In the wake of pandemic, vaccination drive is at its peak &, anaphylaxis is one of the most dreadful side effects of any vaccines or drugs.
These ongoing conditions will occupy a big portion in coming exams. Anaphylaxis is one of the most attention grabbing topics for NEET-PG as well as upcoming NEXT exam. So, let’s discuss one case management here:
A 50 year old man came to get immunized for the first dose of covid-19 vaccination. He had no history of any systemic diseases. After the vaccination he was told to wait for 30 minutes. But after 10 minutes he started to feel dizzy & his skin turned swollen & flushy red. O/E, his pulse rate was rapid & short, blood pressure was 100/60 mm Hg. Soon he felt difficulty in speaking & breathing. On auscultation chest was full of wheezing. Volunteers tried to calm him but he kept on coughing persistently.
What management should be done in this case?
Whenever there is question about management or treatment, first always try to come to a diagnosis. Once the diagnosis is clear, treatment becomes obvious.
In such questions, the most important differentials are immunization related stress response & anaphylaxis.
What is anaphylaxis?
It is a severe, potentially life-threatening allergic (Type-1 hypersensitivity) reaction. It is mediated by IgE.
In the above case, the patient’s response started after 5 minutes of immunization, his face was swollen & flushy. Soon he started noisy breathing i.e. wheezing & started coughing, there was no immediate improvement upon lying down (which can be expected in case of anxiety alone). O/E his blood pressure was found to be low with rapid pulse.
All these manifestations indicate that given patient has anaphylaxis due to vaccine.
If ever confused between stress related response or anaphylaxis; treat as anaphylaxis.
Management of Anaphylaxis:
- Lay down the patient on their side. Lying down & putting legs upwards will imrove venous return to heart. This will help in bringing low BP to normal. Remember that in anaphylaxis supine position is better than sitting position. Sitting position is preferred when breathing difficulties are more prominent than hypotension.
- Apart from hypotension, bronchospasm is the key feature of anaphylaxis. So like any other emergency, the management of anaphylaxis starts with airway, breathing, & circulation management. The drug of choice for anaphylaxis is adrenaline (also called as epinephrine). Adrenaline is sympathomimetic & being beta-1 as well as beta-2 agonist, it is inotropic, vasoconstrictor & bronchodilator. So it increases BP & even more importantly, it dilates the airway & facilitates breathing. CPR is to be administered if necessary.
- 1:1000 Adrenaline intramuscularly in the opposite limb where immunization is done should be administered immediately
- If symptoms continue, repeat adrenaline every 5-10 min till maximum 3 doses. Dose of adrenaline is 0.01ml/kg – up to max 0.5 ml.
- Oronasal oxygen mask for breathing is helpful in anaphylaxis. Hospitalization is preferable.
- Intravenous (IV) antihistamines and cortisone to reduce inflammation of air passages are helpful. Remember that H1 (e.g., diphenhydramine, cetirizine) as well as H2 (e.g., famotidine, cimetidine) antihistaminics can be administered in anaphylaxis.
- A beta2-agonist (such as albuterol) to relieve bronchospasm can be given by nebulization or MDI.
- Intravenous fluids (crystalloids like NS) are helpful in maintaining BP of the patients.
Dr. Shraddha Shah
Medical Content Writer