Management of Anaphylaxis in an 8-Year-Old Male with Respiratory Distress

1. Case Presentation Bianca Cruz

2. General Information • X.R. • 8 year old male • Roman Catholic • Makati • Informant: Mother (80% reliability)

3. Chief Complaint Difficulty of Breathing

4. History of Present Illness • Colds • Productive cough with whitish phlegm • No fever, no DOB, no abdominal pain, no vomiting • No consult done, no meds taken 3 days PTA • Colds • Productive cough with yellowishphlegm • Undocumented fever • No DOB, no abdominal pain, no vomiting • No consult done, no meds taken 2 days PTA

5. History of Present Illness • Colds • Productive cough with yellowishphlegm • Undocumented fever • Difficulty of breathing • Chest pain during inspiration and coughing • Rx:Paracetamol, 5ml (250mg/5ml) • Helpedlyse the fever • No consult done, no meds taken 1 day PTA

6. History of Present Illness • Colds • Productive cough with yellowishphlegm • Undocumented fever • Difficulty of breathing • Chest pain during inspiration and coughing • No consult done, no meds taken • Appearance of non-pruriticerythematous wheals on arms, legs, trunk and torso 2 hours PTA CONSULT

7. Review of Systems • General: (-) weight loss, (-) weakness • HEENT: (-) dizziness, (-) BOV, (-) rhinorrhea, (-) epistaxis, (-) dysphagia • Respiratory: (-) hemoptysis • Cardiovascular: (-) palpitations, (-) cyanosis, (-) easy fatigability, • Gastrointestinal: (-) abdominal pain, (-) changes in bowel movements • Genitourinary: (-) dysuria, (-) frequency, (-) hematuria • Musculoskeletal: (-) muscle pain, (-) dysarthria, (-) weakness of extremities • Dermatologic: (-) erosions, (-) excoriations

8. Past Medical History • No previous hospitalizations • No previous surgeries • No allergies to food or medicines

9. Birth History • Born full term via NSD • Attended by an OB • PNCU > 10 • 4 UTZ • Normal CBC and urinalysis • Non-reactive HbsAg • 25 year old mother, G1P1 (1-0-0-1) • Unrecalled birthweight and APGAR score

10. Nutritional History • Breastfed until less than 6 months • Weaned at 6 months • No food preferences

11. Immunization • BCG • DPT • HIB • Hepa B • Measles • MMR (Incomplete)

12. Family History • Hypertension

13. Physical Examination

14. Physical Examination

15. Primary Impression • Anaphylaxis

16. Differentials • Asthma • Pneumonia • Viral Exanthem

17. CXR • Consider pneumonia, right

18. CBC • Bacterial Infection

19. Plan: Therapeutics • D5NM 1L x 79ml/hr (+ 10%) • Hydrocortisone 100mg/IV every 6 hours • Diphenhydramine 32 mg/IV every 6 hours • Salbutamolnebules, 1 nebule every 4 hours • Paracetamol 250mg/ml, give 6.5ml every 4 hours for temperature >/= 37.8 • Cefuroxime 750mg/IV every 8 hours

20. Plan • Watch out for • Difficulty of breathing • Recurrence of urticarial rashes • Tachypnea

21. Course in the Wards 9 March 2012; Day 4 of Illness; Day 1 of Hospital stay

22. Course in the Wards 9 March 2012; Day 4 of Illness; Day 1 of Hospital stay

23. Course in the Wards 10 March 2012; Day 5 of Illness; Day 2 of Hospital stay

24. Course in the Wards 10 March 2012; Day 5 of Illness; Day 2 of Hospital stay

25. Course in the Wards 11 March 2012; Day 6of Illness; Day 3 of Hospital stay

26. Course in the Wards 11 March 2012; Day 6 of Illness; Day 3 of Hospital stay

27. Anaphylaxis

28. What is Anaphylaxis • Acute multi-organ system hypersensitivity reaction • Needs previous exposure to allergen to develop hypersensitivity reaction • Initial exposure may be through breast milk

29. Hypersensitivity Reaction • Exposure to allergen  sensitization of B-lymphocytes • Re-exposure to allergen  activation of allergen specific IgE molecules  activation of mast cells and basophils  release of cell mediators (histamine, tryptase, prostaglandins, cytokines)

30. Common Allergens • Food • Latex gloves • Medications

31. Clinical Presentation • Cutaneous • Urticaria, angioedema, flushing • Pruritus, sensation of warmth, periorbital edema • Respiratory • Bronchospasm, laryngeal edema • Throat tightness, dry cough, dyspnea, cough, wheezing, nasal congestion

32. Clinical Presentation • Cardiovascular • Hypotension, dysrhythmias, myocardial ischemia • Loss of consciousness • Gastrointestinal • Nausea, abdominal pain, vomiting and diarrhea • Injected allergens – most rapid reaction

33. Diagnosis Fullfilment of any one of the 3 criteria 1. Acute onset of illness with involvement of the skin and/or mucosal tissue AND at least 1 of the ff: • Respiratory compromise • Dyspnea, wheezing, hypoxemia • Reduced BP or associated symptoms of end-organ dysfunction • Hypotonia, syncope, incontinence

34. Diagnosis 2. Two or more of the ff. that occur rapidly after exposure to a like LIKELY allergen for that patient • Skin/ mucosal involvement • Generalized hives, swollen lips/ tongue, uvula • Respiratory compromise • Dyspnea, wheezing, stridor, hypoxemia • Reduced BP • Hypotonia, syncope • Persistent GI symptoms • Vomiting, crampy abdominal pain

35. Diagnosis 3. Reduced BP following exposure to a KNOWN allergen for the patient • Infants and children • Low systolic BP • More than 30% drop in systolic BP • Adults • Systolic BP < 90mmHg • > 30% drop from baseline

36. Laboratory Findings • Briefly elevated plasma histamine • Plasma Beta-tryptase – remain elevated for several weeks

37. Treatment • Ensure adequate airway, circulation and perfusion • Administer Epinephrine • IV: • No IV: given IM • 0.01 mg/kg, max 0.3 – 0.5 mg • Persistence of symptoms: Can be repeated 2-3 times between 5-15 min intervals • Give nebulizedalbuterol

38. Treatment • Administer Histamine-1 receptor antagonist • Ex. diphenhydramine • Give corticosteroids • Helps prevent late phase of the allergic response • Methylprednisone • Prednisone • Volume expanders • NSS, D5LR

39. Complications • Biphasic anaphylaxis • Recurrence of anaphylactic symptoms after resolution • New onset of symptoms – more severe • Late treatment

40. Prevention • Allergen avoidance • Epinephrine autoinjection • Liquid cetirizine or diphenhydramine • Written emergency plan • Usage of oral medications vs. IV • Immunotherapy