MANAGEMENT OF COMMON ALLERGIC EMERGENCIES M. SCOTT LINSCOTT, M.D. UNIVERSITY OF UTAH SCHOOL OF MEDICINE.

MANAGEMENT OF MANAGEMENT OF COMMON ALLERGIC COMMON ALLERGIC

EMERGENCIESEMERGENCIES

M. SCOTT LINSCOTT, M.D.M. SCOTT LINSCOTT, M.D.

UNIVERSITY OF UTAH SCHOOL OF UNIVERSITY OF UTAH SCHOOL OF MEDICINEMEDICINE

CASE #1CASE #1

A 32 Y/O FEMALE PRESENTS WITH A HISTORY OF A 32 Y/O FEMALE PRESENTS WITH A HISTORY OF

SEVERE WHEEZING FOR 24 HOURS. SHE HAS HAD SEVERE WHEEZING FOR 24 HOURS. SHE HAS HAD

ASTHMA SINCE SHE WAS 8 Y/O AND IS CURRENTLY ASTHMA SINCE SHE WAS 8 Y/O AND IS CURRENTLY

USING FLUTICASONE AEROSOL (AZMACORT) 220 mcg USING FLUTICASONE AEROSOL (AZMACORT) 220 mcg

bid, ALBUTEROL MDI 180 mcg q 4 HRS AND THEODUR bid, ALBUTEROL MDI 180 mcg q 4 HRS AND THEODUR

200 mg BID. VS: BP 160/100, P 130, R 30, T 36.6 C. 200 mg BID. VS: BP 160/100, P 130, R 30, T 36.6 C.

SHE IS IN ACUTE RESPIRATORY DISTRESS, GASPING SHE IS IN ACUTE RESPIRATORY DISTRESS, GASPING

FOR EACH BREATH, USING HER ACCESSORY MUSCLES FOR EACH BREATH, USING HER ACCESSORY MUSCLES

AND SITTING IN THE SNIFFING POSITION. SHE IS AND SITTING IN THE SNIFFING POSITION. SHE IS

UNABLE TO SPEAK MORE THAN 2-3 WORDS WITH UNABLE TO SPEAK MORE THAN 2-3 WORDS WITH

EACH BREATH. BREATH SOUNDS ARE DECREASED EACH BREATH. BREATH SOUNDS ARE DECREASED

AND SHE HAS WHEEZING WITH PROLONGED AND SHE HAS WHEEZING WITH PROLONGED

EXPIRATORY PHASE.EXPIRATORY PHASE.

WHAT ADDITIONAL WHAT ADDITIONAL

HISTORY AND PHYSICAL HISTORY AND PHYSICAL

FINDINGS WOULD BE FINDINGS WOULD BE

IMPORTANT?IMPORTANT?

ADDITIONAL HISTORY, ADDITIONAL HISTORY, EXAMEXAM

• PREVIOUSLY STEROID DEPENDENT?PREVIOUSLY STEROID DEPENDENT?

• PREVIOUS HOSPITALIZATIONS FOR PREVIOUS HOSPITALIZATIONS FOR ASTHMA?ASTHMA?

• PREVIOUS ENDOTRACHEAL PREVIOUS ENDOTRACHEAL INTUBATIONS FOR ASTHMA?INTUBATIONS FOR ASTHMA?

• RECENT URI, OTHER INCITING RECENT URI, OTHER INCITING FACTORS?FACTORS?

• PHYSICAL: PULSUS PARADOXICUS?PHYSICAL: PULSUS PARADOXICUS?

HOW SHOULD THIS HOW SHOULD THIS PATIENT BE MANAGED?PATIENT BE MANAGED?

MONITORING / DIAGNOSIS?MONITORING / DIAGNOSIS?

THERAPY?THERAPY?

MONITORING / MONITORING / DIAGNOSISDIAGNOSIS• ECG MONITOR, IVECG MONITOR, IV

• PULSE OXIMETER (INITIALLY ON PULSE OXIMETER (INITIALLY ON ROOM AIR UNLESS THE PATIENT IS ROOM AIR UNLESS THE PATIENT IS IN SEVERE DISTRESS)IN SEVERE DISTRESS)

• PEAK FLOW (PEF) / FEVPEAK FLOW (PEF) / FEV1 1

• THEOPHYLLINE LEVELTHEOPHYLLINE LEVEL

• ABG?ABG?

• CHEST X-RAY?CHEST X-RAY?

HOW SHOULD THIS HOW SHOULD THIS PATIENT BE MANAGED?PATIENT BE MANAGED?

MONITORING / DIAGNOSIS?MONITORING / DIAGNOSIS?

THERAPY?THERAPY?

THERAPYTHERAPY• OXYGENOXYGEN• BETA AGONISTSBETA AGONISTS

INHALED BETA-2 AGONISTS - MDI, INHALED BETA-2 AGONISTS - MDI, NEBULIZER, CPAP, BIPAP, ETCNEBULIZER, CPAP, BIPAP, ETC

SYSTEMIC – SQ/IV EPINEPHRINE OR SYSTEMIC – SQ/IV EPINEPHRINE OR TERBUTALINETERBUTALINE

• IPRATROPIUM?IPRATROPIUM?• CORTICOSTEROIDS - IV, ORAL, INHALEDCORTICOSTEROIDS - IV, ORAL, INHALED• THEOPHYLLINE? MAGNESIUM? HELIOX? THEOPHYLLINE? MAGNESIUM? HELIOX?

LEUKOTRIENE RECEPTOR LEUKOTRIENE RECEPTOR ANTAGONISTS?ANTAGONISTS?

SYSTEMIC BETA SYSTEMIC BETA AGONISTSAGONISTS• UNDERUTILIZED IN PATIENTS WITH SEVERE ACUTE UNDERUTILIZED IN PATIENTS WITH SEVERE ACUTE

ASTHMA ASTHMA

• INHALED BETA-2INHALED BETA-2 AGONISTS ALONE MAY BE AGONISTS ALONE MAY BE INEFFECTIVEINEFFECTIVE

• TERBUTALINE OR EPI 0.3 - 0.5 mg SQTERBUTALINE OR EPI 0.3 - 0.5 mg SQ

• SAFE IN OLDER PTS (ESPECIALLY IF NO CAD)SAFE IN OLDER PTS (ESPECIALLY IF NO CAD)

• IV EPINEPHRINE (0.5-1.0 mcg/min) IF NO RESPONSE IV EPINEPHRINE (0.5-1.0 mcg/min) IF NO RESPONSE TO SQ OR INHALED BETA-2 AGONISTSTO SQ OR INHALED BETA-2 AGONISTS

• AVOID ENDOTRACHEAL INTUBATION IF POSSIBLE AVOID ENDOTRACHEAL INTUBATION IF POSSIBLE (VERY HIGH PRESSURES, PNEUMOTHORAX)(VERY HIGH PRESSURES, PNEUMOTHORAX)

MDI VS NEBULIZERMDI VS NEBULIZER

• EFFICACY: EFFICACY: SIMILAR IF USE MDI WITH SIMILAR IF USE MDI WITH SPACER OR BREATH ACTIVATED MDI SPACER OR BREATH ACTIVATED MDI (MULTIPLE STUDIES)(MULTIPLE STUDIES)

• COST COST (DOLLARS & MAN HOURS): MUCH (DOLLARS & MAN HOURS): MUCH LESS WITH MDILESS WITH MDI

• START WITH MDI (WITH SPACER) AND IF START WITH MDI (WITH SPACER) AND IF NOT EFFECTIVE, USE NEBULIZER NOT EFFECTIVE, USE NEBULIZER

• IF NEBULIZER NOT EFFECTIVE, USE CPAP IF NEBULIZER NOT EFFECTIVE, USE CPAP OR BIPAP (ANN EMERG MED 1995;26:552 OR BIPAP (ANN EMERG MED 1995;26:552 CHEST 2003;123:1018)CHEST 2003;123:1018)

DOSING OF INHALED BETADOSING OF INHALED BETA22 AGONISTS IN SEVERE AGONISTS IN SEVERE ASTHMAASTHMA

• USE 4 SPRAYS (360 mcg) ALBUTEROL MDI USE 4 SPRAYS (360 mcg) ALBUTEROL MDI WITH SPACER OR 6 mg ALBUTEROL (1.0 ml) WITH SPACER OR 6 mg ALBUTEROL (1.0 ml) WITH 2.0 ml NS (NEBULIZER) + NEBULIZED WITH 2.0 ml NS (NEBULIZER) + NEBULIZED ATROPINE (ATROVENT) 500 mcg INITIALLYATROPINE (ATROVENT) 500 mcg INITIALLY

• GIVE ALBUTEROL q 15 MINUTES OR BY GIVE ALBUTEROL q 15 MINUTES OR BY CONTINUOUSCONTINUOUS NEBULIZATION NEBULIZATION

• MOST PATIENTS WITH ACUTE SEVERE MOST PATIENTS WITH ACUTE SEVERE ASTHMA DO POORLY BECAUSE THEY ASTHMA DO POORLY BECAUSE THEY AREN’T GIVEN ENOUGH BETA ADRENERGIC AREN’T GIVEN ENOUGH BETA ADRENERGIC DRUGS!!!DRUGS!!!

SYSTEMIC SYSTEMIC CORTICOSTEROIDS: ORAL CORTICOSTEROIDS: ORAL OR PARENTERAL?OR PARENTERAL?

• IF ACUTE, MILD OR MODERATE: IF ACUTE, MILD OR MODERATE: ORAL ORAL AS EFFECTIVE AS EFFECTIVE AS IV IN AS IV IN ALLALL STUDIES PLUS STUDIES PLUS LESS EXPENSIVELESS EXPENSIVE

• IF ACUTE, SEVERE (VERY ILL): NO IF ACUTE, SEVERE (VERY ILL): NO CONTROLLED STUDIES BUT CONTROLLED STUDIES BUT PROBABLY BEST TO GIVE FIRST PROBABLY BEST TO GIVE FIRST DOSE (S) IVDOSE (S) IV

• DOSE: PREDNISONE 40 - 60 mg po DOSE: PREDNISONE 40 - 60 mg po qd, SOLUMEDROL 1 - 2 mg/kg IV q qd, SOLUMEDROL 1 - 2 mg/kg IV q 12-24 HOURS12-24 HOURS

SYSTEMIC CORTICOSTEROIDS: SYSTEMIC CORTICOSTEROIDS: TO TAPER OR NOT TO TAPER?TO TAPER OR NOT TO TAPER?

• WHY TAPER?WHY TAPER?• IF USE FOR MORE THAN 14-21 DAYS, MAY SEE IF USE FOR MORE THAN 14-21 DAYS, MAY SEE

SUPPRESSION OF HYPOTHALAMIC - PITUITARY - SUPPRESSION OF HYPOTHALAMIC - PITUITARY -ADRENAL AXIS AND IMMUNOSUPPRESSIONADRENAL AXIS AND IMMUNOSUPPRESSION

• IF USE FOR ACUTE EXACERBATIONS, MAY SEE IF USE FOR ACUTE EXACERBATIONS, MAY SEE EXACERBATION OF ASTHMA IF DON'T TAPER EXACERBATION OF ASTHMA IF DON'T TAPER (LITTLE EVIDENCE TO SUPPORT THIS - IF (LITTLE EVIDENCE TO SUPPORT THIS - IF OPTIMUM PEAK EXPIRATORY FLOW (PEF) HAS OPTIMUM PEAK EXPIRATORY FLOW (PEF) HAS BEEN ACHIEVED)BEEN ACHIEVED)

• PROBABLY NO NEED TO TAPER IF PROBABLY NO NEED TO TAPER IF OPTIMUM PEF IS ATTAINED BEFORE OPTIMUM PEF IS ATTAINED BEFORE DISCONTINUING CORTICOSTEROIDSDISCONTINUING CORTICOSTEROIDS

THEOPHYLLINETHEOPHYLLINE

• IN ACUTE ASTHMA – PROBABLY SHOULD NOT BE USED IN ACUTE ASTHMA – PROBABLY SHOULD NOT BE USED AS PRIMARY THERAPY. MOST STUDIES SHOW AS PRIMARY THERAPY. MOST STUDIES SHOW MINIMAL MINIMAL OR NO ADDITIONAL BENEFIT OR NO ADDITIONAL BENEFIT ANDAND INCREASED TOXICITY INCREASED TOXICITY WHEN THEOPHYLLINE IS ADDED TO BETA AGONISTS WHEN THEOPHYLLINE IS ADDED TO BETA AGONISTS AND CORTICOSTEROIDS. HOWEVER, SOME STUDIES DO AND CORTICOSTEROIDS. HOWEVER, SOME STUDIES DO SHOW BENEFIT IN PATIENTS REFRACTORY TO BETA-2 SHOW BENEFIT IN PATIENTS REFRACTORY TO BETA-2 AGONIST THERAPY (CHEST 2003;123:1018)AGONIST THERAPY (CHEST 2003;123:1018)

• CHRONICALLY - MAY BE EFFECTIVE IN SOME CASES, CHRONICALLY - MAY BE EFFECTIVE IN SOME CASES, ESP. NOCTURNAL ASTHMA AND COPD. NEW FDA ESP. NOCTURNAL ASTHMA AND COPD. NEW FDA RECOMMENDED MAXIMUM LEVEL - RECOMMENDED MAXIMUM LEVEL - 15 mg/ml15 mg/ml. BECAUSE . BECAUSE OF ITS LOW THERAPEUTIC INDEX, PROBABLY SHOULD OF ITS LOW THERAPEUTIC INDEX, PROBABLY SHOULD NOT BE FIRST-LINE DRUG FOR CHRONIC ASTHMANOT BE FIRST-LINE DRUG FOR CHRONIC ASTHMA

• HOWEVER, IT IS INEXPENSIVE AND THEREFORE MAY BE THE HOWEVER, IT IS INEXPENSIVE AND THEREFORE MAY BE THE ONLY OPTION IN SOME PATIENTSONLY OPTION IN SOME PATIENTS

IPRATROPIUM, HELIOX, MAGNESIUM, IPRATROPIUM, HELIOX, MAGNESIUM, LEUKOTRIENE RECEPTOR ANTAGONISTSLEUKOTRIENE RECEPTOR ANTAGONISTS

• ALL MAY CAUSE MINIMAL ADDITIONAL BRONCHODILATION ALL MAY CAUSE MINIMAL ADDITIONAL BRONCHODILATION

IN PTS WITH ACUTE ASTHMA TREATED WITH OPTIMUM IN PTS WITH ACUTE ASTHMA TREATED WITH OPTIMUM

BETA ADRENERGIC DRUGS AND STEROIDS, ESP. IN BETA ADRENERGIC DRUGS AND STEROIDS, ESP. IN

MODERATE-TO-SEVERE ASTHMA MODERATE-TO-SEVERE ASTHMA

• IN ACUTE ASTHMA, STUDIES EMPLOYING IPRATROPIUM IN ACUTE ASTHMA, STUDIES EMPLOYING IPRATROPIUM

INITIALLY WITH ALBUTEROL ARE CONFLICTING IN TERMS OF INITIALLY WITH ALBUTEROL ARE CONFLICTING IN TERMS OF

EFFICACY – MOST RECENT STUDIES WOULD INDICATE EFFICACY – MOST RECENT STUDIES WOULD INDICATE

EFFICACY. EFFICACY.

• THEOPHYLLINE, HELIOX, MAGNESIUM AND LRA SHOULD THEOPHYLLINE, HELIOX, MAGNESIUM AND LRA SHOULD

PROBABLY BE RESERVED FOR THE SEVERE CASE WHICH PROBABLY BE RESERVED FOR THE SEVERE CASE WHICH

IS REFRACTORY TO BETA AGONIST, IPRATROPIUM AND IS REFRACTORY TO BETA AGONIST, IPRATROPIUM AND

SYSTEMIC CORTICOSTEROID THERAPYSYSTEMIC CORTICOSTEROID THERAPY

CASE #2CASE #2EMS CALLS TO INFORM YOU THAT THEY ARE EMS CALLS TO INFORM YOU THAT THEY ARE

TRANSPORTING A 22 YEAR OLD MALE WHO IS TRANSPORTING A 22 YEAR OLD MALE WHO IS

COMATOSE AND HAS A BP OF 60/40, PULSE OF 140, COMATOSE AND HAS A BP OF 60/40, PULSE OF 140,

AND RESP OF 16. HE WAS EATING AT A LOCAL THAI AND RESP OF 16. HE WAS EATING AT A LOCAL THAI

RESTAURANT WHEN HE TOLD HIS COMPANION THAT RESTAURANT WHEN HE TOLD HIS COMPANION THAT

HIS THROAT FELT TIGHT AND THEN HE COLLAPSED. HIS THROAT FELT TIGHT AND THEN HE COLLAPSED.

HE HAD INQUIRED OF THE WAITER WHETHER A HE HAD INQUIRED OF THE WAITER WHETHER A

CERTAIN ENTRÉE CONTAINED PEANUTS BECAUSE HE CERTAIN ENTRÉE CONTAINED PEANUTS BECAUSE HE

HAD A VIOLENT ALLERGY TO THEM. THE WAITER HAD A VIOLENT ALLERGY TO THEM. THE WAITER

HAD ASSURED HIM THAT THERE WERE NO PEANUTS, HAD ASSURED HIM THAT THERE WERE NO PEANUTS,

PEANUT OILS, ETC. IN THIS DISH. HIS SYMPTOMS PEANUT OILS, ETC. IN THIS DISH. HIS SYMPTOMS

BEGAN WITHIN 5 MINUTES OF HIS EATING THIS BEGAN WITHIN 5 MINUTES OF HIS EATING THIS

ENTRÉE. ENTRÉE.

MOST LIKELY DIAGNOSIS?MOST LIKELY DIAGNOSIS?

WHAT WOULD YOU WHAT WOULD YOU

INSTRUCT THE EMS INSTRUCT THE EMS

PERSONNEL TO DO FOR THIS PERSONNEL TO DO FOR THIS

PATIENT?PATIENT?

ANAPHYLACTIC SHOCKANAPHYLACTIC SHOCKMANAGEMENTMANAGEMENT

• AT LEAST 2 LARGE BORE (16 GUAGE OR LARGER) IVsAT LEAST 2 LARGE BORE (16 GUAGE OR LARGER) IVs

• CRYSTALLOID (NS) WIDE OPEN (PRESSURE INFUSION CRYSTALLOID (NS) WIDE OPEN (PRESSURE INFUSION IF POSSIBLE) TO DELIVER 1 LITER PER LINE IN FIRST IF POSSIBLE) TO DELIVER 1 LITER PER LINE IN FIRST 5-10 MINUTES. PATIENT WILL OFTEN REQUIRE 10+ 5-10 MINUTES. PATIENT WILL OFTEN REQUIRE 10+ LITERS IN FIRST SEVERAL HOURS (MAJOR CAPILLARY LITERS IN FIRST SEVERAL HOURS (MAJOR CAPILLARY LEAK)LEAK)

• EPINEPHRINE 0.05-0.1 mg IVEPINEPHRINE 0.05-0.1 mg IV

• MONITOR BP AND PULSEMONITOR BP AND PULSE

• CARDIAC MONITORCARDIAC MONITOR

• LIGHTS AND SIREN TO ED!!LIGHTS AND SIREN TO ED!!

CASE #3CASE #3 A 35 YEAR OLD FEMALE PRESENTS WITH THE ACUTE A 35 YEAR OLD FEMALE PRESENTS WITH THE ACUTE

ONSET OF A VERY PRURITIC RASH SIX HOURS PRIOR ONSET OF A VERY PRURITIC RASH SIX HOURS PRIOR

TO ADMISSION. SHE HAD A SIMILAR RASH TWO TO ADMISSION. SHE HAD A SIMILAR RASH TWO

YEARS AGO WHICH CLEARED UP IMMEDIATELY WITH YEARS AGO WHICH CLEARED UP IMMEDIATELY WITH

50 mg OF DIPHENHYDRAMINE ORALLY. SHE TOOK 50 mg OF DIPHENHYDRAMINE ORALLY. SHE TOOK

DIPHENHYDRAMINE AGAIN THIS TIME WITH SLIGHT DIPHENHYDRAMINE AGAIN THIS TIME WITH SLIGHT

IMPROVEMENT IN THE ITCHING FOR TWO HOURS. IMPROVEMENT IN THE ITCHING FOR TWO HOURS.

THE ITCHING AGAIN BECAME SEVERE AND THE RASH THE ITCHING AGAIN BECAME SEVERE AND THE RASH

SPREAD. SHE DENIES TAKING MEDICATIONS OR ANY SPREAD. SHE DENIES TAKING MEDICATIONS OR ANY

NEW SOAPS, MAKEUP, ETC. THERE IS A NEW SOAPS, MAKEUP, ETC. THERE IS A

GENERALIZED ERUPTION OF RAISED WHEALS WITH GENERALIZED ERUPTION OF RAISED WHEALS WITH

ERYTHEMATOUS MARGINS WHICH THE PATIENT IS ERYTHEMATOUS MARGINS WHICH THE PATIENT IS

VIGOROUSLY SCRATCHING.VIGOROUSLY SCRATCHING.

ADDITIONAL HISTORY?ADDITIONAL HISTORY?

(POTENTIALLY LIFE (POTENTIALLY LIFE

THREATENING PROBLEM?)THREATENING PROBLEM?)

ADDITIONAL HISTORY?ADDITIONAL HISTORY?

• MUST WORRY ABOUT ANGIOEDEMA (SAME MUST WORRY ABOUT ANGIOEDEMA (SAME PROCESS AS URTICARIA, BUT INVOLVING PROCESS AS URTICARIA, BUT INVOLVING DEEPER TISSUES)DEEPER TISSUES)

• MOST SENSITIVE QUESTION RE: LARYNGEAL MOST SENSITIVE QUESTION RE: LARYNGEAL ANGIOEDEMA – ANY CHANGE IN YOUR VOICE ANGIOEDEMA – ANY CHANGE IN YOUR VOICE (HOARSENESS)?(HOARSENESS)?

• THROAT TIGHTNESS?THROAT TIGHTNESS?• STRIDOR?STRIDOR?• LIP OR TONGUE SWELLING?LIP OR TONGUE SWELLING?

DIAGNOSIS?DIAGNOSIS?

MANAGEMENT?MANAGEMENT?

ACUTE URTICARIAACUTE URTICARIAMANAGEMENTMANAGEMENT

• DIPHENHYDRAMINE 25 mg IVDIPHENHYDRAMINE 25 mg IV

• HH2 2 BLOCKERS IVBLOCKERS IV RANITIDINE 50 MG IVRANITIDINE 50 MG IV FAMOTIDINE 20 mg IVFAMOTIDINE 20 mg IV CIMETIDINE 300 MG IVCIMETIDINE 300 MG IV

• IF PATIENT HAS WHEEZING, HOARSENESS, THROAT IF PATIENT HAS WHEEZING, HOARSENESS, THROAT TIGHTNESS, LIP/TONGUE SWELLING: EPI 0.3 – 0.5 mg sq TIGHTNESS, LIP/TONGUE SWELLING: EPI 0.3 – 0.5 mg sq

• REFRACTORY: HYDROXYZINE 50 mg po, DOXEPIN 50 mg REFRACTORY: HYDROXYZINE 50 mg po, DOXEPIN 50 mg po, SYSTEMIC STEROIDS, REFER TO DERMATOLOGIST po, SYSTEMIC STEROIDS, REFER TO DERMATOLOGIST FOR BIOPSY TO R/O URTICARIAL VASCULITISFOR BIOPSY TO R/O URTICARIAL VASCULITIS

HH11 BLOCKERS BLOCKERS

• OLDER (“FIRST GENERATION”): OLDER (“FIRST GENERATION”): DIPHENHYDRAMINE (BENADRYL), DIPHENHYDRAMINE (BENADRYL), CHLORPHENIRAMINE (CHLORTRIMETON), CHLORPHENIRAMINE (CHLORTRIMETON), CYPROHEPTADINE (PERIACTIN), HYDROXYZINE CYPROHEPTADINE (PERIACTIN), HYDROXYZINE (ATARAX, VISTARIL), PROMETHAZINE (ATARAX, VISTARIL), PROMETHAZINE (PHENERGAN), CLEMASTINE (TAVIST), ETC.(PHENERGAN), CLEMASTINE (TAVIST), ETC.

• NEWER (“SECOND GENERATION”): NEWER (“SECOND GENERATION”): LORATADINE (CLARITIN), CETIRIZINE (ZYRTEC), LORATADINE (CLARITIN), CETIRIZINE (ZYRTEC), FEXOFENADINE (ALLEGRA), FEXOFENADINE (ALLEGRA), ASTEMIZOLE ASTEMIZOLE (HISMANAL),(HISMANAL), TERFENADINE (SELDANE),TERFENADINE (SELDANE),

HH11 BLOCKING ANTIHISTAMINES BLOCKING ANTIHISTAMINES

DRUGDRUG COST/DAY*COST/DAY* ASAS PARPAR METMETURUR VAVA

DIPHENHYDRDIPHENHYDR -- ++++++ ++++ --

HYDROXYZINEHYDROXYZINE oo ++++++ ++++++ --

TERFENADINETERFENADINE ++ ++++++ ++++ ++

ASTEMIZOLEASTEMIZOLE ++++++ ++++ ++

LORATADINELORATADINE ++++++ ++++

CETIRIZINECETIRIZINE ++++++++ ++++++

--

--

++

++

++++

HEPHEP

RENREN

HEPHEP

HEPHEP

HEPHEP

RENREN

ONON

<30<30

<30<30

>60>60

>120>120

>60>60

<60<60

$0.85$0.85

$0.90$0.90

$2.50$2.50

$2.10$2.10

* DAILY COST TO PATIENT OF 30 DAY PRESCRIPTION (AVERAGE* DAILY COST TO PATIENT OF 30 DAY PRESCRIPTION (AVERAGE OF SMITHS, DANS, WALMART, UUMC) IN SLC, UTAH, USA SEPT 2003OF SMITHS, DANS, WALMART, UUMC) IN SLC, UTAH, USA SEPT 2003

++ ++++++ ++++ HEPHEP >60>60 -- $2.40$2.40FEXOFENADINEFEXOFENADINE

SUMMARYSUMMARY

• ASTHMAASTHMA IF MILD, ALBUTEROL ± IPRATROPRIUMIF MILD, ALBUTEROL ± IPRATROPRIUM IF MODERATE, ABOVE PLUS SYSTEMIC CORTICOSTEROIDSIF MODERATE, ABOVE PLUS SYSTEMIC CORTICOSTEROIDS IF SEVERE, ABOVE PLUS SYSTEMIC BETA AGONISTS – GET IF SEVERE, ABOVE PLUS SYSTEMIC BETA AGONISTS – GET

CXR AND ABGsCXR AND ABGs EPINEPHRINE DRIP – AVOID ET INTUBATIONEPINEPHRINE DRIP – AVOID ET INTUBATION

• ANAPHYLACTIC SHOCKANAPHYLACTIC SHOCK MOST IMPORTANT IS MASSIVE IV CRYSTALLOID INFUSIONMOST IMPORTANT IS MASSIVE IV CRYSTALLOID INFUSION EPINEPHRINE 0.05-0.1 mg IVEPINEPHRINE 0.05-0.1 mg IV ANTIHISTAMINES, STEROIDS?ANTIHISTAMINES, STEROIDS?

• ACUTE URTICARIA/ANGIOEDEMAACUTE URTICARIA/ANGIOEDEMA DIPHENHYDRAMINE 25 mg IVDIPHENHYDRAMINE 25 mg IV HH22 BLOCKER IV BLOCKER IV EPI IF SUSPECT ANGIOEDEMA, ESP. OF THE LARYNXEPI IF SUSPECT ANGIOEDEMA, ESP. OF THE LARYNX