RESUS

ResponseSevere tongue oedema occupying most of the mouth with tongue protrusion
Periorbital oedema
Pale

Suggest:
Tongue oedema >> threatened airway
Pale >> Cardiovascular compromise

Airway obstruction impending when
Stridor
hypoxia/cyanosis
Increased WOB
Fatigue >> dropping GCS

ResponseAcute onset illness with typical skin features (Urticarial rash or erythema/flushing and./or angoedema) PLUS involvement of respiratory and/or cardiovascular and/or severe persistent gastrointestinal symptoms
OR
Acute onset of hypotention or bronchospasm or upper airway obstruction where anaphylaxis is possible even if typical skin features are not present.

ResponseAll the urticarial stuff:
Asthma
Atopic disease
Delay to adrenaline
Upright posture during shock
Cardiorespiratory disease in general (COPD, IHD etc)
Misdiagnosis
Carelesseness/deliberate exposure to allergen or drug

ResponseItch (Pruritis)
Flushing (erythema)
Hives/Wheals (Urticaria)
Angioedema
Palllor (in shock)

ResponseAirway

• Stridor
• Hoarse voice

Respiratory

• Hypoxia – sats <90%
• Tiring respiratory effort

Cardiovascular

• Hypotension <80-90 systolic BP
• Poor mentation

ResponseStop offending agent (? antibiotic)
O2 15L NRBM for sats >95%
IM adrenaline 10 mics./kg into lateral thigh
Repeat at 5 minutes
N/S bolus 10-20 mL/kg + repeat.
Endpoints MAP >65 or SBP >90, CRT <2s, reduction in angioedema
Hydroctortisone 4mg/kg
Prescribe alternate therapy for original condition (eg: clindamycin instead of penicillin)

Alternative:
IM adrenaline 500 mics
Oxygen to sats >94%
IV fluids 1000 mL stat
Cease offending antibiotic, change antibiotic regime, record allergy in notes
Steroids - IV hydrocortisone 4mg/kg to 200 mg

End –points are – systolic BP greater than 90mmHg and normal mentation, also sats >90- 92% and decreased work of breathing

ResponseIV adrenaline infusion 0.1-1 mic/kg/min
Further IM adrenaline
Nebulised adrenaline if predominantly upper airway oedema
IV antihistamine - if significant urticarial component

ResponseRefractory hypoxia
Cardiac arrest
Upper airway obstruction
Apnoea/ loss of respiratory drive
Coma or obtundation
Refractory shock

ResponseEstimated ~5% (3-20%) incidence
Time to onset average 10 hours but up to 30
Role of antihistamines - none
Role of glucocorticoids in prevention - no reduction in biphasic episodes, may have utility in reducing asthma/wheeze and urticaria.

ResponseClinical:
Remains well for period of time (accept almost anything reasonable)
Underlying condition managed to the point that outpatient management reasonable i.e. tolerating oral diet, pain under control, has discharge instructions re Abx
Anaphylaxis specific:
Clear understanding of allergy and NEVER for penicillin agents
Script for 3 days of steroid at appropriate dose (?Controversial)

ResponseStore the EpiPen at room temperature
Use the EpiPen as soon as you recognise you are having an anaphylactic reaction
Flip open the yellow cap (green if EpiPen Junior) carrier tube
Grip in your hand with orange tip (needle end) pointing downward (ready to inject)
Remove / pull off the blue safety cap on the other end of the EpiPen
Place EpiPen orange tip against your upper, outer thigh (must say thigh, not arm)
Push the EpiPen inwards firmly, until you hear a ‘click’
Hold in place for 3 seconds after adrenaline delivery (needle pops out with the click)
Remove EpiPen and massage injection area for 10 seconds
Make certain someone else (or you if alone) has called an Ambulance at the same time ie. ‘call for help’

ResponseEnsure adequate education re: technique (parental education)
Script must include at least two pens for different locations – ie home/school/car etc
Letter for school to ensure they are aware and can store +/- administer Epipen

ResponseSevere/protracted anaphylaxis (repeat IV adrenaline doses, significant fluid resus)
History of severe/protracted anaphylaxis
Concomitant severe asthma, arrhythmias
Possible continued allergen absorption
Lives alone, poor social support, late at night, no easy access to care
Parental anxiety

ResponseAlpha 1

• Increased vasoconstriction >> increased TPR >> Increase in BP
• Decreased mucosal oedema

Beta 1 (1 heart)

• Chronotropy
• Inotropy

Beta 2 (2 sets of lungs)

• Bronchodilation
• Decreased mediator release from mast cells

ResponseTremor
Agitation/anxiety
Nausea
Headache
Palpitations

ResponseHypertension/hypertensive crisis
Myocardial ischaemia/infarct
VT/VF
ICH
APO
Peripheral ischaemia/gangrene