Anaphylaxis Reminders and Pearls

http://www.aafp.org/afp/2011/1115/p1111.html

     I linked the above article, but it is through the American Family Physician website and may be restricted. AAFP members can log in and find it in the AFP list, but for others who want a full text, the end of the report has the full article listing, which may be available via the Rex library.

Regardless, this was an excellent and current overview article on anaphylaxis. Below were some instructive pearls:
1. Recall the risk of anaphylaxis is doubled in patients with mild asthma and tripled in severe asthma.
2. 1-20% of anaphylaxis cases suffer the dreaded "biphasic reaction" where symtpoms recur later, despite initial treatment. Most commonly, this "second wave" is within 8hrs, but can occur up to 24-72 hours post exposure (yikes!). Hence, this is why many people recommend a brief ER visit/monitoring as well as po steroids afterwards for a few days. From various ER referrals and call backs, I have seen ER docs observe patients anywhere from 2-12 hours, with admits usually only occuring after blatant and refractory hypotension. Please chime in on your observations, either direct (via ER work) or indirect (via patient call backs) of ER holding periods.
3. The #1 anaphylaxis imposter/mimic is a vasovagal event.
4. The #1 medicine is always epinephrine. I sense that ER's seem to "frown on", or "take pride" in not having to give epinephrine, but being in a suburban location, the #1 priority is to avoid intubation. The article, with regards to possibly being leery of epinephrine in older people with possible or confirmed coronary artery disease, flatly states, "while there are no controlled studies that have weighed the risk, at this time, best evidence shows that benefits (of epinephrine) outweigh the risk."
5. Recall and remind nurses the BEST epinephrine route is IM, not subcutaneous. All the clinics should have adult Epi-Pens and Epi-Pen Jrs. The Jr. pens are for children less than 30kg. The article specifically says the PREFERRED method is Epi-Pens, due to several cases of misjudging the dose when drawn hurriedly from a vial of epinephrine.

6 .Reminder of Epi-Pen points- it is injected through the pants and hold for 10 seconds.
7. THE most crucial point of all from the AFP article was to remember that although H1 receptor blockers help the patient "look" and "feel" better- via less cutaneous erythema and less pruritus-they yield no benefit in improving hypotension or lessening upper airway obstruction!!!
 
Thanks for reading, I look forward to comments, and check in frequently for new authors and discussions!
Linwood

Full article citation- A Review of "Anaphylaxis Recognition and Management", American Family Physician. November 15, 2011. Vol 84. No. 10.