 log every 20-30 minutes. A typical desensitization regimen involves administering the antibiotic of choice in an initial dose of 0.01 mg. While observing the patient, double the dose every 20-30 minutes until a full dose has been administered.
Desensitization regimens do not protect against non-IgE-mediated reactions that may be severe or even life threatening (eg, Stevens-Johnson syndrome).
Administration of Anti-IgE
Anti-IgE (eg, omalizumab) complexes circulating (but not receptor-bound) IgE and keeps it from binding to its receptors. It does not remove IgE bound to receptors and can take several weeks to months to have a substantial effect. It should not be used in an acute setting and would not be expected to influence IgE-independent or nonimmunologic events.
Due to the potential for delayed anaphylaxis after omalizumab (0.09% of recipients in 1 report), observation periods of 2 hours for the first 3 injections and 30 minutes for subsequent injections have been recommended. Patients should also be prescribed an epinephrine autoinjector (see above for epinephrine autoinjector instruction) and advised to carry it before omalizumab injection and for the ensuing 24 hours.
The presenting manifestation(s) of anaphylaxis dictate inpatient care. Essentially, this care consists of continuing the care initiated in the ED.
Most patients with anaphylaxis may be treated successfully in the ED and then discharged. Treatment success operationally may be defined as complete resolution of symptoms followed by a short period of observation. The purpose of observation is to monitor for recurrence of symptoms (ie, biphasic anaphylaxis). An observation period of 10 hours appears sufficient for most reactions, but some investigators recommend 24 hours.
Hospital admission is required for patients who (1) fail to respond fully, (2) have a recurrent reaction or a secondary complication (eg, myocardial ischemia), (3) experience a significant injury from syncope, or (4) need intubation. As with many other conditions, consider a lower admission threshold when patients are at age extremes or when they have significant comorbid illness.
Consider ICU admission for patients with persistent hypotension. The primary means of support are adrenergic agents (eg, epinephrine, dopamine) and fluid resuscitation. Persistent hypotension in the face of pressors and fluid resuscitation is an indication for invasive hemodynamic monitoring with evaluation of cardiac function and peripheral vascular resistance. Use of these parameters provides the basis for objective decisions regarding the use of fluids and pressors.
Persistent bronchospasm should be treated by continuing albuterol and intravenous steroid administration. Cutaneous manifestations of anaphylaxis are treated with repeated doses of antihistamines.
Therapy with antihistamines and oral glucocorticoids should probably continue at home for another 2-3 days to prevent recurrence.
Prevention of Anaphylaxis
Avoidance is the only form of prevention for most inciting agents. Insect sting anaphylaxis can be prevented with allergen immunotherapy, which is highly effective. This recommendation is supported by updated reports of the Joint Task Force on Practice Parameters.[47, 46]
Anti-IgE may be a good prophylactic agent for severe food allergy, but the one study published to date was with TNX-901, which is not being marketed. A phase II multicenter study with omalizumab (Xolair) in peanut allergy was discontinued prematurely because of safety concerns in some study subjects. Obtained data were insufficient to draw any conclusions, but a slight trend existed toward greater tolerability of peanuts in subjects treated with omalizumab compared to placebo.
While theoretically attractive, premedication regimens have not been clinically shown to decrease incidence or severity of IgE-mediated allergic reactions to antibiotics.
Patients at risk for recurrent anaphylaxis should consider wearing a MedicAlert bracelet. They should also avoid the use of beta-blockers if at all possible since this class of medication may not only increase the risk of anaphylaxis, but also block the effects of epinephrine. ACE inhibitors have also been theorized to potentially increase the risk of anaphylaxis. Tricyclic antidepressants and monoamine oxidase inhibitors should also be avoided because of potential drug interactions with necessary therapies.
Reactions to radiocontrast media
Patients with a history of severe reactions to IV radiocontrast media may require use of contrast in an urgent or emergency situation. Alternatives (eg, noncontrast spiral computed tomography [CT] for ureteral stone, Doppler ultrasonography for deep venous thrombosis [DVT], nuclear scans or spiral CT for pulmonary embolism) should be considered but are not always feasible. In these circumstances, a prophylactic regimen of corticosteroids and antihistamines may be used.
The precise efficacy of these regimens is difficult to evaluate, but they generally are considered effective. One author states that the recurrence rate for patients with a previous reaction was reduced from 17-60% to 9% when conventional contrast material was used; the rate was reduced to less than 1% when low osmolality material was used after a pretreatment regimen.
Prophylaxis for IgE-independent anaphylactic reactions to radiocontrast media involves prednisone (or hydrocortisone), diphenhydramine, and possibly ranitidine (or another H2 antihistamine), and/or the use of a different contrast agent.
Administer prednisone (50 mg PO) or hydrocortisone (200 mg IV) at 13, 7, and 1 hour before the radiocontrast procedure.
Administer diphenhydramine (50 mg PO/IV) and ranitidine (150 mg PO or 50 mg IV) with or without ephedrine (25 mg PO) 1 hour before the procedure. Ephedrine should not be used in patients with hypertension, coronary artery disease (CAD), a strong family history of CAD (for older patients), arrhythmia, thyrotoxicosis, monoamine oxidase inhibitor use, or porphyria.
Select a radiocontrast agent with lower osmolarity.
The only dietary consideration is the future avoidance of a suspect or culprit food. Clinical trials are presently evaluating short-term oral desensitization for some foods, such as peanuts.
Most patients with anaphylaxis should be referred to an allergist-immunologist for further evaluation and treatment. However, the Rochester County study demonstrated that 42% of patients were referred for such a consultation, and emergency departments fared worse in both civilian and military settings, 12-20% and 29%, respectively.
Consultation with an allergist (when available) is appropriate when desensitization to an antibiotic is contemplated. When no inciting agent has been identified, consider referral to an allergist to identify the cause of anaphylaxis.
Some anaphylactic reactions are so severe that treatment is unsuccessful and death occurs. This underscores the critical importance of education, avoidance, and prevention. An allergist-immunologist can provide comprehensive professional advice on these matters.
In the case of severe anaphylaxis requiring admission to the ICU, a critical care specialist should be consulted. When a patient at high risk for contrast reaction is under consideration for a contrast study, consultation with the radiologist regarding pretreatment and choice of contrast agent is appropriate.
The most important aspect of outpatient follow-up is evaluation by an allergist-immunologist.[47, 66, 46, 48] Skin testing and/or in vitro IgE tests for foods, stinging insects, medications, or latex should be performed as directed by the patient’s history. Documented hypersensitivity to latex is an indication for evaluation of possible allergy cross-reacting foods (eg, banana, kiwi, avocado). If the patient’s history and skin test or in vitro IgE tests results confirm Hymenoptera sensitivity as the probable cause of anaphylaxis, venom-specific immunotherapy should be initiated to significantly decrease the likelihood of future episodes.
Future avoidance of culprit foods, medications, latex, or radiocontrast media must be emphasized. If a culprit medication is required in the future and no other alternatives are available, a desensitization procedure should be performed by the allergist/immunologist, usually in an ICU setting. If radiocontrast media are required in the future, a pretreatment protocol may be used. (See Prevention of Anaphylaxis.)
The patient must be provided a prescription for an epinephrine autoinjector (EpiPen, EpiPen Jr, or Twinject) and instructed in its proper use.
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