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Approach to Mx of Anaphylaxis

Feb 09 | 3:30 PM

Anaphylaxis is one of the most severe allergic reactions, with a rapid onset and a high risk of death. Although anaphylaxis affects up to 2% of the population and its incidence appears to be rising, the fatality rate is minimal. However, it is critical to introduce appropriate measures to minimize the risk of fatality from anaphylaxis. Join us live on Medflix with Dr. Mahadev Desai as he discusses the nuances of managing anaphylaxis!

[Music] good evening everyone i am dr rishali a dentist and then a hospital management professional now working with medflix i would like to welcome you on behalf of netflix for this very informative session on management of anaphylaxis for that we have with us our dr mahadev they say a super knowledgeable super enthusiast physician with us and moderating the session would be dr narayan dr narayan tawker has worked previously in the field of cardiac anesthesiology for about six years in one of the corporate hospitals in india then he moved on to join the central government services at chs specialist anaesthetist and he is also working as an associate professor in the medical college in the andaman and nicobar islands thank you very much ma'am good evening respected elders seniors and my dear colleagues i'm dr narendra rajaram and we are going to have a small discussion about anaphylaxis anaphylaxis is an acute potentially fatal multi-organ systemic reaction caused by the chemical mediators from mass cells and basophils the term anaphylaxis was coined in 1902 by portia and richard when a dog died after second vaccinating dose of cne montoxin the term is derived from the greek words and anamines again and phalaxis means immunity usually it is usually saying that once we get exposed to an antigen there might be some reaction and it might be a mild disease again if the second time the person gets exposed to the same antigen he might have he he can he might have an anaphylaxis so now let us hear about this important topic from none other than the eminent physician dr mahadev from abnormal he is a senior consultant physician served as teaching faculty in various medical colleges and honorary editor of gujarat medical journal he takes active participation in various medical forums on behalf of medical fields netflix i welcome dr mahadeva to speak about anaphylaxis over to you sir dr madison thank you dr naran thakur for introducing me generously as well as introducing the topic you made my job easier i was just finding who has found coined the term and you got me right so thank you everyone for joining and this is the first of its uh topic to be discussed under the heading of rapid response and i don't think there can be a better subject than anaphylaxis for the discussion of a rapid response anaphylaxis is something where your prompt action whether it's for diagnosis for management the right drug right those in the right sequence will make the difference between life and death so it is very very important and this is not something we come across daily and that is why something which we don't come across routinely it may be difficult to remember memorize so we have to remember the exact sequence of treatment to be given and if you don't remember anything at least remember one thing and this is what i start with i would start with take home message and end with take home message so first and foremost thing remember anaphylaxis is a life-threatening medical emergency right and but all allergic events are not anaphylaxis whenever you suspect anaphylaxis first try to make sure that you are not dealing with anaphylaxis with shock if the patient is anaphylaxis in shock then it has to be treated as early as possible without wasting time for anything else the reason is as i said the outcome depends on how prompt you are treating the patient and how effectively use adrenaline if at the end of this session if you remember only one thing that when in doubt about or when you have the slightest doubt of anaphylaxis and if you ruled out the contraindications give so if we give adrenaline i think we have done half the job or more than half the job so that's what the number one takeoff message is that adrenaline adrenaline adrenaline right and always keep in mind when you are treating the patients that patient can have many other comorbid conditions patient may be diabetic hypotensive thyroid toxicoses or ischemic heart disease or patient may be a pregnant lady or patient maybe on certain medications that may make our treatment with an adrenaline or other drugs little difficult to respond so all these things we have got to keep in mind right and another important thing just saving the patient is not enough we have just definitely need to make sure that patient does not develop another episode of anaphylaxis our patient is ready for facing that if god forbid he gets that day by another allergen so that's very very important that if you remember these things my job of today's presentation is done so to begin with as dr taugher has already introduced that it's a severe allergic reaction involving multi systems but it comes out of blue suddenly sudden unexpected symptoms coming at any age which could be anything from childhood to old age person may develop anaphylaxis even at the later part of the life right for the first time it's possible then symptoms symptoms come very fast they can immediately and as i said earlier also we have got to make sure that the patient has anaphylaxis with or without shock because the treatment differs and very important thing is recognizing and starting the treatment especially adrenaline as fast as possible as dr naren has already said anaphylaxis is a combination of two greek words anna means either up back again and file axis in protection or guarding or immunity so by definitions anaphylaxis is a life-threatening hypersensitivity response that usually appears within minutes but as you can notice minutes is having under asterisks that does not mean it always has to be minutes and if some somebody comes after an hour of a suspected expose that doesn't mean he cannot have enough alexis it depends on the entry and the type of substances we'll see more in detail about which substance that it may take hours for the development of anaphylaxis and again the classic form as dr naren has again said that person is already sensitized on a previous exposure and the second exposure that makes the patient worse because of the ig immediate antibodies which are already present in the patient's circulations so it's most of the time it's an immunologic mechanism that is involved but there are enough electric like reactions which are called anaphylactoid or pseudoenophylectic reactions in which the mechanism is not ig mediated so it's very important to understand of course the science symptoms management is practically same it's only the prevention that where the difference comes but anaphylaxis is a type one hypersensitivity reaction which is ige mediated while naphylectoid is a no pseudoanaphylaxis or non-ig mediated the classical example is radio contrast induce the reactions that we look at sometimes when the patient is subjected to the contrast dye studies like intravenous spilography or any other such studies nowadays of course we use low molecular weight radio contrast so the chances of getting anaphylaxis are much less with that now as we say that it's a immunologically mediated reaction so i would like you to concentrate for the next two three slides so that you understand what are the cascade of events and why the patient develops so many sign symptoms widespread multisystem involvement the reason is whenever a person who is previously sensitized is exposed again to the same allergen the body has the ig antibodies which are present right and they get attached to the muscles or basophils depending on the root of entry if the root of entry is intravenous then it's a basophils the mast cells are present in the connective tissues and around the nervous tissues and the other the skin and sickness tissue so if the allergen comes in contact with the muscles or with the basophils the outcome is the same that is the series of processes like signals from the degradations both muscles as well as basophils contain the granules which are in an inactive form when they are degenerated or released from their granules from the nucleus they start releasing the mediators so signals for degradation then they also affect the cytokine gene activations and they release cytokines we know cytokines are the small proteins which are the messenger proteins they help in bringing about the inflammations anti-inflammations depending on the case and the type of cytokine and they also release the phospholipase a which lead to membrane phospholipids and all these three go parallel and they come in they release the mediators so primary mediators which are released from the muscles granules then the cytokines which are secreted which also bring about the signs of inflammations and the secondary mediators which come from the arachidonic acid which is the phospholipids membrane phospholipids so this lead to the primary mediators which are the histamine which is the most important most of the symptom signs are because of the histamine then proteases also are there and chemotactic factors which are again kind of cytokine the small proteins which bring about the interleukins into the play for the inflammations so histamine protease and chemotactic factors and many more mediators are present also the arachidonic acid will produce the leukotrienes which are named as liquid trines b4 c4d4 and the prostaglinders which are the pg d2 they all lead to the end organ response in the form of involvement of the skin cutaneous tissues respiratory system cardiovascular system and even central nervous system so all sign symptoms are because of the release of mediators the most important being histamine now let's see what are the effects of these mediators on the systems the cardiovascular system and respiratory systems are the most important effected as far as the symptoms and signs are concerned but the most dramatic presentation comes on the skin and cuteness succulents tissue so because of the histamine which is a very powerful vasodilators and it also increase the permeability of the venules so it leads to vasodilation hypotension tachycardia and edema and respiratory system histamine is a very powerful bronchoconstrictor and is stimular for the bronchial secretions so that's how the patient develops severe bronchospasm as well as the presence of secretions and in gastrointestinal system there is increased smooth muscle contractions leading to severe abdominal pain and diarrhea and over the skin because of the release of histamine and many other substances and because of the increased permeability there can be articularia there can be edema non-fitting edema we know as ngoedema we'll come to the sine symptoms in a minutes time so these are the tissue effects of the mediators which are released on because of the muscles or vasophils which come in contact with the ig antibodies the we need to know what are the triggers for the anaphylaxis i remember my teacher used to say anything under the sun including the sun can produce anaphylaxis right so which is true and but here we are talking of the most common kinds of triggers amongst the food which is one of the very important trigger for anaphylaxis milk that is protein in the milk then eggs seafood and peanuts these are the very common food substances which can lead to anaphylaxis amongst drugs the antibiotics whether it is penicillin cephalosporins nitropharyntoin or vitamins like thiamine folic acid even if the patient keeps on insisting about the injectable b complex for so-called weakness please do not give thiamine or folic acid without taking the history or just like that if there is no such thing do not give thiamine or folic acid intravenously because the root also makes a difference oral thiamine will may not road as much anaphylaxis as the injectable thiamine v1 and folic acids the amphotericin b monoclonal antibodies they all can cause anaphylaxis and that's why these days we use monoclonal antibodies for the kobe treatment we have to be extremely careful and watch out for the symptoms of anaphylaxis then enzymes we know that we do give the thrombolytic agent streptokinase in the case of acute marker infection of course now we go more for the primary angioplasty and molecular infection that is called palm your interventions but good old days we used two streptokinase then would always check and we also give the anti-staminics and steroids before giving the streptokinase but it's very very important to remember and the patients who go into hypotension following alkaline function could be either streptokinase induce the anaphylaxis or because of the muscle infection we have got to know about it and treat accordingly then polar neck stress grass trees pollens can produce anaphylaxis we know it anti-sera the horse anti-sera of course we now have got most of them are the prepared in the human right through the genetic engineering mechanisms but we still have many of the anti-sera which are available from the horse serum that is the diphtheria anti-serum or anti-gas gangrene serum aggs and occupational related latex rubber products do produce anaphylaxis common with the surgeons then the mistings one of the very important if somebody asked me the three important cause or triggers for anaphylaxis i would say one is food another is drug and third is the stings stink bites of the insects that's very very important and as i said the diagnostic agents like radio contrast studies are definitely one of the important cause of anaphylactoid reaction so these are the triggers but it could be many more if the list is not ex exhaustive or exclusive right though we come to the clinical manifestations it's very important that we should try to diagnose as soon as possible as fast as possible because time is life very important so the anyone who comes with the sudden unexpected symptoms which occurs in a matter of minutes right then and there to the symptoms combination especially of the succulents tissues and the skin manifestation and the respiratory manifestations respiratory system may be involved because of the obstruction at the upper respiratory level that is at the oropharynx or the nasopharynx or at the larynx that is the angioedema because of that the acute as fixation like a picture or a foreign body like picture or the lower aspect of obstruction because of the bronchospasm in bronchial secretions skin and mucous membranes are one of the most common presentation of the anaphylaxis is through the presentation of skin and mucous membrane findings gastrointestinal and cardiovascular symptoms do occur in about half of the patients but the main symptoms from which we can diagnose are the skin and the respiratory manifestations so the respiratory manifestations are very important here which we have to be very careful in asking what the worst patient use or how the patient describes his symptoms patients who have got laryngeal edema would always complain of lump in the throat or something some foreign body in the throat or he would put his hand over here and said something is wrong here something is stuck here or his voice changes or if you be very careful in listening you can see in spirit strider so upper respiratory obstructions come as lump or in the throat or foreign body sensing the throat while the lower respiratory obstructions because of the secretions and the spasm would lead to the complaint of tightness of the chest or heaviness of the chest or patient may complain that there is some whistling going on or there is an audible vision whizzing we can hear from a distance and on auscultation you will get widespread bronchial repetitions on both sides of the lungs so these are the respiratory findings then skin findings are very very typical and very important for the diagnosis because the respiratory findings may be there in the other conditions that will come with the differential diagnosis so the skin manifestations are mainly mediated by the histamine and the widespread increased permeability articularia which is also called hives these are the very typical large arithmetic probiotic lessons it's very important the word provided patient has intense itching and he has got the very raised from the skin layer the swellings which are that's why they are called hives and there may be flushing in some patients you will get flushing in some patients your typical articurial big patches which are ah in a different shape that is called serpignus right and there is intense itching in some people the flushing is so much that you can write down right something with the hand only and that is called thermographism so dermographism intense itching rhotic lesions and flushing are very important complaints that the patient would see with the very onset of the symptoms and there are some patients who have got the edema at the deep dermis levels of the subconscious levels typically we find this in the as it is shown here in the lips or in the near the eyes and they are called angioedema and they are not right they are non-pitting that's an edema in the substance tissues but that is because of as i said vascular leakage so angioedema is different than arctic area arctic area is erotic and genome is non-probiotic engineering involves the deeper layers and it typically affects the lips and also affects the upper lower eyelids sometimes the angioedema features might be present because of the involvement of the gastrointestinal form of abdominal pain then the gastrointestinal symptoms are again because of the increased movements or contractions of the smooth muscles that can crampy abdominal pain diarrhea vomiting cardiovascular symptoms are a combination of the direct effect of the histamine as well as the because of the hypotension and the fluid extravasations so there can be tachycardia there can be hypotension patient may develop syncope dizziness patients various arrhythmias and patients has so much of extra position of the intravascular fluid that when a matter of minutes patient can have 30 to 40 percent of the volume can reduce and patients go into high potential in shock and there are some patients who also develop what is called biphasic reactions that means initially the patient may so sign symptoms you treat them and after eight to twelve hours when you are feeling that everything is okay person okay starts the symptoms and that is because of the delayed release so the biphasic reaction is what is the also some people call it a second anaphylactic reaction in fact it is nothing but the delays wheels of the allergens which are in the systems and because of the hypotension which if you correct it and now they come into the circulations and maybe because of the under treatment some people say it's because of the under treatment that you get the biphasic reaction and there is the very reason that you should not discharge any patient of an anaphylactic reactions at least before 12 to 1 i would say 24 hours because there is a chance of getting a delayed reactions in the next 8 to 12 hours coming back to respiratory system the as i said the findings can be in the form of the obstruction of the upper respiratory tract that is the larynx and the glottis because of the laryngeal edema patient would complain of the lump in the throat or foreign body sense in the throat patient may have difficulty in speaking or there may be a visible or audible inspiratory strider then on the lower respiratory tract because of the severe bronchospasm because of the histamine release as well as the secretions of the bronchial tree that patients will have severe wrong repetitions and peso would complain anything depending on how he describes either tightness of the chest or the heaviness in the chest or maybe the whistling as a complaint death usually results from the spx's or cardiovascular collapse so that's why the very important thing is we have got to attend the cardiovascular complications and the respiratory involvement in the form of hypotension and the bronchospasm that is our prime treatment because that is where the there are treatment for the skin manifestations but they do not decide the outcome as far as the mortality outcome is concerned so it's better that we concentrate mainly on the stopping the mass cells releasing the granulation so that's very very important treatment we come to that in a minutes time so how to diagnose enough phylaxis anaphylaxis is a clinical diagnosis please do not waste any time in sending any investigations or any look for anything else of course you have to keep in mind the differential diagnosis that means in the next slide but what is important is whenever the patient has combination of symptoms like the arctic area flushing dermographism or hypotension cyanosis and on respiratory system having a extensive wrong kind of repetitions and if happens to have been exposed to something that he would point out that this is the one from which i have started these symptoms well you definitely are dealing with anaphylaxis and you have got to start the treatment do not waste time for the investigations and not of course you have hardly any time for the investigations but if the patient is in the hospital obviously you may parallely send the investigations by the time you take the line and all or sometimes you need investigations to exclude other differential diagnoses so what are the differential diagnosis these are the main differential diagnosis and at times it may be really difficult to differentiate an acute attack of asthma from anaphylaxis in a patient who is a known patient of asthma what is very important is in acute episodes of asthma what we now call it acute severe asthma or what used to be called status asthmaticus right we do not expect any cutaneous manifestations we do not expect any skin and in the form of arctic area or the njd mall so it's basically the absence of skin cuteness symptoms which as we said is almost 90 percent of the patients would get it right that makes it even if the patient is a known person of asthma that anaphylaxis is a probability even in that patient i would say that acute left ventricular failure or pulmonary edema definitely something that needs to be kept in mind an elderly patient patients with known patient of ischemic heart disease hypertension was undergone previous surgery or angioplasty and all but the patient would definitely have more symptoms and very very dramatically in a matter of minutes it's very unlikely not that it cannot occur again the absence of kin manifestations would make it unlikely to be and or enough i'll exit the place in the symptoms and in your slightest doubt definitely we should go for some of the investigations we are coming in the next time tension pneumothorax symptoms of breathlessness chest pain hypotension can come but the respiratory system examination will clearly make out that there is no entry on one side or track case if the media stream is shifted and there is a hyper resonance note on the side of the pneumothorax and of course the absence of skin manifestations foreign body obstructions again patients would definitely have absent of error entry on the one side but we do not expect the wrong height repetitions or the other manifestations and there will be history of some horrible injustice or a history of something like aspiration would be available either case if at all we need some investigations that investigation is mainly as i said the slightest doubt we go for the alternative diagnosis then we can go for the ecg exercise or blood chemistries but we i wouldn't suggest to waste time for that we start treatment give at least one or two dosages of adrenaline and then parallely go for the investigations if somebody asks something like in the examination somebody asked what is the test for anaphylaxis maybe then we have got to go for the mast cell cryptase assay because it is the cryptase levels which decide which run parallel to the severity of the nfl axis it's a very sensitive marker very expensive i don't think it is available in our setup or in their setups wherever it is available is x exhaustively expensive and it's also you have to have perfect timing of sending the blood for the muscle cryptase levels because it's half life it is in minutes and ideally they say that you send it between one and three hours of the onset of symptoms that is one and then of course ah you have to repeat it actually after the treatment is over so practically we have never done this but it may be required in a medical legal case is when we have to establish the diagnosis as a cause of anaphylax anaphylaxis is the cause of death in that case it will definitely help if the blood is collected from that or there is a rare condition called mastocytosis where you have to take the serial samples of the blood at the time of episodes after two hours or three hours and whether the levels not rise but remains the same and it is elevated from the normal maybe you can say that it's for that diagnosis but extremely rare conditions and similarly the urine as well as the plasma histamine levels can also be measured again theoretical or only for the academic purpose or for the postmodern ige levels that to allergen specific ing which is a food related or the sting related or the fish kind of ig specific antibodies are are available in the laboratories but that is more when the place at the time of discharge we can talk about that right with the patients and establish the diagnosis and make him prepare for the to prevent the next episode but in the acute episodes there is no role of ig2 now coming to the treatment somebody is asked about the dose of adrenaline and coming to that dr santos kumar so again this particular one slide itself use all the line of treatment will deal each one of them separately but make sure that you secure the airways and the every breathing and circulation of resuscitation is of paramount importance more so here because because there are chances of the laryngeal edema then also there is a chances of the secretions and all so the airways maintaining may be a very important crucial role so easy maintenance of circulation because of the hypotension because of the extra resistance of the fluid adrenaline remains the top of the order treatment number one treatment if somebody asked me which drug will keep in your emergency box i would say at least two impulse of attendant then i'll go for the another truck so it's that important and life-saving drug iv excess is very important but because of the severe fluid hypovolemia that the patient undergoes so we need two whiteboard needles for the iv access then comes antihistaminics we have got h1 and h2 antagonist structures available we'll come to that in detail but this is the list of drugs that we should give in this order only airways adrenaline iv excess antihistaminics bronchodilator either nebulizations or iv are both as required steroids you can see the steroids come much later in the hierarchy because steroids are not life-saving when it comes to anaphylaxis if the patient is bronchal asthma maybe you bring it higher up in the ladder but for enough phylaxis steroids come much later steroids are mainly to prevent the secondary reaction that we say the biophasic reaction their steroids are helpful and special situations like either the patient could be a pregnant lady or patient is on beta block or surface in the other comorbid conditions and there are situations like exercise induce asthma that will talk later and very importantly we cannot decide the patient without the explaining him in detail and getting his self investigated for the type of allergy so this is how we treat so what is important is 3i identify inject and inquire identify means just diagnose that is how anaphylaxis and straight away go for the injection adrenaline after securing abc and later on before discharge inquire so this 3i are very important secure airways we know about it more and we do not have to again dealt with this because it's a basic abc of most of the resuscitation what is important here that do not delay intubation if it's required if you feel that the patient is having an embedding respiratory failure right of the patient is oxygenation is not maintained by the mask normally by face mask we can give not more than eight to ten liters we may need a raw non-reading breathing non-rebreathing mask that may give you a little higher oxygen concentration but there may be a time when the patient has severe laryngeal edema and then we may have to go for emergency cricothyrotomy it's very important that this is very very important step and this will again be a life-saving step so emergency cricothyroidotomy is very very important and at the same time make sure that the patient has developed the enough alexis because of something that is hydrogenic that means a doctor induced or physician induced a patient is having some injections like the cephalexin injection or amino file injection i mean uh mp injection is going on its develop then we have to stop that infusion that's very very important so memphis of infusion that process is discontinued so stopping the infusion or inhalations whatever the patient is in inciting agent for a trigger it's very important remove the inciting agent start the intubations give thorough suctions if there are secretions in the upper respiratory these nasopharynx right and then very important treatment is adrenaline adrenaline is the life-saving drug i cannot over emphasize but i'll keep on repeating that adrenaline retinol adrenaline and very important thing is adrenaline unfortunately in our setup we do not have auto injectors or the pre-filled syringes of adrenaline it's not available otherwise that is the best thing to occur in other countries western countries the autofill or pre-filled syringes ready to use syringes are available we have got only adrenaline available as adrenaline one milligram per ml remember very important somebody has asked those and i would also say that adrenaline is available as one milligram per ml the ample maybe one ml or two ml and it's 1 000 dilution that is all are by pharmacopic standards it is one in thousand so that may or may not be mentioned it's important when we give intravenous when we have to have one in ten thousand dilutions but one in thousand dilution adrenaline important thing is the dose is point three to point five milligram so we should not give one ml whole ampl if it is one ml we should not give one milligram of adrenaline we should be giving only 0.5 milligram that is 0.5 ml 1 milligram is 1 ml usually so give 0.5 ml at a given time no more than that because it can create a certain complications we'll see later so important things give adrenaline 0.5 milligram we can keep repeating every 5 to 10 minutes but the maximum dose is 0.5 milligram when it comes to anaphylaxis adrenaline one milligram is made available mainly for as a part of treatment for advanced cardiac life support what we call it acls where in a cardiac arrest we give one milligram of adrenaline we can give one milligram of adrenaline when the patient is symptomatic bradycardia these are different situations in the advanced cardiac life support but when it comes to enough phylaxis the dose is 0.5 milligram at a time that too in the adults in children the dose is 0.1 to 0.3 milligrams so that is why in other countries when the pre-fill syringes are available they are available at 0.1 milligram in 0.1 ml or 0.3 milligram in point 3 ml or 0.5 milligram point 5 ml these are available in separate there is no maximum dose doctor but yeah you just keep on giving it but generally if the patient has to respond he would respond in the first 15 minutes mainly so that's why after five or ten minutes if you adrenaline doesn't work you try to find out that will come the later part maybe the patient who has on beta blockers then the adrenaline the all receptors are blocked so it may not work then we have to give the other sympathobiometic agents like the isoparatenerol or dopamine right and we also use drugs which work on other receptors like the glucagon we'll come to that later in a special situation but as somebody is asked uh definitely we have to keep in mind that if the patient is not responding there could be other reasons like probably we are not correcting the volume first hypomolema is very important if you given one or two dosages of adrenaline it's bound to work and stop the muscles releasing the granules so there now the treatment is mainly of hypovolemia and for that we have to give aggressive fluids next would be aggressive fluids that's very important giving adrenaline and hypovolemic will predisposed to adrenaline toxicity in the form of cardiac arrhythmias so it's very important that adrenaline we can repeat because the half-life of wedding is not beyond 30 minutes so we can give three four dosages but later on we have got to think of why the patient is not responding rather than giving only adrenaline right so that's very important there is no contraindications the next as i said is the hypoallerma correction of hypovolem is as important as giving the adrenaline and stabilizing the muscles right so patient as i said earlier there is massive shift of fluids because of the increased permeability right so as i said patient can have as much as 25 to 30 percent of the blood volume is into the extravascular compartment and that brings the hypovolemia we have to literally push one to two liters of the normal saline right in the initial stage and then we have to continue giving at least 125 ml per hour i'm talking the adult children accordingly will have to give children usually the dose recommended is 20 milligram per kilogram in the boluses children we don't give very high low suddenly we give bolos is of 20 ml per kg every 5 to 10 minutes that's what the recommendation is but very importantly we give fluids we get the iv excess iv excess may not be easy and that is why the alternative route suggested is intraosseous root in the temporal in the tibial tuberosity sometimes the injections are given i have no personal experience of the same but that's what the literature says that if the iv access is not available you can give interosseous root likewise the i just just a minute in as when it comes to adrenaline we should give it over the intramuscular region and that too at least in children of the outer part of the thigh adults also the thigh is the preferred side right it's very important that we they want adidas to go to the system as fast as possible earlier if you remember when we were students the adrenaline was given subconsciously but we know that when the patient is in severe shock the absorption is unpredictable if it is subcutaneous so that is why nowadays suckiness root is out you give intra muscular and that too if your doubt you can give one injection directly intratrackable there you give two milligram of adrenaline if you want to give intratracheal that you can give it so that's about the root of administration for adrenaline iv fluids is very important we have got to keep on giving normal salines if there is too much of normal saline it can produce hyperchloremia but that we can take care of later on or after the initial two or three liters we can switch to the ringer lactate which has less of chloride and less of sodium so we can switch over to the ringer lactate after the volume is maintained because for maintaining the volume normals line is the best then the and if when we have to give intravenous adrenaline we have got to make sure that the line is very much in the vein there is no extra vision because it is very very through the succulents tissue it is quite necrotizing and when you we have to give it one in ten thousand dilutions anti-histaminics are very important people have been giving only antihistamines which is h1 but ideally we should give both h1 and h2 receptor antagonist that means we have to give the phenylamine malleate or rife and erythramine and also the ranitidine because there is overlapping of the histamine receptors across the body and including the coronary circulation the histamine receptors work and there have been instances of coronary ischemia because of the massive histamine release so we have got to give both antihistaminics the phenylamine that is the evil that we know uh that's around 25 milligram and 2 ml and diphenhydramine that is the banana drill that is one and when we give it is 50 milligrams so give ranitidine as well as the phenylamine both entry stomachs to be given the bronchodilator therapy is again very important because patient has bronchospasm patient has secretions so we can have a nobilization with salvation we can also add anti-colonies like eprotropium to reduce the secretions and injectable ones we have got the aminophylline and the theophilus preparations available so definitely we can keep this but most of the time the adrenaline works best even for the secretions as well as for the bronchospasm but anyway we can give this as an event required coming to the steroids as i said steroids prevent only the recurrence of the second phase of the reaction that is the biphasic reactions for the delayed enough electric reactions articular and g demand and it has no helpful outcome in the initial resuscitation so better reservate steroid or give it after you have finished with our first important priorities then give steroids whatever steroids available in your setup whether it's methylprednisolone or hydrocortisone or dexamethasone these are the equipotent dosages and if the patient vitals happens to be on steroids maybe we need to give the higher dose we may straight away give the 500 milligram metal prednisones generally we give 125 to 250 milligrams without prednisolone hydrocortisone of 200 milligram or dexamethasone 8 or at the most 16 milligram of the examination we need to give now specific situations like beta blockers beta blockers if the patient is racing beta blockers the response of adrenaline may not be as good and we need to give higher better response so initially we will give adrenaline a patient does not respond and if by the time we get the history the pace in this beta blocker whether we give isoprene uh what is known as isopropanol in usa which is a pure beta agonist or we can also use dopamine or dopamine dopamine is a better as far as effect or the vasopressor effect is concerned and we can also give glucagon which works as an ionotropic as well as chronopic effects or which is not beta receptor mediated so it's a direct effect on the myocardium and that is why glucagon injection should better be kept in the emergency and it is in the hospital setup we have used on few occasions with a very good results so isopronaline or glucagon is something to be used if the patient happens to be in pregnancy in the last trimester and develop anaphylaxis most of the treatment remains same but here our priorities are both mother as well as the fetus and the fitter circulation is geoparadise if we are late or not correcting the treatment or maintaining the blood pressure so it's very very important that we give enough fluids what is important is when the pregnant uterus is falling on the inferior neck it compresses and produce further decrease in the venous return and hypotension adds to the hypotension so always the patient should be kept in the left lateral positions to reduce the compression of the vena cava and they need a higher oxygen supplemental oxygens and we must try to maintain the blood pressure of at least 90 millimeters for the fetal circulation to be maintained and filter monitoring is very very important when we give drugs like sympathetometers like adrenaline and other drugs definitely they are going to effect on the uterine contractions and we do expect uterine atroni or the postpartum hemorrhages that's one something we have to keep in mind we should try to cut down the second stage of labor by the use of these drugs and the forceps and all so it's very very important that pregnancy does carry little more risk to the mother as well as the fetus and we have to be very careful in dealing with another situation is that when the patient does not have edema of the upper part it is the as i said the laryngeal edema it is better that keep the patient the recombined positions and elevate the legs up lower extremities so that we prevent the hypotension and the cardiac filling the venous return is maintained the hypotension is corrected to some extent when the fluid is exhausted again because of the gravity it will come down if the legs are elevated but many patients who have got the feeling of vomiting gi symptoms uh right or severe respiratory stress they may not be in a position to keep the recommended positions it's better to keep them on one side so that they prevent the aspirations but very very important the patient has severe hypotension no matter how the patient is stressful please give fluids before making the patients sit up because there have been sudden death in matter of minutes because of the what they call it empty ventricle syndrome patient has no fluid in the ventricles and you make the upright posters that further drops the venous return so will always give enough fluids before making the patient upright and setting of hypotension and hypoperfusion it's very very important now the last part of it the exercise induced anaphylaxis this is a special entity where the patient develops symptoms of anaphylaxis only after physical activity most often it is after the vigorous physical activity like jogging or playing tennis or dancing or bicycling but many times even with the almost say the normal near normal physical activity like walking also might have produced the episodes of anaphylaxis here the symptoms would aggravate if the patient continues the physical activity so patient has to know or the sad by persons or onlookers or if you are happen to be necessary you should make sure that the patient stops because in exercise induce enough alexis the moment patient stops the exercise or the exertion the symptoms gradually recede so it's very important that patient has to stop the exertion suddenly here no warming open cooling of type suddenly and treatment practically is same right the only important thing is that the patient has to find out the triggers and whether it is just an exercise and it's not that every time patient does the same degree of exercise and patient would have anaphylaxis it's we do not know the exact mechanisms some people say it is probably because of the release of the direct effect of the exercise induced the endorphins over the mastocytes which are so endorphins are the secretor god some people say the mastocytes are directly stimulated by the exercise exact mechanism is not known so it may not be possible only thing is patient has to learn by himself or herself that how much exercise he or she can do second part he has to have adrenal injections and other things ready and the first symptom is to stop the excess that is what we have to do for the exercise in this anaphylaxis and there is another entity called x is a an entity called food dependent exercise induced anaphylaxis patient when takes certain food say suppose popcorn it doesn't develop anaphylaxis but when patient takes popcorn and does exercise it gets the enough phylaxis this is called food dependent exercise induced anaphylax it's a known entity and the common foods are the wheat selfies tomatoes peanuts and corn and again probably the it's because of the exercise the food absorption is increased whatever food is thickens the quantum is more that's one of the mechanisms and that is why the patient develops this and in that situations you have to confirm the diagnosis as i said by exposing the patient to the food without doing the exercise and second part under supervision uh giving the food and the exercise and have you do it so another important fact is that the ig mediated anaphylaxis usually develops in minutes as we've been telling from the beginning and maximum that it takes is about an hour but there are certain food substances like a specific food called alpha 1 3 galactose which is present in red meat this is known to have developed the patients who have consumed this red meat and who are allergic have developed symptoms after four to six hours of the injection so this is called the algel alpha three one three galactose which is present which is a carbohydrate in the red meat can develop the ig immediate reactions after as many many as six hours people have also developed anaphylaxis because of the vapors from the cow milk if you are allergic to milk that's also been reported and patients have died because of this then these are we already mentioned that the ringer lactate alone may increase the metabolic alkalosis right so better the q and if you give only ns will give hyper chloramic entablic acidosis so that current practice even otherwise in non endophyletic switches also is we always give normal saline and ring electric alternatively when we give more than two or three liters of the fluid somebody has asked about the infusion rate of the normal saline again as i said initially when the patient is severe high polymer we literally push by literally pushing the bottles or the polythene bags right and push the blood with white board needles that is why we need to take 14 or 16 gauge needle so that we can give large fluids right and then we usually not less than 125 to 150 ml of fuel every hour right so very importantly very very important that before discharge as i said we must of the patient for at least 8 to 12 hours that's minimum i would say 24 hours and make sure that you look for the in another symptom signs right and second part is that we need to find out now why the patient developed these symptoms and what should he do when he develops the symptoms again and then whenever the patient is quiet means of this episode he should go for the allergic testings ig levels ig allergen specific ig levels are also available that we need to do we must give him the printed information that he can carry always with him what are the allergens that he is ex has experienced the reactions and what it meant home to contact and all this ideally he should also carry either an identity card or a plus bracelet or anything in the form of which can be seen by the onlookers when somebody is found right unresponsive on the road and again personal details of his triggers and the he should also be very very food level detective they say that whenever you go to the mall or buy for shopping that you should see whether the contains substances to which he is allergic and not only he but his family members colleagues and in case of students that the teachers should be informed about the allergies and the possible science symptoms so this is all very very important so what we have learned right this is the last slide before we go to the take home message is this is the very last study study comprised over 30 years it started in 19 they have started collecting all the fatal fatal anaphylactic reactions uh in the uk registry of all fatal enough electric creation since 1992 and till last reported that is they recorded about 164 fatal enough electing means unsuccessful or the cause of death mentioned as anaphylaxis all those cases were collected and analyzed and they could say that roughly it comes to about 20 fatal reactions every year out of which the 50 percents were hydrogenic 50 percents are hydrogenic and in the iotogenic we have no time because most of them iogenic means either giving the intravenous drugs that we have been giving right and it's an intervenous route patient is unchecked getting it and if you don't miss if you miss that right in the first five minutes patient straight away goes into the respiratory or cardiac arrest so five minutes for the hydrogenic reactions in this 164 patients 15 minutes for the sting induced and 30 minutes the four didn't use enough that was the duration between the cardiac arrest and the patient's admissions and the cardiac arrest what is important is that 28 persons were revived from the initial cardiac arrest right following enough alexis 28 persons were revived but unfortunately they died again in 3 to 30 3 hours to 30 days later mainly because of the hypoxian brain damage that means they were revived but not revealed in time that's another thing and the most important thing is the last line that's what we have been tracing from first minute that adrenaline was used in the treatment and 62 percent of the fatal reactions but that was used more as a part of acls that is only when they got cardiac arrest uh they received another in 14 percent of the patients and in others really they had not received adrenaline before so that's something that even the studies in the such centers also let us teach that the most important twin remains adrenaline remember anaphylaxis is a life-threatening medical emergencies but all allergies are not enough alexis and anaphylaxis with shock is the to be treated on a war footing without wasting time and adrenaline is the drug of choice and there is no contraindication for anaphylaxis right and we have got to keep in mind the patient's other conditions like patients on medications like beta blockers or patient has happens to be a pregnant or a child and also discharge specifications very very important about the explaining the disease and keeping the identity card with them so that's all about the anaphylaxis from my side all questions welcome thank you first of all it was a very very informative session thank you so much and sir i would like to know sometimes uh we often see the patient with angio neurotic edema of course that cannot be classified as nf alexis but i have few patients who often come with a swollen lips and eyelid swollen uh i know them because they come every month or if every few months but it can be a first attack also so how to uh how we can be a doubly shooter is not an nf alexis and it is not an engine neurotic edema uh and generally it's called angiodema number one and it's more as i said non-probiotic but the very fact that they respond there the mechanism is slightly different usually it is not a histamine which is released it is the bradykinin right it is it affects the calicrine system and it affects the bradycardia and that is why there is vasodilators and symptoms most of the time it is self-limiting and there are drugs which specifically work there you can use steroids for a short course you can use it but this specific drug called ecarbitant or something like that i am not sure whether it's available here or not but that is the drug that is used for the angioedema and otherwise you have to got to look for the again inciting agent which causes this nj edema and we have got to for diagnosis as you said there is a what level is called c4 complement level that is we do the blood test for the c4 complement because it is a complement complement mediated uh reaction and there is another there are some people who are born with the c1 inh that is the c1 earlier is to be called c1 stress inhibitors so c1 inhibitor uh if it is deficient then they would have this symptom so that is possible but otherwise they would not be having the typical symptoms of anaphylaxis in the form of the protic intense priority gracing or hypotension only thing that worries is the laryngeal edema because there you have got to go for the emergency tractors from your intubations before the otherwise elsewhere if the njd markers it's not life threatening and it may lead to delayed diagnosis particularly impeachment gi involvement in the form of abdominal pain some people have got frequent abdominal pain with some food and if you don't think of angioedema as one of the cause probably they remain undiagnosed patients like patients who are on drugs like ace inhibitors right like uh remember they also can have engineer because this kind of same mechanisms the bradykini related so sir we can give them anti-allergic plus dexamethasone we can give yes for that particular episode we give because as i said mainly we are worried about the laryngeal otherwise they are going to subside elsewhere i am not much worried okay thank you so much thank you ma'am i am not sure about whether the economic habitant is available i am not sure i did try to look for but i couldn't find will again try again normally we give allegra in dexamethasone it subsides with that yeah that's what is that's fine right i have accepted your request meanwhile somebody has asked they develop the reactions the following vaccines well it is very difficult so there are allergic reactions that is one right uh very difficult to say that allergic reactions usually wouldn't last like that so maybe there is some non-allergic involvement or maybe that we have got to rule out the chord infection itself and then it could be something different somebody has asked about histogram injections normally we don't give it right but non-specific immunoglobulins are being treated right in for the d i would say hyposensitization or desensitization but not in the acute i don't think that it is available it's prescribed ever in the acute management of any allergies or the nf indexes yes satiji yeah uh good evening sir excellent presentation thank you uh so i had a question uh if a patient is a cardiac patient who has a president who has a history of cardiac disease is it right to push in iv fluids at the initial stage of anaphylaxis knowing that the patient might i agree but see issue is that if you don't give the same things happen that hypovolemia itself can lead to the severe hypotension induced complications so we have got to give fluids but the moment we feel that the patient is better we can push the diuretics and try to remove the overload but we can give it there is absolutely no questions only thing is these patients are better managing iso with cvp line and all monitoring echocardiogram everything weight side but definitely initially we have got to give the fluids so uh i have a second question yes we have seen a few times when we have given the patient iv fluids and all of our patient all of a sudden patient has had severe rigors with hypotension and severe bronchospasm so in that setting would it be wise to give adrenal injections in cases usually that rigorous is because of the either the fluid is too cold number one or maybe there is some pyrogenic reactions so i don't think giving adrenaline should uh come in the way of any of this i don't think these are the allergic reactions okay primarily a pyrogen reaction yeah or the fluid which is cold if it is kept in the very cool and now suddenly we get large quantity fluid then piston will get righters they are not indicative of our allergic reactions thank you yes dr would you like to take the questions yeah yes actually one more small point to add to the previous question uh if a patient in a patient with cardiac disease many a good amount of peoples are likely to have people are likely to have a lb dysfunction in fact it is all the more recent when you give an imaginary it is going to work nicely and probably the requirement for the fluids will automatically come down that is why they say it's earlier the better nmba agents can trigger anaphylaxis yes neuroblocking agents are supposed to be one of the known agents which can cause so again the treatment will be in the same sequence same yeah among the neuromuscular blocking agents the depolarizing agents are supposed to be more common with succinate choline is supposed is supposed to be one of the main reason and reflux is due to lignocaine in dental clinic the treatment will be the same so you want to add it will be the same right it'll be the same only thing is we have got to find out that it's definitely nf alex is not simple hypotension because it can cause hypotension more often uh rather than the enough otherwise treatment would remain same and many times we give ligno with it adrenaline itself over there but that's for a different purpose for the vasoconstriction and bloodless field and prolonging the action of lignocaine but a treatment would remain same but more often it is hypotension rather than the anaphylaxis exactly and nothing against any group but we often see that anaphylaxis is being diagnosed more often in dental clinic when they give local lignocline they tend to see it as anaphylaxis every time they say it's as right you rightly told it most of them it's high potential see basically uh i don't know i don't know what this really means for article vascularities but the treatment would remain both both antihistaminics and the steroids which anyway we are giving it uh i think there's a question based on what dr said that often it happens that nfl access is like it's wrongly diagnosed is just a hypotension so dr jagdish is asking uh if diagnosis of anaphylaxis is wrong uh will giving adrenaline cause any side effects so that's a very important question i would say that when you are giving one atrial anil probably a patient would not have other symptoms will not further inversion and anyway when we say that if the patient is sitting in the suppose the dental chair and there is hypo first thing that you do is the lower the head and raise the legs and that will bring down symptoms so you would not be getting more than one dose of adrenaline if the patient is young that one rose will not case problem but if the patient is elderly or already high potency or thyroid sources definitely we have got to make sure that we do take care of his blood pressure and everything and good part is the adrenaline half life is not much so we have got a next uh what that we have to matter is the next 30 minutes that we have to see whether there is any such side effects maybe we need to go for the ecg we can involve the physician on a cardiologist if you feel that the patient is worsened one more important point here is we are giving yes yes so it usually doesn't cause any harm even in the patients with some degree of commodities yeah the single dose of higher maternal is not harmful there is benefit ratio will anyway favor the ai material my point was that if the patient is already have hypertension or something you have to be a little careful about it that's it otherwise yes and we can give diabetic and the patient does not have enough alexis iot could take care of the part mostly so dr anjali would like you to reiterate on the exact role of a gp in such emergency condition before referring the patient you don't have to refer the person you have to treat the patient no question about it right because you don't have time to refer see as i said that if you are sure about the diagnosis of anaphylaxis by simple combinations of sudden appearance of symptoms of artic area or angioedema or intense protest with severe bronchospasm or wrong kind repetitions and that to coming up with some possible exposure of an allergen straight over the diagnosis anaphylaxis give at least one dose of adrenaline intramuscular at this that is what we can do and make sure that there is no laryngeal demand there is no laryngeal edema right then we have got more time we can give the nebulizations that also can be known at the general practices level or then you can shift right if you give one or two doses of adrenaline at the interval of five minutes you have done the best thing and then you call the one zero eight and that they come with the full team and at least there is intubation facilities and everything available no adrenaline no intercalating because it's definitely can create more problems it can damage the myocardium it can produce arrhythmias and it's not the root it has to be out right there's a question that pediatric hydrocortisone dose i am not sure about it because i don't deal with it it's usually four milligram per kilogram okay it's usually four milligrams thank you so much in autopsy i don't you'll have to send it to the species laboratories i'm sure because it's not done routinely so all that is from the textbook that we read and tell you and the processing also takes time sir so usually what they say is that by the time the results come either of the result would have been either the patient would have been completely okay or at the other end so yeah and as i said it's only for the postmodern diagnosis is confirming when there is a yeah right and somebody asked about the pheochromocyto and carcinogen i don't think the symptoms are saying you do not get the cuteness manifestation or skin manifestations and they are more episodic right in the first episode itself you might have the increased blood pressure at the most in fuel carbon cytomedic typical tired of headache palpitation and high blood pressure but for that there would not be other symptoms so uh if the patient is already having 200 blood pressure i would not think of anaphylax or give adrenal in any way right and facing this tachycardia high severe hypertension there is no question of mistaking it as an anaphylaxis number carcinoid syndrome again symptoms are more really if at all it's a bronchial cause you know then maybe there are some symptoms but the gi carcinoid symptoms of diarrhea and borrowing and all and i don't think that patients are typically that bad feochromocitamia that's because of the hypertension emergency not because of anaphylax like symptoms carcinoid we have got the diagnostic test available uh blood test and urinary test are available phi hia what that we do yes you are i i for one believe that if a diagnosis enough alex is con sure and if you're not giving it definitely is a deficiency in services and you can be liable if they can prove it and obviously that if our documentation does not show adrenaline and even with the timings even if the diagnosis at 11 a.m when you give one at 12 noon that is definitely a deficiency delay diagnosis a delay treatment is as good as no treatment so definitely it's a medical negligence if you have not given adrenaline with a diagnosis of anaphylaxis because that is the treatment we should be giving uh there's one question and steroid injection should be given after how much time after giving abdomen no that's not a question of how far but see anti-histaminics and they are mainly for symptomatic relief if you relieve the symptoms patients anxiety and also we need to take care we have to do the symptomatic treatment so if you have given every five minutes after giving one injection five minutes of adrenaline next sixth minute only i can give it not that we have to wait for if i return in the order in the fourth or fifth doesn't mean that we wait for half an hour so we can give it then we have given adrenaline once we got next five minutes for the next additional meanwhile we can give this injection there is no question of delaying for no good reasons right so definitely we'll give it in the sixth or the seventh minute itself because ultimately we have to relieve the symptoms so that patient's anxiety is reduced and anxiety-induced symptoms are also reduced the patient's itching is reduced the swelling is reduced it is going to help us further so no question we have to give it somebody has asked whether the antibiotics can cause edema what we mean by demise it is enough alexis definitely it can cause otherwise i don't think that antibiotics when you give a large quantity of sodium containing antibiotics like forage conditions like bacterial endocarditis or meningitis things are different then there can be edema because of the sodium returns and otherwise edema can occur because of the as i said part of the electric reaction or enough electric access thank you so much for such a lively interactions a good audience and very receptive audience i also enjoyed thank you dr narayan for everything thank you sir it's my pleasure comments coming in uh one comment was very interesting that they are feeling more confident in going and dealing and i think that's what netflix always strives uh that that comment made my day frankly that if if this session can give a confidence to someone to practice in his life then it's really great right and as i said to begin with that this is not something we are going to encounter daily enough i'll actually get once in i have had four enough electric socks treated thankfully all successfully out in my entire practice of 40 years right so it's not that routinely we encounter enough alexis but it's very important that if you remember at this i say remember only adrenaline and these symptoms i think we have done our job [Music] in your presentation you said the fault the folic is it should not be given regularly that is vitku what i mean see that intravenous folic acid we better avoid unless the patient had had received already in the past right otherwise the first time i would be very skeptical in giving a tattoo he may go to a family physicians or to a parametric person takes it if he's hospitalized i don't mind giving because then we are always going to watch i am not afraid of anaphylaxis when it occurs in my presence i am only afraid of anaphylaxis very outside the hospital setting where difficult to diagnose and manage in the hospital setup and that's why we are never worried about giving vaccines or any drugs which can have potential side effects people who had complications because of the vaccine earlier vaccines we told them that come to the hospitals and will give the vaccines so these carved vaccines also coverage and cognition we had given right because in the hospital we are not worried about the enough alexis right and so one more question does adrenaline has any side effect like as the gp we have never given and if we diagnose something as anaphylaxis then suppose it comes out to be angioedema and adds and we have given the adrenaline does it has any side effect i don't think see as i said the side effects are rise in the blood pressure palpitations that matters only when the patient has angina something or severe hypertension otherwise it's a very half-life is short right so next half an hour it will be out from the circulation we don't have to worry about it right we observe the patient for next half an hour and that's enough okay thank you thank you so yes like i was saying a very informative session i would like to thank you uh you've covered all points and like i said if it's giving confidence to our doctors i think our work here is done thank you dr narayan for taking out the time for moderating it was wonderful having you here like i said we have always seen your insightful comments on our questions and we did enjoy having you here hope to see you again on the stage soon you are always there with us in the comments today it was nice to see you here and i'd like to thank all our doctors the audience

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Senior Consultant Physician | Ahmedabad

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