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1st Paediatric Emergency Conference Kuwait October 2011

Disclaimer. I have no actual or potential conflict of interest to declare. Photographs, images, charts and information were selected from The Hospital for Sick Children teaching file, my personal collection or downloaded from the internet.Dr. D. A. Jarvis. Learning Objectives. On completion o

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1st Paediatric Emergency Conference Kuwait October 2011

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    1. 1st Paediatric Emergency Conference Kuwait October 2011 Emergency Treatment of Anaphylaxis in Infants and Children Dr. D. Anna Jarvis

    2. Disclaimer I have no actual or potential conflict of interest to declare. Photographs, images, charts and information were selected from The Hospital for Sick Children teaching file, my personal collection or downloaded from the internet. Dr. D. A. Jarvis

    3. Learning Objectives On completion of this session participants will: Understand the full range of paediatric anaphylaxis presentations Know the high risk criteria for delayed and biphasic reactions Be prepared to treat anaphylaxis in concordance with published consensus guidelines

    4. Historical Perspective 1902 Prof Richet and Dr. Porter named ana (against) and phylaxis (protection) 1904(approximately) Arthus described anaphylaxis in rabbits 1911 Auer ascribed lethal rabbit anaphylaxis to heart failure associated with impaired coagulation 1960s role of mast cells and IgE described 2005-6 collaborative symposia established Epinephrine as first-line treatment and clinical definitions of anaphylaxis confirmed

    5. Challenges – Multiple definitions World Health Organization (WHO) “anaphylaxis is a severe, life-threatening generalized or systemic hypersensitivity reaction” National Institute of Allergy and Infection Disease (NIAID) and Food Allergy and Anaphylaxis Network (FAAN) “ a serious allergic reaction that is rapid in onset and may cause death” (clinical criteria defined)

    6. Anaphylaxis – Definition 2006 Anaphylaxis is a severe, acute, potentially life-threatening medical condition caused by systemic release of mediators from mast cells and basophils, often in response to an allergen. Note: Clinical criteria described on following slides Second Symposium on the Definition and Management of Anaphylaxis: Summary Report Samson J Allergy Clin Immunol 2006; 117:391-97

    7. Clinical Definition: Anaphylaxis 2006 Anaphylaxis is likely if any of the following 3 criteria is satisfied within minutes to hours of an exposure: 1. Acute onset of illness with cutaneous and / or mucosal involvement AND at least one of the following: Respiratory compromise (example: dyspnoea, bronchospasm, stridor, hypoxia) Cardiovascular compromise (examples: hypotension, collapse)

    8. Clinical Definition: Anaphylaxis 2006 Two or more of the following occur rapidly after exposure to a likely allergen (minutes to several hours): Involvement of skin or mucosa (examples: generalized hives, itch, flushing, swelling) b. Respiratory compromise Cardiovascular compromise Persistent Gastrointestinal symptoms (examples: crampy abdominal pain, vomiting)

    9. Clinical Definition: Anaphylaxis 2006 Hypotension after exposure to known allergen for that patient (minutes to several hours): Age-specific low blood pressure or greater than 30% decline from baseline Hypotension in children is defined as: less than 70mm Hg 1 month to 1 year less than 70mm Hg + (2x age) from 1 to 10 year less than 90 mm Hg from 11 to 17 years American Heart Association 2010 Guidelines

    10. Challenges - Presentations presentations vary with age and gender marked geographical differences in incidence and triggers reported literature has multiple small series and retrospective reviews, few prospective studies Consensus view 2011: anaphylaxis incidence rates increasing especially in first 2 decades of life the majority of children with anaphylaxis continue to be undertreated due to lack of recognition and/or failure to administer epinephrine

    11. Anaphylaxis – Age considerations Gender: younger ages – many more males adolescents - males equal females Infants: hives and vomiting more common *many had no BP documented on chart 2 - 5 years: wheezing, hoarse voice, stridor more common Up to 5 years: generalised swelling 56% Adolescents: trouble breathing 57% trouble swallowing 48%

    12. Paediatric Anaphylaxis – Germany Mehl 2005 – questionnaire paediatricians/primary care about children with anaphylaxis in previous 12 months 103 cases – median age 5 years – 58% boys Triggers: food 57% (peanut 20% tree nut 20%) stings 13% immunotherapy 12% unknown 8% Previous anaphylaxis 27% (50% same allergen) Severe anaphylaxis cases 36% received adrenalin On discharge 17% prescribed adrenalin self injector

    13. Paediatric Anaphylaxis – Melbourne, Australia de Silva 2008 – 5 year retrospective review of paediatric emergency records 123 children 117 events Median age 2.4 years (oldest 18 years) Allergic history: 17% had previous anaphylaxis 40% eczema 32% asthma (54% on inhalers) 9% rhinitis Triggers: food 85% (peanut 18% cashew 13% cow milk 11%) Median time from exposure to anaphylaxis 10 minutes onset to therapy 40 minutes Presentations: respiratory 97% skin 97% gastrointestinal 29% cardiovascular 17%

    14. Anaphylaxis Management epinephrine (adrenalin) anaphylaxis CAB (ABCs) PALS / ACLS adequate intravenous fluids shock H1 - antihistamines itch and hives H 2 - antihistamines ß2 – adrenergic agonists bronchospasm glucocorticoids may prevent protracted or biphasic symptoms NOTE: very little evidence for management exists! Consensus that epinephrine is medication of choice Simons 2009, 2010 Samson 2006

    15. Epinephrine (Adrenalin) pharmacology

    16. Epinepherine Intrinsic Limitations rapidly metabolized (parental administration) if swallowed rapidly metabolized by: catechol - o - methyltransferase - GI tract wall monoamine oxidase - GI tract wall + liver narrow therapeutic / toxic dose range break down in solution (12 - 18 months?) NOTE: danger of injuries during administration “missed dose” hazard with incorrect administration technique

    17. Risk factors for sting anaphylaxis angiotension converting enzyme inhibitors pre-existing vespid allergy male sex serum mast cell tryptase levels above 5ng/l Bonadonna 2009 J Allergy Clin Immunol 379 patients with hymenoptera stings 11.6% had tryptase levels over 11.4 ng/l 70.5% of these had systemic anaphylaxis 34 patients with elevated levels underwent bone marrow biopsy 61.7% had systemic mastocytosis

    18. Do large local reactions increase risk of future anaphylaxis? 5-10% patients with large local reactions have anaphylaxis 17% patients with anaphylaxis to stings have no history of prior exposure Golden 2009 reported 41 patients with large local reactions after controlled sting challenge, randomly assigned to venom immunotherapy then re-challenged after 7-11 weeks: 42% treated patients had smaller reactions 18% untreated patients had smaller reactions

    19. Anaphylaxis: risks of biphasic reaction

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