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Updated: Dec 16 2021


  • Snapshot
    • A 15-year-old male presents to the emergency room with dyspnea, wheezes, and urticaria. His symptoms developed approximately under an hour after eating at a restaurant. Medical history is significant for asthma and a severe allergic reaction to peanuts and shellfish. Airway, breathing, and circulation is intact. Patient is started on intramuscular epinephrine.
  • Introduction
    • A potentially life-threatening systemic allergic reaction
      • can result in airway obstruction as well as cardiovascular collapse
      • rapid onset (minutes to hours)
    • Type I hypersensitivity reaction
      • mast cell and basophil activation leads to inflammatory mediator release
        • via IgE and non-IgE mediated mechanisms
    • Causes
      • foods (e.g., peanuts)
      • insect stings/bites (e.g., bee stings)
      • medications (e.g., sulfa-medications)
  • Presentation
    • Physical symptoms
      • must include at least 2 organ systems
        • skin and mucosa
          • hives, itching, swelling of the conjunctiva, and swollen lips/tongue/uvula
        • respiratory
          • stridor, wheezes, and shortness of breath
        • cardiovascular
          • syncope
          • hypotension
          • tachycardia
  • Evaluation
    • Clinical diagnosis
  • Differential Diagnosis
    • Vasovagal syncope
    • Diseases associated with flushing
      • alcohol-induced
      • rosacea
      • carcinoid tumor
  • Treatment
    • Ensure airway, breathing, and circulation is intact
    • Intramuscular (IM) epinephrine
      • first-line therapy
      • IM epinephrine is the preferred route of administration
      • epinephrine mechanism of action
        • α1 agonism results in
          • increased vasoconstriction and decreases mucosal edema
        • β1 agonism results in
          • increased chronotropy and ionotropy
        • β2 agonism results in
          • bronchodilation and decreases inflammatory mediator release from mast cells and basophils
    • Glucocorticoids and antihistamines have a slower onset of action
      • should only be used as adjunctive therapy to epinephrine
  • Prognosis, Prevention, and Complications
    • Prevention
      • avoid triggers
      • patient education
    • Complications
      • airway obstruction and cardiovascular collapse
      • Kounis syndrome
        • allergic angina that can lead to acute coronary syndrome or myocardial infarction
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