Bog standard anaphylaxis is easy–just give epi, watch them for a couple of hours and send 'em home with more epi and a referral. It gets a bit more fraught when they are refractory to initial treatment or the reaction is severe. In this episode, we review the building blocks of the approach to the critically ill patient with anaphylaxis.
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Editor-in-Chief, at EMCrit.org
An ED Intensivist from NY.
Professor
Nassau University Medical Center
No conflicts of interest (coi).
Professor
Nassau University Medical Center
No conflicts of interest (coi).
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I think observation for a potential biphasic reaction requires nuance. There certainly seems to be a knee-jerk reaction in my setting (Australia) to observe any patient that has needed epi for four to six hours. When I question this, the concept of the biphasic reaction always comes up but I think there is a general lack of awareness of the literature. Lee et al. (2007) give a median of 11 hours till onset and Kim et al (2019) suggest a 12 hour period of observation. The folk that make up most of the definitions (Shaker et al. 2020) suggest it… Read more »
Hey Andy
I think we need to take the analysis a little further. It is only important to have the biphasic response occur under our care if we are going to offer something different. In the pts who get 1 shot of epi and no further treatment, we will really not be providing anything different than the pt auto-injecting and calling for an ambulance. The actual yield for observation in low risk initial anaphylaxis presentation is virtually nil. What do you think?
Hi Scott. Great podcast and nice summary. Could you clarify the nebulized epinephrine dosing. Racemic epi is 22.5mg/cc typically diluted as 0.5cc in 3cc NS totaling 3.75mg/cc. Is your recommendation to use standard epinephrine 1:1000 vials, 5 (1:1000) vials (5cc total and 5mg total) delivered by nebulizer. Honestly not sure that there is much of a difference. It’s not like we are splitting the atom, but I haven’t used nebulized epinephrine previously in the form suggested and typically do racemic since it is available.
yes. 5 mg of l-epinephrine is the dose. it is a huge pain in the butt to track down refs for this seemingly ubiquitous therapy. I added a peds safety paper for this dose and will try to track down the others.