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anaphylaxis and drug adverse reactions Flashcards

1
Q

Serious allergic reaction, rapid in onset and may cause death

A

ANAPHYLAXIS

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2
Q

____in infants and children

A

Underdiagnose

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3
Q

Sudden release of potent biologically active mediators from

A

mast cells
basophils

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4
Q

leading to cutaneous, respiratory,
cardiovascular, gastrointestinal symptoms

A

basophils

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5
Q

allergic reaction to medications and latex

A

Hospital-related –

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6
Q

Community-related

A

– food allergy

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7
Q

important cause of food induced anaphylaxis

A

Peanut allergy –

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8
Q

pathology

A

Acute bronchial obstruction with pulmonary hyperinflation,
pulmonary edema, intra-alveolar hemorrhage, visceral
congestion, laryngeal edema, urticaria, and angioedema

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9
Q

Result of the activation of mast cells and basophils via cellhound allergen

A

specific IgE.

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10
Q

CLINICAL MANIFESTATION

A
  • Vary depending on the cause of the reaction
  • Ingested allergen (food, medication) delayed in onset – mins
    to 2 hours
  • Injected allergens (meds, sting) – GI symptoms
  • Pruritus mouth and face, sensation warmth, weakness, and
    apprehension; flushing, urticaria and angioedema, oral or
    cutaneous pruritus, tightness in the throat, dry staccato cough
    and hoarseness, periocular pruritus, nasal congestion,
    sneezing, dyspnea, deep cough, and wheezing; nausea,
    abdominal cramping, and vomiting; faintness and loss of
    consciousness in severe cases
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11
Q

Ingested allergen (food, medication) delayed in onset

A

– mins to 2 hours

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12
Q

GI symptoms

A

Injected allergens (meds, sting) –

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13
Q

clinical manifestations

A

Pruritus mouth and face, sensation warmth, weakness, and
apprehension; flushing, urticaria and angioedema, oral or
cutaneous pruritus, tightness in the throat, dry staccato cough
and hoarseness, periocular pruritus, nasal congestion,
sneezing, dyspnea, deep cough, and wheezing; nausea,
abdominal cramping, and vomiting; faintness and loss of
consciousness in severe cases

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14
Q

ANAPHYLAXIS SYMPTOMS THAT
INFANTS CANNOT DESCRIBE >GENERAL

A

Feeling of warmth, weakness, anxiety,
apprehension, impending doom

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15
Q

ANAPHYLAXIS SYMPTOMS THAT
INFANTS CANNOT DESCRIBE >SKIN/MUCUS MEMBRANES

A

Itching of lips, tongue, palate, uvula, ears,
throat, nose, eyes, etc.; mouth-tingling
or metallic taste

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16
Q

ANAPHYLAXIS SYMPTOMS THAT
INFANTS CANNOT DESCRIBE >RESPIRATORY

A

Nasal congestion, throat tightness; chest
tightness; shortness of breath

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17
Q

ANAPHYLAXIS SYMPTOMS THAT
INFANTS CANNOT DESCRIBE >GASTROINTESTINAL

A

Dysphagia, nausea, abdominal pain/
cramping

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18
Q

ANAPHYLAXIS SYMPTOMS THAT
INFANTS CANNOT DESCRIBE >CARDIOVASCULAR

A

Feeling faint, presyncope, dizziness,
confusion, blurred vision, difficulty in
hearing

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19
Q

ANAPHYLAXIS SYMPTOMS THAT
INFANTS CANNOT DESCRIBE >CENTRAL NERVOUS SYSTEM

A

Headache

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20
Q

ANAPHYLAXIS SIGNS THAT MAY BE DIFFICULT
TO INTERPRET/UNHELPFUL IN INFANTS,
AND WHY>GENERAL>

A

Nonspecific behavioral changes such as persistent crying, fussing, irritability, fright, suddenly
becoming quiet

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21
Q

ANAPHYLAXIS SIGNS THAT MAY BE DIFFICULT
TO INTERPRET/UNHELPFUL IN INFANTS,
AND WHY>SKIN/MUCUS MEMBRANES

A

Flushing (may also occur with fever, hyperthermia, or
crying spells)

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22
Q

ANAPHYLAXIS SIGNS THAT MAY BE DIFFICULT
TO INTERPRET/UNHELPFUL IN INFANTS,
AND WHY>RESPIRATORY

A

Hoarseness, dysphonia (common after a crying spell);
drooling or increased secretions (common in
infants)

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23
Q

ANAPHYLAXIS SIGNS THAT MAY BE DIFFICULT
TO INTERPRET/UNHELPFUL IN INFANTS,
AND WHY>GASTROINTESTINAL

A

Spitting up/regurgitation (common after feeds),
loose stools (normal in infants, especially if
breastfed); colicky abdominal pain

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24
Q

ANAPHYLAXIS SIGNS THAT MAY BE DIFFICULT
TO INTERPRET/UNHELPFUL IN INFANTS,
AND WHY>CARDIOVASCULAR

A

Hypotension (need appropriate-size blood pressure
cuff; low systolic blood pressure for children is
defined as <70 mm Hg from 1 mo to 1 yr, and less
than (70 mm Hg + [2 × age in yr]) from 1-10 yr;
tachycardia, defined as >140 beats/min from 3 mo
to 2 yr, inclusive; loss of bowel and bladder control
(ubiquitous in infants)

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25
Q

ANAPHYLAXIS SIGNS THAT MAY BE DIFFICULT
TO INTERPRET/UNHELPFUL IN INFANTS,
AND WHY>CENTRAL NERVOUS SYSTEM

A

Drowsiness, somnolence (common in infants after
feeds)

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26
Q

ANAPHYLAXIS SIGNS IN INFANTS>SKIN/MUCUS MEMBRANES

A

Rapid onset of hives (potentially difficult
to discern in infants with acute atopic
dermatitis; scratching and excoriations
will be absent in young infants);
angioedema (face, tongue, oropharynx)

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27
Q

ANAPHYLAXIS SIGNS IN INFANTS>RESPIRATORY

A

Rapid onset of coughing, choking, stridor,
wheezing, dyspnea, apnea, cyanosis

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28
Q

ANAPHYLAXIS SIGNS IN INFANTS>GASTROINTESTINAL

A

Sudden, profuse vomiting

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29
Q

ANAPHYLAXIS SIGNS IN INFANTS>CARDIOVASCULAR

A

Weak pulse, arrhythmia, diaphoresis/
sweating, collapse/unconsciousness

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30
Q

ANAPHYLAXIS SIGNS IN INFANTS>CENTRAL NERVOUS SYSTEM

A

Rapid onset of unresponsiveness, lethargy,
or hypotonia; seizures

31
Q

Diagnosis of Anaphylaxis

A

Anaphylaxis is highly likely when any 1 of the following 3 criteria is
fulfilled:
1. Acute onset of an illness (minutes to several hours) with
involvement of the skin and/or mucosal tissue (e.g., generalized hives, pruritus or flushing, swollen lips/tongue/uvula)
AND AT LEAST 1 OF THE FOLLOWING:
a. Respiratory compromise (e.g., dyspnea, wheeze/
bronchospasm, stridor, reduced peak PEF, hypoxemia)
b. Reduced BP or associated symptoms of end-organ
dysfunction (e.g., hypotonia [collapse], syncope, incontinence)
2. Two or more of the following that occur rapidly after exposure
to a likely allergen for that patient (minutes to several hours):
a. Involvement of the skin/mucosal tissue (e.g., generalized
hives, itch/flush, swollen lips/tongue/uvula)
b. Respiratory compromise (e.g., dyspnea, wheeze/
bronchospasm, stridor, reduced PEF, hypoxemia)
c. Reduced BP or associated symptoms (e.g., hypotonia
[collapse], syncope, incontinence)
d. Persistent gastrointestinal symptoms (e.g., crampy abdominal
pain, vomiting)
3. Reduced BP following exposure to known allergen for that
patient (minutes to several hours):
a. Infants and children: low systolic BP (age-specific) or >30%
drop in systolic BP
b. Adults: systolic BP <90 mm Hg or >30% drop from patient’s
baseline

32
Q

Acute onset of an illness (minutes to several hours) with
involvement of the skin and/or mucosal tissue (e.g., generalized hives, pruritus or flushing, swollen lips/tongue/uvula) AND AT LEAST 1 OF THE FOLLOWING:

A

a. Respiratory compromise (e.g., dyspnea, wheeze/
bronchospasm, stridor, reduced peak PEF, hypoxemia)
b. Reduced BP or associated symptoms of end-organ

33
Q
  1. Two or more of the following that occur rapidly after exposure to a likely allergen for that patient (minutes to several hours):
A

a. Involvement of the skin/mucosal tissue (e.g., generalized
hives, itch/flush, swollen lips/tongue/uvula)
b. Respiratory compromise (e.g., dyspnea, wheeze/
bronchospasm, stridor, reduced PEF, hypoxemia)
c. Reduced BP or associated symptoms (e.g., hypotonia
[collapse], syncope, incontinence)
d. Persistent gastrointestinal symptoms (e.g., crampy abdominal
pain, vomiting)

34
Q
  1. Reduced BP following exposure to known allergen for that
    patient (minutes to several hours):
A

a. Infants and children: low systolic BP (age-specific) or >30%
drop in systolic BP
b. Adults: systolic BP <90 mm Hg or >30% drop from patient’s
baseline

35
Q

TREATMENT

A
  • Medical emergency and requires aggressive management.
  • IM/IV epinephrine (IM epinephrine is safer), IM/IV
    H1(Ranitidine) & H2(Diphenhydramine) antihistamines, O2,
    inhaled B2 agonist, corticosteroid
  • Ensure adequate airway and effective respiration, circulation,
    and perfusion (low bp → hydrate px, give epinephrine first)
36
Q
  • IM/IV epinephrine (which is safe)
A

(IM epinephrine is safer)

37
Q

IM/IV H1

A

(Ranitidine)

38
Q

IM/IV H2

A

(Diphenhydramine)

39
Q

Ensure adequate airway and effective respiration, circulation,
and perfusion

A

(low bp → hydrate px, give epinephrine first)

40
Q

Occur when anaphylactic symptoms recur after apparent
resolution

A

biphasic anaphylaxis

41
Q

biphasic anaphylaxis occur when treatment is initiated late & symptoms is mild

A

severe

42
Q

biphasic anaphylaxis 90% occur within

A

4 hours

43
Q

Anaphylaxis preparedness>Patient presents with possible/probable acute anaphylaxis>Initial assessment supports potential anaphylaxis? e.g., non-localized urticaria after immunotherapy> no

A

Consider other diagnosis

44
Q

Anaphylaxis preparedness>Patient presents with possible/probable acute anaphylaxis>Initial assessment supports potential anaphylaxis? e.g., non-localized urticaria after immunotherapy> yes

A

Immediate intervention
* Assess airway, breathing, circulation, mentation
* Inject epinephrine and reevaluate for repeat injection if necessary
* Supine position (if cardiovascular involvement suspected)

45
Q

Anaphylaxis preparedness>Patient presents with possible/probable acute anaphylaxis>Initial assessment supports potential anaphylaxis? e.g., non-localized urticaria after immunotherapy> yes> Immediate intervention> Goodclinical response?>

A

yes> * Observation Length and setting of observation must be individualized, * Autoinjectible epinephrine> Consultation with allergistimmunologist

46
Q

Anaphylaxis preparedness>Patient presents with possible/probable acute anaphylaxis>Initial assessment supports potential anaphylaxis? e.g., non-localized urticaria after immunotherapy> yes> Immediate intervention> Good clinical response?

A

no>Subsequent emergency care that may be necessary
depending on response to epinephrine:
Consider:

  • Call 911 and request assistance
  • Recumbent position with elevation
    lower extremity
  • Establish airway
  • O2
  • Repeat epinephrine injection if indicated
  • IV fluids if hypotensive; rapid volume expansion

Consider inhaled bronchodilators if wheezing
* H1 and H2 antihistamines
* Corticosteroids

47
Q

Anaphylaxis preparedness>Patient presents with possible/probable acute anaphylaxis>Initial assessment supports potential anaphylaxis? e.g., non-localized urticaria after immunotherapy> yes> Immediate intervention> Good clinical response?> Subsequent emergency care that may be necessary depending on response to epinephrine>no>

A

Call 911 if not already done Consider:
* Epinephrine intravenous infusion
* Other intravenous vasopressors
* Consider glucagon

48
Q

Cardiopulmonary arrest during anaphylaxis:

A
  • CPR and ACLS measures
  • Prolonged resucitation efforts encouraged
    (if necessary)
49
Q

cardiopulmonary arrest during anaphylaxis consider:

A
  • High-dose epinephrine
  • Rapid volume expansion
  • Atropine for asystole or pulseless electrical activity
  • Transport to emergency dept. or ICU
50
Q

GELL AND COOMBS CLASSIFICATION

A
  1. Immediate hypersensitivity reaction (Type I)
  2. Cytotoxic antibody reaction (Type II)
  3. Immune complex reactions (Type III)
  4. Delayed type hypersensitivity reaction (Type IV)
51
Q

o Histamines and leukotrienes

A

Immediate hypersensitivity reaction (Type I)

52
Q

Urticaria, bronchospasm, anaphylaxis

A

Immediate hypersensitivity reaction (Type I)

53
Q

Complement

A

Cytotoxic antibody reaction (Type II)

54
Q

Drug induced hemolytic anemia and thrombocytopenia

A

Cytotoxic antibody reaction (Type II)

55
Q

Immune complex activating complement cascade

A

Immune complex reactions (Type III)

56
Q

Immune complex activating complement cascade

A

Immune complex reactions (Type III)

57
Q

Serum sickness

A

Immune complex reactions (Type III)

58
Q

Appear 1-3 weeks after last dose of offending drug

A

Immune complex reactions (Type III)

59
Q

Immune complex reactions (Type III) Appear ____ after last dose of offending drug

A

1-3 weeks

60
Q

Drug specific T lymphocytes

A

Delayed type hypersensitivity reaction (Type IV)

61
Q

Occur in topical route

A

Delayed type hypersensitivity reaction (Type IV)

62
Q

o Contact dermatitis

A

Delayed type hypersensitivity reaction (Type IV)

63
Q

RISK FACTORS

A
  • Prior exposure
  • Previous reactions
  • Age (20-49 yo)
  • Route of administration (parenteral/topical)
  • Dose (high)
  • Dosing schedule (intermittent)
  • General predisposition
64
Q

Age occur

A

(20-49 yo)

65
Q

DIAGNOSIS

A
  • Accurate medical history
  • Identification of the drug
  • Skin testing
  • Coombs test (direct and indirect)
66
Q

o Most rapid and sensitive method of demonstrating
the presence of IgE antibody to a specific Ag

A

skin testing

67
Q

Drug induced hemolytic anemia

A

Coombs test (direct and indirect)

68
Q

TREATMENT

A
  • Desensitization
  • Drugs causing non-IgE related reactions
  • Severe non-IgE mediated hypersensitivity should not
    receive predisposing agents even in small amounts
69
Q

Progressive administration of an allergen to render
effector cell less effective

A

Desensitization

70
Q

Reserve for patients with IgE antibodies to a particular
drug for whom an alternative drug is not available or
appropriate

A

Desensitization

71
Q

Graded challenges done by giving drug in an
incremental fashion until therapeutic dose is achieved

A

Drugs causing non-IgE related reactions

72
Q

sjs

A

<10%

73
Q

sjs-ten

A

10-30%

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