Allergy

sites.google.com/view/fmres/105-topics/allergy

1. In all patients, always inquire about any allergy and clearly document it in the chart.
Re-evaluate this periodically.
2. Clarify the manifestations of a reaction in order to try to diagnose a true allergic
reaction (e.g., do not misdiagnose viral rashes as antibiotic allergy, or medication
intolerance as true allergy).
3. In a patient reporting allergy (e.g., to food, to medications, environmental), ensure
that the patient has the appropriate medication to control symptoms (e.g.,
antihistamines, bronchodilators, steroids, an EpiPen).
4. Prescribe an EpiPen to every patient who has a history of, or is at risk for,
anaphylaxis.
5. Educate appropriate patients with allergy (e.g., to food, medications, insect stings)
and their families about the symptoms of anaphylaxis and the self-administration of
the EpiPen, and advise them to return for immediate reassessment and treatment if
those symptoms develop or if the EpiPen has been used.
6. Advise patients with any known drug allergy or previous major allergic reaction to get
a MedicAlert bracelet.
7. In a patient presenting with an anaphylactic reaction:
1. Recognize the symptoms and signs.
2. Treat immediately and aggressively.
3. Prevent a delayed hypersensitivity reaction through observation and
adequate treatment (e.g., with steroids).
8. In patients with anaphylaxis of unclear etiology refer to an allergist for clarification
of the cause.
9. In the particular case of a child with an anaphylactic reaction to food:
1. Prescribe an EpiPen for the house, car, school, and daycare.
2. Advise the family to educate the child, teachers, and caretakers about signs and
symptoms of anaphylaxis, and about when and how to use the EpiPen.
10. In a patient with unexplained recurrent respiratory symptoms, include allergy (e.g.,
sick building syndrome, seasonal allergy) in the differential diagnosis.

Drug Reaction Classification

Type A - Adverse reaction

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 Type B - Hypersensitivity
Exaggerated sensitivity to known drug toxicity (eg. tinnitus with single dose of
aspirin)
Idiosyncratic drug reaction (due to genetic differences, eg. hemolytic anemia in
G6PD after primaquine)
Immunologic/Drug allergy
Type I - Immediate IgE (mast cells +/- basophils)
Within 30mins-1h
Urticarial rash, pruritus, flushing, angioedema, wheezing, GI
symptoms, hypotension
Anaphylaxis is most severe type of presentation
Type II - Delayed antibody (IgG) mediated cell destruction
Usually 5-8d after exposure
Hemolytic anemia, thrombocytopenia, neutropenia
Type III - Delayed IgG:drug immune complex deposition and complex
activation
Usually 1-2 weeks after exposure
May have low complement, high ESR
Serum sickness - fever, urticarial/purpuric rash, arthralgia, acute
glomerulonephritis (eg. antitoxin)
Vasculitis - palpable purpura/petechiae, often lower extremities (eg.
penicillins, cephalosporins, sulfonamides, phenytoin, allopurinol)
Arthus reaction - localized skin inflammation, necrosis (post-
vaccine)
Type IV - Delayed T-cell mediated
>48h, usually days-weeks after exposure (but <24h upon re-
exposure)
SJS/TEN - fever, painful diffuse erythema, bullae, oral/mucosal
erosions, necrosis and skin sloughing/epidermal detachment (eg.
allopurinol, lamotrigine, anticonvulsants, sulfonamides, COX2i
NSAIDs, mycoplasma pneumoniae)
DRESS - fever, skin eruption, eosphinophilia (or atypical
lymphocytosis), lymphadenopathy, organ involvement
(anticonvulsants, sulfonamides)
Other: Contact dermatitis, maculopapular eruptions

Anaphylaxis Diagnosis
If one of the following

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 1. Acute onset of illnesss (minutes to several hours) with involvement of skin,
mucosal tissue or both (eg, generalized hives, pruritus or flushing, or swollen
lips-tongue-uvula) and at least one of the following:
Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor,
reduced PEF or hypoxemia)
Reduced BP or associated symptoms of end-organ dysfunction (eg,
hypotonia [collapse], syncope or incontinence)
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
or swollen lips-tongue-uvula)
Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor,
reduced PEF or hypoxemia)
Reduced BP or associated symptoms of end-organ dysfunction (eg,
hypotonia [collapse], syncope or incontinence)
Persistent gastrointestinal symptoms (eg, crampy abdominal pain or
vomiting)
3. Reduced BP after exposure to a known allergen for that patient (minutes to
hours)
Low BP for children defined as <70mmHg + [2 x age] up to 10yo

History
Anaphylaxis symptoms
General/CNS - Lethargy, somnolence, altered LOC, syncope
Upper airway - Hoarseness, stridor, oropharyngeal/laryngeal/uvular edema,
lip/tongue swelling, obstruction
Lower airway - Cough, dyspnea, tachypnea
Skin - Flushing, erythema, pruritus, urticaria, angioedema, maculopapular rash
CVS - Tachycardia, hypotension, arrhythmia, acute coronary syndrome
GI - N/V/D, abdominal pain
Trigger
Food (peanuts, tree nuts, fish, milk, eggs, shellfish [shrimp, lobster, crab,
scallops, oysters])
Hymenoptera (bee/wasp) stings
Medications
Previous allergies and allergical reaction

Physical Examination

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 ABC, Vitals (Hypotension, tachycardia)
CVS
Resp
Abdominal exam
Skin

DDx
Respiratory
Asthma
Foreign body aspiration
Cardiovascular
Pulmonary embolism
Acute coronary syndrome
Shock
Mast cell disorder

Management of Anaphylaxis
ABC, vitals, monitors, IV x2, oxygen
Airway (intubation if impending airway obstruction)
Epinephrine 0.5mg IM mid-antero-lateral thigh q5mins x3 doses (Caution if
bolus via IV)
0.01mg/kg (0.01mL/kg of 1:1000 = 1mg/1mL) in children up to 0.3mg (eg.
30kg child should receive 0.3mg IM)
Infusion of epinephrine 0.1mcg/kg/min IV titrate to vitals (usually need 5-
15mcg/min)
If on beta-blockers and poor response to epinephrine, consider glucagon 1-
5mg IV over 5 minutes
Aggressive fluid resuscitation
Lie down, elevate legs
>1-2L (20mL/kg) NS IV bolus, repeat PRN
Salbutamol for bronchospasm 2.5-5mg in 3mL saline via nebulizer (or 5-10 puffs
MDI with spacer), repeat PRN

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 Adjunctive
Antihistamine
H1 antagonist, eg. Diphenhydramine (1mg/kg/dose) 25-50mg PO/IM/IV
q4-6h PRN
H2 antagonist, eg. Ranitidine 150mg IV
Glucocorticoids (Note: no evidence in decreasing return ER visits or biphasic
reactions)
Methylprednisolone 1-2mg/kg/d (max 125mg IV)
Prednisone 1mg/kg PO (max 50mg PO)
Observation period for biphasic reactions (incidence of 20%, can occur up to 6 days)
Although most guidelines suggest 4, 6 or 24h of observation there is no data to
suggest this improves outcomes
Consider discharge in patients with prompt and complete symptom
resolution
Consider observation if
Risk factors (Previous biphasic, asthma)
Severe features (Refractory hypotension, laryngeal edema, and
respiratory compromise)
Delayed or suboptimal treatment
If not improved with anti-histamine treatment consider bradykinin-mediated
angioedema
Treat with Tranexamic acid 1g IV, Fresh frozen plasma (2 units), C1-inhibitor
concentrate

Investigations
Serum tryptase levels taken 15-180mins after symptom onset may support diagnosis
Compare to baseline tryptase improves accuracy
If no cause identified, rule out mast cell disorder

Discharge
Education to patient, friends/family
Risk of biphasic reaction
Avoidance of triggers
Anaphylaxis emergency plan (self-administered epinephrine, call 9-1-1)
Printed and explain information about signs/symptoms of anaphylaxis
and treatment
Teaching and practice on how to administer the self-injectable
epinephrine

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 Prescribe minimum two epinephrine auto-injector to be carried on patient at all
times
EpiPenJR or TwinjectJR <25kg
EpiPen or Twinject>25kg
MedicAlert bracelet
Allergy referral if needed to clarify trigger

References:

ASCIA 2017. https://www.allergy.org.au/health-professionals/papers/acute-

management-of-anaphylaxis-guidelines
WAOJ 2015. https://waojournal.biomedcentral.com/articles/10.1186/s40413-015-
0080-1
CPS 2011. http://www.cps.ca/en/documents/position/emergency-treatment-
anaphylaxis
CMAJ 2003. http://www.cmaj.ca/content/169/4/307.full

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