Is this anaphylaxis?

18 Sep

RAGING HYPOTHETICAL:
7 yo female with h/o peanut allergy ate a pistachio and had diffuse urticaria and wheezing. Stable vital signs.

Is this anaphylaxis?

DIAGNOSTIC CRITERIA:

Anaphylaxis is highly likely when any ONE of the following criteria is fulfilled:

•Criterion 1 — Acute onset of an illness involving the skin, mucosal tissue, or both (eg, generalized hives, pruritus or flushing, swollen lips-tongue-uvula) and at least one of the following:

Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, reduced peak expiratory flow, hypoxemia).

Reduced blood pressure or associated symptoms and signs of end-organ dysfunction (eg, hypotonia [collapse] syncope, incontinence).

–Note: Skin symptoms and signs are present in up to 90 percent of anaphylactic episodes. This criterion will therefore frequently be helpful in making the diagnosis.

•Criterion 2 — Two or more of the following that occur rapidly after exposure to a likely allergen for that patient (minutes to several hours):

–Involvement of the skin-mucosal tissue (eg, generalized hives, itch-flush, swollen lips-tongue-uvula)

Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, reduced peak expiratory flow, hypoxemia)

Reduced BP or associated symptoms and signs (eg, hypotonia [collapse], syncope, incontinence)

–Persistent gastrointestinal symptoms and signs (eg, crampy abdominal pain, vomiting)

–Note: Skin symptoms or signs are absent or unrecognized in up to 20 percent of anaphylactic episodes [editor’s note: just to make you look at it from the other side. nothing’s 100%. that’s why you get paid the big bucks.]. Criterion 2 incorporates symptoms and signs in other organ systems and is applied to patients with exposure to a substance that is a likely allergen for them.

•Criterion 3 — Reduced BP after exposure to a known allergen for that patient (minutes to several hours)

In a series of 164 fatalities due to anaphylaxis, the median time interval between onset of symptoms and respiratory or cardiac arrest was 5 minutes in iatrogenic anaphylaxis, 15 minutes in stinging insect venom-induced anaphylaxis, and 30 minutes in food-induced anaphylaxis [i.e. if they’re going to die, they tend to do it early—again, MEDIAN times]

Submitted by M. Smith.

References: Simons FER, Camargo CA. Anaphylaxis, Rapid Recognition and Treatment. www.uptodate.com, 2012.; picture
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