Resuscitation of Refractory Anaphylaxis

Daniel Cabrera wants you to play the game of anaphylaxis… a serious game! You are faced with a monster, with the name anaphylaxis. Daniel takes you through the resuscitation of refractory anaphylaxis. We do a terrible job managing anaphylaxis, missing 50% of the diagnoses, only giving epinephrine in 50% of the cases who need it. After the acute episode, only 40% of patient go home with an epinephrine auto-injector and only 20% get the appropriate follow up! 1-2% of the population will be affected by anaphylaxis, and 2% will die. Although this may not seem like a huge number, Daniel stresses the point - deaths from anaphylaxis are highly preventable Anaphylaxis is a sudden onset, rapid progressing multi-system organ failure due to the activation of mast cells. Anaphylactic vs anaphylactoid… it does not matter. What does matter is that it is becoming more common. Further, fatal anaphylaxis is very fast to progress highlighting the need to make the diagnosis and make it quickly. Although anaphylaxis kills through shock, hypoxia, ischemia, arrhythmia, and myocardial dysfunction, it is the lack of education and access of providers and patients that is the real issue here. Lack of education of what anaphylaxis is, and how it presents. Lack of access of patients to early care and lack of access to epinephrine. Daniel guides you through the management of a patient suffering from anaphylaxis. His advice: epinephrine (adrenaline) is the only thing that will change mortality outcomes. Use it and use it early! Remember to decontaminate the patient – be it a bee string, or food exposure, get rid of it. The patients will also need lot of crystalloids. There is weak evidence for steroids and antihistamines – they will not save your patients. Use them if you like but not at the expense of early epinephrine and fluids. In refractory cases, increasing dose of epinephrine, norepinephrine, vasopressin, glucagon, methylene blue and ECMO are considerations. Patients with airway compromise require advanced management. Finally – when patients go home they need three things: education, an epipen auto-injector and an anaphylaxis action plan! So know your enemy when dealing with anaphylaxis and you too can be the hero and save the day!

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