- Email: [email protected]
Epinephrine shot in kiwi anaphylaxis—yes but not yet
626
Correspondence / American Journal of Emergency Medicine 31 (2013) 621–630
Subramanian Senthilkumaran MD Sri Gokulam Hospitals and Research Institute Salem, Tamil Nadu E-mail address: [email protected] Namasivayam Balamurugan MD Manipal Hospital, Salem, Tamil Nadu Ritesh G. Menezes MD Srinivas Institute of Medical Sciences and Research centre Mangalore, India Ponniah Thirumalaikolundusubramanian MD Chennai Medical College Hospital and Research Center Irungalur, Trichy, India http://dx.doi.org/10.1016/j.ajem.2012.11.033
References [1] Sodhi R, Khanduri S, Nandha H, Bhasin D, Mandal AK. Brain death—think twice before labeling a patient. Am J Emerg Med 2012;30(7):1321. [2] Shea GM. The distribution and identification of dangerously venomous Australian terrestrial snakes. Aust Vet J 1999;77:791–8. [3] Ariaratnam CA, Sheriff MH, Arambepola C, Theakston RD, Warrell DA. Syndromic approach to treatment of snake bite in Sri Lanka based on results of a prospective national hospital-based survey of patients envenomed by identified snakes. Am J Trop Med Hyg 2009;81:725–31. [4] Gawarammana IB, Mudiyanselage Kularatne SA, Kularatne K, Waduge R, Weerasinghe VS, Bowatta S, et al. Deep coma and hypokalaemia of unknown aetiology following Bungarus caeruleus bites: exploration of pathophysiological mechanisms with two case studies. J Venom Res 2010;1:71–5. [5] Sethi PK, Rastogi JK. Neurological aspects of ophitoxemia (Indian krait)—a clinicoelectromyographic study. Indian J Med Res 1981;73:269–76. [6] Facco E, Machado C. Evoked potentials in the diagnosis of brain death. Adv Exp Med Biol 2004;550:175–87. [7] Bomb BS, Roy S, Kumawat DC, Bharjatya M. Do we need anti snake venom (ASV) for management of elapid ophitoxaemia. J Assoc Physicians India 1996;44:31–3.
peak levels [4]. In addition, there are no absolute contraindications to use epinephrine in a true anaphylactic emergency. Adverse effects are extremely rare with correct doses injected intramuscularly. If the authors had used epinephrine immediately after the onset of reaction, this patient might not have deteriorated. As it as an αreceptor agonist, it reverses peripheral vasodilation and reduces edema. Its β-receptor activity dilates the bronchial airways, increases the force of myocardial contraction, and suppresses release of histamine and leukotriene. Interestingly, it also attenuates the severity of immunoglobulin E–mediated allergic reactions by inhibiting the β-2 adrenergic receptors on mast cells [5]. Corticosteroids do not reverse the cardiovascular effects of anaphylaxis, and it should not be used in place of epinephrine. Educational deficit regarding correct administration of epinephrine among physicians, regardless of seniority and specialty, was brought out by Droste and Narayan [6] recently. Hence, they have proposed a mnemonic for remembering the recommended treatment for anaphylaxis in adults as “A Thigh 500” for epinephrine into anterolateral thigh, 500 μg [7]. We teach treatment of anaphylaxis to our students as ABC: A-Adrenaline (Epinephrine), B-Benadryl (antihistamine), C-Corticosteroids. The failure to use or the delay in the administration of epinephrine will exacerbate the anaphylactic shock as reported in this case; there is a need to conduct clinical audit of cases treated for anaphylaxis and physicians and nurses be periodically trained on the management of anaphylaxis through continuous medical education programs and mock drills. Acknowledgments We thank Dr K. Arthanari, MS, for his logistic support.
Subramanian Senthilkumaran MD Sri Gokulam Hospitals & Research Institute Salem, Tamil Nadu, India E-mail address: [email protected]
Epinephrine shot in kiwi anaphylaxis—yes but not yet☆,☆☆
Ritesh G. Menezes MD Srinivas Institute of Medical Sciences & Research Centre Mangalore, India
To the Editor, We read the case report of Zhu et al [1] with great interest. Kiwi is an exotic fruit and has gained popularity in domestic markets of many countries now. Because of its wide availability, various forms of allergic reactions to kiwifruit ranging from localized oral allergy syndrome to life-threatening anaphylaxis were reported. Three allergens have been described in green kiwifruit so far, and several more await discovery. Moreover, it is also recognized as part of the “latex-fruit syndrome,” and crossreactivity has been confirmed [2]. In the case reported [1], the authors had not used epinephrine, which is the cornerstone of anaphylactic shock treatment. All advanced life support courses have put anaphylaxis into focus for emergency care providers, and it is highlighted as a “peri-arrest” condition, in which on-time treatment may avert cardiac arrest [3]. Use of medications such as antihistamines, glucocorticoids, and βagonists, either alone or in combination, is considered next to epinephrine. Practitioners shall remember that epinephrine has to be given intramuscularly for all types of anaphylactic reactions and the preferred site being vastus lateralis muscle. The subcutaneous route is no longer recommended in view of delayed absorption and decreased
☆ Financial support: Nil. ☆☆ Conflict of interest: Nil.
Srinivasan Jayaraman MD Hamad General Hospital, Doha, Qatar Ponniah Thirumalaikolundusubramanian MD Chennai Medical College Hospital & Research Center Irungalur, Trichy, India http://dx.doi.org/10.1016/j.ajem.2012.12.006 References [1] Zhu T, Zhou D, Shu Q. Anaphylactic shock due to kiwifruit. Am J Emerg Med 2012;30:2096.e1–2. [2] Lucas JSA. Kiwi fruit allergy: a review. Pediatr Allergy Immunol 2003;14:420–8. [3] Working Group of the Resuscitation Council (UK). Emergency treatment of anaphylactic reactions, guidelines for healthcare providers. Available from:www. resus.org.uk; 2008. Accessed on 20th November 2012. [4] Simons FE, Gu X, Simons KJ. Epinephrine absorption in adults: intramuscular versus subcutaneous injection. J Allergy Clin Immunol 2001;108:871–3. [5] Kay LJ, Peachell PT. Mast cell beta2-adrenoceptors. Chem Immunol Allergy 2005;87:145–53. [6] Droste J, Narayan N. Anaphylaxis: lack of hospital doctors' knowledge of adrenaline (epinephrine) administration in adults could endanger patients' safety. Eur Ann Allergy Clin Immunol 2012;44:122–7. [7] Droste J, Narayan N. Doctors' knowledge of adrenaline (epinephrine) administration in anaphylaxis in adults is deficient: there is still need for significant improvement. Resuscitation 2010;81:1744–5.
Correspondence / American Journal of Emergency Medicine 31 (2013) 621–630
Subramanian Senthilkumaran MD Sri Gokulam Hospitals and Research Institute Salem, Tamil Nadu E-mail address: [email protected] Namasivayam Balamurugan MD Manipal Hospital, Salem, Tamil Nadu Ritesh G. Menezes MD Srinivas Institute of Medical Sciences and Research centre Mangalore, India Ponniah Thirumalaikolundusubramanian MD Chennai Medical College Hospital and Research Center Irungalur, Trichy, India http://dx.doi.org/10.1016/j.ajem.2012.11.033
References [1] Sodhi R, Khanduri S, Nandha H, Bhasin D, Mandal AK. Brain death—think twice before labeling a patient. Am J Emerg Med 2012;30(7):1321. [2] Shea GM. The distribution and identification of dangerously venomous Australian terrestrial snakes. Aust Vet J 1999;77:791–8. [3] Ariaratnam CA, Sheriff MH, Arambepola C, Theakston RD, Warrell DA. Syndromic approach to treatment of snake bite in Sri Lanka based on results of a prospective national hospital-based survey of patients envenomed by identified snakes. Am J Trop Med Hyg 2009;81:725–31. [4] Gawarammana IB, Mudiyanselage Kularatne SA, Kularatne K, Waduge R, Weerasinghe VS, Bowatta S, et al. Deep coma and hypokalaemia of unknown aetiology following Bungarus caeruleus bites: exploration of pathophysiological mechanisms with two case studies. J Venom Res 2010;1:71–5. [5] Sethi PK, Rastogi JK. Neurological aspects of ophitoxemia (Indian krait)—a clinicoelectromyographic study. Indian J Med Res 1981;73:269–76. [6] Facco E, Machado C. Evoked potentials in the diagnosis of brain death. Adv Exp Med Biol 2004;550:175–87. [7] Bomb BS, Roy S, Kumawat DC, Bharjatya M. Do we need anti snake venom (ASV) for management of elapid ophitoxaemia. J Assoc Physicians India 1996;44:31–3.
peak levels [4]. In addition, there are no absolute contraindications to use epinephrine in a true anaphylactic emergency. Adverse effects are extremely rare with correct doses injected intramuscularly. If the authors had used epinephrine immediately after the onset of reaction, this patient might not have deteriorated. As it as an αreceptor agonist, it reverses peripheral vasodilation and reduces edema. Its β-receptor activity dilates the bronchial airways, increases the force of myocardial contraction, and suppresses release of histamine and leukotriene. Interestingly, it also attenuates the severity of immunoglobulin E–mediated allergic reactions by inhibiting the β-2 adrenergic receptors on mast cells [5]. Corticosteroids do not reverse the cardiovascular effects of anaphylaxis, and it should not be used in place of epinephrine. Educational deficit regarding correct administration of epinephrine among physicians, regardless of seniority and specialty, was brought out by Droste and Narayan [6] recently. Hence, they have proposed a mnemonic for remembering the recommended treatment for anaphylaxis in adults as “A Thigh 500” for epinephrine into anterolateral thigh, 500 μg [7]. We teach treatment of anaphylaxis to our students as ABC: A-Adrenaline (Epinephrine), B-Benadryl (antihistamine), C-Corticosteroids. The failure to use or the delay in the administration of epinephrine will exacerbate the anaphylactic shock as reported in this case; there is a need to conduct clinical audit of cases treated for anaphylaxis and physicians and nurses be periodically trained on the management of anaphylaxis through continuous medical education programs and mock drills. Acknowledgments We thank Dr K. Arthanari, MS, for his logistic support.
Subramanian Senthilkumaran MD Sri Gokulam Hospitals & Research Institute Salem, Tamil Nadu, India E-mail address: [email protected]
Epinephrine shot in kiwi anaphylaxis—yes but not yet☆,☆☆
Ritesh G. Menezes MD Srinivas Institute of Medical Sciences & Research Centre Mangalore, India
To the Editor, We read the case report of Zhu et al [1] with great interest. Kiwi is an exotic fruit and has gained popularity in domestic markets of many countries now. Because of its wide availability, various forms of allergic reactions to kiwifruit ranging from localized oral allergy syndrome to life-threatening anaphylaxis were reported. Three allergens have been described in green kiwifruit so far, and several more await discovery. Moreover, it is also recognized as part of the “latex-fruit syndrome,” and crossreactivity has been confirmed [2]. In the case reported [1], the authors had not used epinephrine, which is the cornerstone of anaphylactic shock treatment. All advanced life support courses have put anaphylaxis into focus for emergency care providers, and it is highlighted as a “peri-arrest” condition, in which on-time treatment may avert cardiac arrest [3]. Use of medications such as antihistamines, glucocorticoids, and βagonists, either alone or in combination, is considered next to epinephrine. Practitioners shall remember that epinephrine has to be given intramuscularly for all types of anaphylactic reactions and the preferred site being vastus lateralis muscle. The subcutaneous route is no longer recommended in view of delayed absorption and decreased
☆ Financial support: Nil. ☆☆ Conflict of interest: Nil.
Srinivasan Jayaraman MD Hamad General Hospital, Doha, Qatar Ponniah Thirumalaikolundusubramanian MD Chennai Medical College Hospital & Research Center Irungalur, Trichy, India http://dx.doi.org/10.1016/j.ajem.2012.12.006 References [1] Zhu T, Zhou D, Shu Q. Anaphylactic shock due to kiwifruit. Am J Emerg Med 2012;30:2096.e1–2. [2] Lucas JSA. Kiwi fruit allergy: a review. Pediatr Allergy Immunol 2003;14:420–8. [3] Working Group of the Resuscitation Council (UK). Emergency treatment of anaphylactic reactions, guidelines for healthcare providers. Available from:www. resus.org.uk; 2008. Accessed on 20th November 2012. [4] Simons FE, Gu X, Simons KJ. Epinephrine absorption in adults: intramuscular versus subcutaneous injection. J Allergy Clin Immunol 2001;108:871–3. [5] Kay LJ, Peachell PT. Mast cell beta2-adrenoceptors. Chem Immunol Allergy 2005;87:145–53. [6] Droste J, Narayan N. Anaphylaxis: lack of hospital doctors' knowledge of adrenaline (epinephrine) administration in adults could endanger patients' safety. Eur Ann Allergy Clin Immunol 2012;44:122–7. [7] Droste J, Narayan N. Doctors' knowledge of adrenaline (epinephrine) administration in anaphylaxis in adults is deficient: there is still need for significant improvement. Resuscitation 2010;81:1744–5.