PedsCases – Anaphylaxis www.pedscases.

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PedsCases Case: Anaphylaxis

Chris Gerdung, BSc, University of Alberta

Sim Grewal MD, FRCPC, Assistant Professor, Division of Pediatric Medicine, Department of
Pediatrics, University of Alberta

Step #1

Craig is a 12-year-old boy who presents to you at the Emergency with worsening stridor, light-
headedness, urticaria, pruritis and a numb sensation in his mouth. He was brought in by
ambulance from a friend’s house after consuming a meal that contained shell-fish. His mother
met the ambulance at the hospital and introduces herself to you. She informs you that Craig had a
similar episode when he was 6 years old after eating shrimp. Which of the following is the most
likely diagnosis for Craig?

a. Anaphylactic Reaction
b. Anaphylactoid reaction
c. Epiglottitis
d. Croup
e. Asthma

Answer: A

Explanation:

This is an anaphylactic reaction. Anaphylaxis is a Type 1 hypersensitivity reaction between an

antigen and IgE bound to mast cells in the body. This reaction causes mast cells to release
histamine, leukotrienes and cytokines as well as other immunologically active agents. The
release of these chemicals stimulates chemoattraction of neutrophils and eosinophils causing
systemic vasodilation, increased vascular permeability, and smooth muscle spasms.

An anaphylactoid reaction is similar to anaphylaxis, however it is not mediated by IgE, and is

therefore not an immune mediated reaction. In anaphylactoid reactions, the ingested material is
directly responsible for the release in histamine and the other agents. While it is impossible at
this point in the case to say whether this reaction was mediated by IgE or not, it is very unlikely
for food to cause an anaphylactoid reaction. Most anaphylactoid reactions are caused by drugs,
physical stimuli (such as cold or exercise), as well as contrast material used in radiographic
studies.

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Epiglottitis, croup and asthma do not fit with this clinical picture. With epiglottitis, one would
expect to see a child in a tripod position, breathing with great difficulty and drooling. If the
pharynx were to be examined, one would see an inflamed, erythematous epiglottis. Although
epiglottitis can present quickly, it does not present with systemic symptoms such as urticaria and
pruritis.

Croup can present with stridor, however there would likely be a 1-4 day history of rhinorrhea,
pharyngitis, and cough before the obstruction of the airway occurred. Like epiglotttitis, croup
would not present with urticaria and pruritis.

Asthma can also present with stridor and light-headedness, however there are no systemic
symptoms associated with asthma.

Step #2

After Craig arrives in the emergency department, what is the first thing you should do?

a. Take a complete history and physical exam

b. Call Pediatric ICU to assist with intubation
c. Assess Craig’s airway, breathing and circulation
d. Obtain AP and lateral X-rays of Craig’s neck
e. Administer Epinephrine

Answer: C

Explanation:

Anaphylaxis is potentially lethal as a result of hypoxia and hypotension (anaphylactic shock).

The most important thing for the clinician to do at this time is determine Craig’s ability to
ventilate adequately and perfuse tissues adequately. Once this is complete, one can then begin to
implement the appropriate management plan. If the patient was able to ventilate properly and
their blood pressure was adequate for tissue perfusion, the clinician may decide that a history and
physical exam could provide needed information. Alternatively, if the patient is unable to
ventilate, and his/her blood pressure was inadequate for tissue perfusion, intervention may be
necessary.

Step #3

You assess Craig’s ABC’s and realize that medical therapy is necessary, as his upper airway is
becoming increasingly obstructed. What is the appropriate medical management? (Choose all
that are appropriate)

a. 0.5-1mg/Kg diphenhydramine (Benadryl), up to 50 mg

b. 1-2 mg/Kg IV solumedrol, up to 125 mg
c. 0.01 mg/Kg IM epinephrine, up to 0.3 mg
d. 100% Oxygen via nasal prongs

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e. 20 mg/Kg IV bolus of normal saline

f. 0.05 mg/Kg nebulized ventolin, up to 5 mg
g. 1-2 mg/Kg ranitidine, up to 150 mg
h. 0.02 mg/Kg glucagon

Answer: A, B, C, D, E, F, G

Explanation:

All of the above are appropriate medical management for a patient with anaphylaxis, however
epinephrine must be administered, and is the most important treatment option in anaphylaxis.
Due to the systemic release of histamine and other immune mediators, a number of interventions
are needed in the appropriate management of anaphylaxis. The most important aspect in
treatment however is the administration of epinephrine.

Epinephrine (adrenaline) acts at Beta-1 receptors in the heart to increase the heart rate and the
force of contraction with each beat. Epinephrine also acts on Beta-2 receptors resulting in
bronchiolar smooth muscle relaxation, thereby decreasing the obstruction in the upper airway.

Additionally, Epinephrine acts at Alpha-receptors systemically, causing vasoconstriction.

Diphenhydramine works as an H1 receptor antagonist, while ranitidine works as an H2 receptor
antagonist. Together these medications work to vasoconstrict blood vessels, relax bronchial
smooth muscles, prevent the progression of hives and decrease pruritis.

Ventolin also acts on Beta-2 receptors, causing relaxation of bronchial smooth muscles, thereby
reducing obstruction of the upper airway.

Solumedrol is a corticosteroid, and is given for its anti-inflammatory properties.

Glucagon causes an increase in heart rate, an increase in heart contractility and also stimulates
the release of endogenous catecholamines, however it is not routinely used for treating
anaphylaxis.

Oxygen and saline are given as supportive measures. With airway obstruction, airflow into the
lungs is decreased, and over time the alveolar concentration of oxygen will decrease. Oxygen is
given in order to maintain high concentrations of alveolar oxygen, thus maintaining the alveolar-
arterial concentration gradient. Saline is only given to hypotensive patients and is given to
maintain blood volume. Many of the immune mediators released during anaphylaxis cause
vasodilation, resulting in low blood pressures. If the blood pressure becomes too low, tissues and
organ systems will be under-perfused, and will become ischemic.

Step #4

After you treat Craig, you notice that the stridor that he first presented with has improved, as has
the light-headedness. What do you do next?

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a. Discharge home and advise mother to watch for any sign of recurrent upper airway
obstruction
b. Discharge home with an Epinephrine pen, and educate the patient and his mother when it
is appropriate to use
c. Discharge home after arranging follow up as an outpatient with an allergist
d. Observe in the emergency for 8 hours
e. Admit to Pediatrics

Answer: D

Explanation:

The appropriate next step is observation in the emergency department. Anaphylaxis is a biphasic
reaction, with the second phase usually presenting 1-8 hours after the acute phase. It is important
to have the patient remain in the hospital, as any further obstruction of the upper airway needs to
be managed medically. If the patient were discharged home for observation and obstruction of
the airway occurred, the patient could be in severe respiratory distress by the time he returned to
the hospital.

Although discharging home with an Epinephrine pen does provide some way for the patient to
prevent the second phase of the reaction, observation in the hospital allows for continued
monitoring of oxygenation, blood pressure and any other complications that might arise. A
follow up appointment with an allergist may be appropriate, however the patient must be
followed closely before being discharged.

Generally patients can be treated in the emergency department and then discharged. Admission
to the hospital usually only occurs if the patient does not respond to initial treatment, if
complications arise, if the patient has some other significant injury or if the patient is intubated,
or requires intubation.

Step #5

After Craig is observed in the emergency department overnight, you decide it is safe for him to
be discharged. What medication should Craig take for the next 3 days?

a. Cetirizine
b. Solumedrol
c. Epinephrine
d. Ventolin
e. Glucagon

Answer: A

Explanation:

Craig should continue to take anti-histamines (Ie. Cetirizine) for 2 to 5 days after discharge from

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the hospital. This will help control any itching or urticaria that developed, and will also relax the
bronchial smooth muscles and prevent smooth muscle spasm.

Craig should also continue to take oral Prednisone for 3 days in order to reduce the amount of
inflammation from the initial reaction. Although Solumedrol is a corticosteroid, it is given as an
intramuscular or intravenous injection. Oral mediation is a much safer and a better-tolerated
route of administration.

Epinephrine, Ventolin, and glucagon can all be used in the acute setting, but have no role in the
management of a patient days after an acute reaction, unless a second anaphylactic reaction
occurs.

As mentioned earlier, Craig will be given a prescription for an Epinephrine pen, along with
instructions on how to use it properly, as a precautionary measure for future anaphylactic attacks.
He will also benefit from a referral to an allergist, who will be able to investigate the
anaphylactic reaction further.