Couple of things to consider:
1) Epinephrine IM is considered the first line treatment for anaphylaxis. Its use is recommend even in mild reactions.
2) H1 and H2 blockers should be used in tandem in the ED as the combination appears more effective in reducing cutaneous manifestations than with H1-antagonists alone (Lin RY, Curry A, Pesola G. Improved outcomes in patients with acute allergic syndromes who are treated with combined H1 and H2 antagonists. Ann Emerg Med 2000;36:46227).
Cetirizine is a reasonable alternative to diphenhydramine as the H1 antagonist for allergic reactions (Banerji A, Long AA, Camargo, Jr CA. Diphenhydramine versus nonsedating antihistamines for acute allergic reactions: A literature review. Allergy Asthma Proc 2007;28:418 -426).
3) The effectiveness of systemic corticosteroids has not been shown in placebo controlled studies. However, extrapolation of their use in other allergic condition suggest they may be useful in anaphylaxis.
4) The risk of a biphasic reaction is greatest in those who present with severe reactions. In patients with fatal or near fatal reaction, 20% had a biphasic response (Sampson HA, Mendelson LM, Rosen JP. Fatal and near-fatal
anaphylactic reactions to food in children and adolescents. N Engl J Med. 1992;327:380-384.)
The best recommendations in the literature is a 4-6 hour observation period following epinephrine administration.
Here are a couple good reference articles you might find of interest:
Sampson HA, Muņoz-Furlong A, Campbell RL et al. Second Symposium on the Definition and Management of Anaphylaxis: Summary Report-Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network Symposium. Ann Emerg Med. 2006;47:373-380.
Liberman DB, Teach SJ. Management of Anaphylaxis in Children. Ped Em Care 2008;861-869.
Jeffrey Linzer Sr., MD, FAAP, FACEP
Associate Professor of Pediatrics and Emergency Medicine
Emory University School of Medicine
Associate Medical Director for Compliance
EPG/Division of Pediatric Emergency Medicine
Children's Healthcare of Atlanta
[cid:[log in to unmask]]
From: Pediatric Emergency Medicine Discussion List [mailto:[log in to unmask]] On Behalf Of Lesley Stephens Hanes
Sent: Sunday, January 06, 2013 2:59 PM
To: [log in to unmask]
Subject: Anaphylaxis and EpiPen Use Observation
Hello, here are a few questions to the group regarding anaphylaxis management in the ED --
How long do or would you monitor patients in the ED who have received an EpiPen at home for a mild to moderate anaphylactic reaction to food?
An example case includes a 6 y/o telling his mother that he feels itchy and feels tightness in his throat and chest after eating a dinner prepared at home (nut-free presumably), and develops a hive on his forehead. He has previously been admitted for anaphylaxis to nuts. The mother appropriately administered the EpiPen, Benadryl and came to the ED. Upon arrival,the child was completely asymptomatic.
If the patient is well, remains asymptomatic (no hives, pruritis, swelling, wheeze, etc) and playing in the ED -- how long would you watch them, particularly after receiving an EpiPen injection (you gave steroids and H2 blocker and he already received Benadryl)?
Do you monitor for 2, 4, 6, 8 hrs?
Do you admit because of his anaphylactic history or since he has a food allergy?
Is there any census or literature regarding length of observation after the acute phase reaction; or after Epinephrine administration?
Thank you for your responses!
Lesley Stephens Hanes, MD MSc
Saint Agnes Medical Center
Pediatric Emergency Department
900 Caton Ave.
Baltimore, MD 21229
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