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Reuben Strayer says forget confusing guidelines for evaluating patients with anaphylaxis. Keep it simple. For A, B, or C, give E.
Strayerisms: Anaphylaxis Rebuttal
Reuben Strayer MD
Take Home Points
● An allergic reaction is dangerous when it involves the airway, breathing or circulation.
● Change in voice, stridor, mishandling of secretions and airway posturing demonstrate airway compromise.
● Order epinephrine in a dose of 300 to 500mcg IM. Don’t worry about calculating 1:1000 or 1:10000.
● Consider glucagon in patients not responding to treatment.
● A recent segment on anaphylaxis by Howie Mel, Anand Swaminathan and Bryan Hayes advised a low threshold to give epinephrine. This is true. When in doubt, give epinephrine. They also discussed that evolving changes to the definition of anaphylaxis are confusing and lead to suboptimal care. This is also true. However, they cited the World Allergy Organization Guidelines definition which is three parts, confusing and impossible to remember.
● Emergency medicine physicians care whether this allergic reaction is dangerous. It doesn’t matter how many systems are involved. It matters which system is involved.
● An allergic reaction is dangerous when it involves the airway, breathing or circulation and that is all. If you have rash and abdominal pain, you do not need to give epinephrine. If you have rash and hand tingling, you do not need to give epinephrine. If you have involvement of the airway, breathing or circulation without another system involved, you must use epinephrine.
● What are the signs of airway compromise? There are four: Change in voice. Stridor. Mishandling of secretions. Airway posturing.
○ Airway posturing is not tripoding which is using the arms to splint the lungs. Airway posturing is assuming a sniffing position. It is usually seen in children with epiglottitis. If you see it, you should be alarmed.
○ Many patients develop tingling or scratching in the back of their throat. Some are anxious and screaming that they can’t breathe. If you aren’t sure, give a dose of epinephrine and prepare for airway management. However, if the patient is screaming they can’t breathe but using full sentences with a normal voice and no signs of airway compromise, you can be more measured in your approach.
● What are signs of breathing compromise? Wheezing and evidence of lung dysfunction such as tachypnea, increased respiratory effort and hypoxia.
● What are signs of circulatory compromise? Hypotension, hypoperfusion and syncope.
● Don’t try to understand 1:1000 and 1:10,000. Even if you understand it, the person you are shouting verbal orders to will not and will give you the wrong dose. Know the dose so you can give the right dose. The correct dose is 300-500mcg IM. If you call for this, you will get the right dose whether your nurse has the 1:1000 or 1:10,000 available.
● Should you use push dose epinephrine? This is difficult to do and is going to get screwed up. If you are managing the crashing anaphylaxis patient, do not try to draw up and push 5mcg of epinephrine.
● How do you manage the crashing anaphylaxis patient? Give 500mcg (½ of 1 mg) of epinephrine intramuscularly and get ready to manage the airway while someone else establishes IV access. If your patient is not improving in a few minutes, give a second dose of 500mcg IM epinephrine and start an intravenous epinephrine drip.
○ How do you start an intravenous epinephrine drip? Take 1 mg of epinephrine in any concentration you like. The crash cart epinephrine is preferred because it comes drawn up in a syringe. Add 1mg of epinephrine to a liter of saline and drip it in. This takes 30 seconds to set up. You get epinephrine in a concentration of 1mcg/cc. 20 drops per cc. 2 drops/second is about 6mcg/min which is your target. Use the knob on the IV tubing to titrate up and down to effect. When things settle down, you can switch to formal drip on a pump.
○ Using vasopressors as bolus doesn’t make sense because their effect lasts for seconds to minutes.
● When a patient can’t breathe from dynamic airway obstruction such as trauma, burns or anaphylaxis, there is a reasonable chance that you will not be able to pass an endotracheal tube through the cords for the same reason the patient can’t breathe through the cords. Announce to your team and to yourself that this patient is likely going to require a surgical airway but you will look via laryngoscopy to be sure. Be prepared for cricothyrotomy. Have your colleague standing next to you with a scalpel in their hand.
● If the patient is still not responding to epinephrine despite all your best efforts, reach for glucagon. The patient may be on a beta-blocker. There is weak evidence to support vasopressin and methylene blue as therapies for anaphylaxis in patients who are deteriorating despite everything. However, almost all anaphylaxis patients will respond to epinephrine.
Chris M., M.D. - May 6, 2016 9:03 AM
Listened with interest and appreciation of Dr Strayer's approach to anaphylaxis. While his epinephrine tips and generally low threshold to dose are great I wanted to comment on the use of the WAO guidelines. Like any guidelines the intent is to provide a framework. Time and again the literature shows that in cases of fatal anaphylaxis a tragically high percentage of patients die without being given epinephrine (steroids yes, antihistamines yes, the actual antidote, often not). This is true in the ED, inpatient and outpatient settings.
The guidelines are obtuse but the take home point is not: have a low threshold for considering anaphylaxis. GI symptoms in the right setting (that is with reasonable clinical/historical concern) are often the only indication of pending anaphylaxis. More and more data suggests that early epinephrine is BETTER epinephrine and waiting until obvious respiratory or circulatory compromise is too late and creates a more refractory physiology. The downside to a dose of IM epinephrine is miniscule.
Reuben Strayer (@emupdates) - May 6, 2016 10:43 AM
Thanks for your comment Chris. Absolutely agree that the threshold to give epinephrine should be low, and when in doubt administer, and I say as much in the segment. But there are in my opinion downsides that are non-miniscule, including how a dose of epinephrine makes some patients feel (anxious, tremulous, nauseous) and the occasional but very dangerous epinephrine dosing error. So my position is that if the only symptoms in "anaphylaxis" are non-dangerous (diarrhea, hives) it's reasonable to withhold and observe. It's also reasonable, especially if symptoms are progressive (but not involving ABCs) to give, with the argument that in these cases there is a higher likelihood that ABC compromise will follow.
Mike J., M.D. - May 11, 2016 1:35 PM
Thank you Reuben, I hesitate to leap into this fray, but I too suggest that epinephrine is not without a downside. Anecdotally, I have witnessed 3 cases of acute MI that I belive to have been precipitated by IM epi. In all 3, the pre epinephrine ECG was nonischemic and the post epinephrine ECG demonstrated STEMI. None were hypotensive. All met the B criteria, and all had hives.
It is my belief that the best management of Anaphylaxis is a competent ED physician, at the bedside, epinephrine in hand, obseving the patient for progression, while ALL of the other interventions take place.
For entertainment value, take a dive into the evidence base for epinephrine in anaphylaxis. NO Trials, just opinion.
Reuben Strayer (@emupdates) - May 12, 2016 1:23 PM
Epinephrine for anaphylaxis is not evidence-based, but I don't think anyone doubts its efficacy in severe allergy (lack of evidence ≠ evidence of lack) and I think it's also clear that the most important problem we have with epinephrine utilization is not giving it when it's indicated.
There are potential harms, it should not be given indiscriminately, it should be given when it's indicated. Which is why I proposed a simplified (compared to many of the guidelines) mental model. Despite the potential harms, though, I would submit that when in doubt, give IM epi - that fails much better than the converse.
Owen S. - September 26, 2016 9:38 PM
Hi Reuben (and Mike),
Love this simplified, common sense type approach. Unfortunately, it can be hard to defend common sense against the dogma from fancy titles like "World Allergy Organization anaphylaxis guidelines", or even UpToDate... and I'm just talking about with my attending physician. I would imagine it would be an even harder defense to make in court, if a bad outcome were to occur. I don't suppose you know of any big guns on this ship, like an Annals article, a formal CPG, etc? Anything that I can use to argue the case that's more convincing than the reasoning of an EM intern, and an opinion I heard on EM:RAP...
Perhaps once I'm an attending, I can practice common sense more easily...
Reuben Strayer (@emupdates) - September 26, 2016 11:07 PM
Functionally, I don't have much of a disagreement with the major guidelines, the most prominent (I think) is this one: [ https://goo.gl/vQvUmO ]. Their definition of anaphylaxis is not usable by an emergency clinician at the bedside, but in practice I'm not sure how much that matters, as long as the larger point is understood: have a low threshold to give epinephrine, do not withhold epinephrine where concern exists for a dangerous allergic reaction. An EM working group also released a document [ https://goo.gl/CvGP2U ] where they tried to refine the definition to make it more usable, but came up with something so vague as to also be useless: "Anaphylaxis is a serious reaction that is rapid in onset and may cause death. It is usually dueto an allergic reaction but can also be non-allergic."
I don't care how anyone defines anaphylaxis, the point is to know when to give epinephrine. If you want to define anaphylaxis as the condition that requires epinephrine, then the definition becomes important, but again this just makes things more complicated. It is hard for me to imagine that in a patient who has compromise of airway, breathing, or circulation thought to be the result of an allergic reaction that the decision to give epi could be criticized by anyone. Conversely, if the patient is otherwise well but has non-ABC symptoms thought to be allergic, that patient, as long as she continues to only have non-ABC symptoms, is going to do well, so it's hard to imagine criticism coming from that end either, but if someone wants to give epi to a patient with rash and significant abdominal symptoms, that's perfectly reasonable.
My rant is only that the multi-part criteria definition is unlikely to be committed to memory and is not helpful, and that you shouldn't wait even a moment to give epi when ABC findings are present. I'm not advocating for withholding epi when concerning/rapidly progressive non-ABC symptoms are present. Emergency providers should know that dangerous allergic reactions can start with rash and abdominal symptoms, and progress.
But to answer your question directly, I am unaware of any CPG that states if ABC do E, with or without a jingle.
Owen S. - October 1, 2016 11:12 AM
Thanks for your response, Reuben. I think I have a better grasp of your intent now of what you were getting at on the show. For now, at this point in my career, I'm going to err on the side of early IM epi, with the knowledge that maybe sometimes in the patient with only mild skin + GI, it could be appropriate to watch closely, if in the right setting.