201111122348anaphylaxis 嚴重全身性過敏反應 治療藥物與頻次劑量
統一名詞翻譯
anaphylaxis 急性嚴重全身性過敏反應, 沒有適當處置通常會致命
allergy 過敏. 與anaphylaxis 差異極大, 過敏不治療, 通常會自然好.
antihistamine 抗組織胺, 又分成 H1 blocker, H2 blocker
H1 blocker 第一型組織胺拮抗劑
H2 blocker 第二型組織胺拮抗劑
Glucocorticoids — 葡萄糖皮質素, 底下都翻譯成類固醇
另外兩篇相似的在此
1. 名詞翻譯~嚴重全身性過敏反應 anaphylaxis
2. 全身性嚴重過敏反應診斷標準與治療
藥物, 劑量, 頻次
腎上腺素 epinephrine 0.3-0.5 mg every 5-15 minutes *備註
類固醇 Prednisone - 成人每天吃 20-80 mg 連續吃 2-5 天; 兒童依照體重給, 每公斤 0.5-1 mg, 一天一次, 連續吃 2-5 天. 不需逐漸減量.
(備註: 腎上腺素2010 年ACLS 建議 5-15 分鐘打一次, 2005年ACLS建議每 15-20 分鐘打一次, 舊版medscape 建議 3-5 分鐘打一次.)
H1B 選一種即可
= diphenhydramine (Benadryl) - Adults: 25 mg PO q6h for 2-5 d; Children: 1 mg/kg PO q6h for 2-5 d
= Hydroxyzine (Atarax) - Adults: 25 mg PO q8h for 2-5 d; Children: 1 mg/kg PO q8h for 2-5 d
H2B 選一種即可
= Ranitidine
= Cimetidine - 300 mg PO qid for 2-5 d 不建議兒童使用.
統一名詞翻譯
anaphylaxis 嚴重全身性過敏反應, 沒有適當處置通常會致命
allergy 過敏. 與anaphylaxis 差異極大, 過敏不治療, 通常會自然好.
antihistamine 抗組織胺, 又分成 H1 blocker, H2 blocker
H1 blocker 第一型組織胺拮抗劑
H2 blocker 第二型組織胺拮抗劑
Glucocorticoids — 葡萄糖皮質素, 底下都翻譯成類固醇
2020-10-14 from medscape. 內容在 16 May, 2018 更新. medscape 裡面提到. 到底要多久施打一次腎上腺素,. 目前仍無定論.
Data are limited concerning the frequency with which patients might require repeated doses of epinephrine to treat anaphylaxis (reports range from 16-36% and multiple cofactors might be involved.
ACLS 建議劑量是 0.3-0.5 mg (0.3-0.5 cc)
至於多久打一次. 有些舊的文獻(例如medscape)說 3-5 分鐘打一次, 但 2010 ACLS 建議 5-15 分鐘打一次腎上腺素.
2010年 ACLS Part 12: Cardiac Arrest in Special Situations
Epinephrine68 should be administered early by IM injection to all patients with signs of a systemic allergic reaction, especially hypotension, airway swelling, or difficulty breathing (Class I, LOE C). The recommended dose is 0.2 to 0.5 mg (1:1000) IM to be repeated every 5 to 15 minutes in the absence of clinical improvement (Class I, LOE C).69 The adult epinephrine IM auto-injector will deliver 0.3 mg of epinephrine and the pediatric epinephrine IM auto-injector will deliver 0.15 mg of epinephrine. In both anaphylaxis and cardiac arrest the immediate use of an epinephrine autoinjector is recommended if available (Class I, LOE C).
2005年的 ACLS
建議 anaphylaxis 時每 15-20 分鐘打一次腎上腺素 (這是 2005年的 ACLS 建議, 2010 年建議 5-15 分鐘打一次)
Epinephrine
–Absorption and subsequent achievement of maximum plasma concentration after subcutaneous administration is slower and may be significantly delayed with shock.10,11 Thus, intramuscular (IM) administration is favored.
Administer epinephrine by IM injection early to all patients with signs of a systemic reaction, especially hypotension, airway swelling, or definite difficulty breathing.
Use an IM dose of 0.3 to 0.5 mg (1:1000) repeated every 15 to 20 minutes if there is no clinical improvement. (這是 2005年的 ACLS 建議, 2010 年建議 5-15 分鐘打一次)
–Administer IV epinephrine if anaphylaxis appears to be severe with immediate life-threatening manifestations.12
Use epinephrine (1:10 000) 0.1 mg IV slowly over 5 minutes. Epinephrine may be diluted to a 1:10 000 solution before infusion.
An IV infusion at rates of 1 to 4 μg/min may prevent the need to repeat epinephrine injections frequently.13
–Close monitoring is critical because fatal overdose of epinephrine has been reported.3,14
–Patients who are taking β-blockers have increased incidence and severity of anaphylaxis and can develop a paradoxical response to epinephrine.15 Consider glucagon as well as ipratropium for these patients (see below)
https://www.ahajournals.org/....../CIRCULATIONAHA.105.166568
2020-05-24 from uptodate
Glucocorticoids — 類固醇
類固醇是過敏性休克常用的藥物, 但是否有用則缺乏足夠證據支持. 類固醇作用開始時間需數小時, 所以緩不濟急, 因此, 類固醇無法改善急性過敏的症狀, 也無法改善過敏性休克(無法穩定心跳血壓及氣管黏膜腫脹), 給予類固醇的理由, 理論上是預防少數病患的雙相式或頑固型過敏反應, 但有一篇文獻回顧, 分析了 31 篇研究報告, 研究過敏反應或過敏性休克的急診病患, 使用類固醇無法降低再回診率(因症狀未改善又再次掛急診), 也無法改善雙相式反應, 此外, 更多一般系統性文獻回顧也找不到隨機研究支持類固醇療效.
雙相式: 經過初步治療有改善, 但之後又惡化.
Glucocorticoids are commonly given in the treatment of anaphylaxis, although there is little evidence of clear benefit. The onset of action of glucocorticoids takes several hours. Therefore, these medications do not relieve the initial symptoms and signs of anaphylaxis. The rationale for giving them, theoretically, is to prevent the biphasic or protracted reactions that occur in some cases of anaphylaxis. However, a review of 31 publications, as well as a study of emergency department patients with allergic reactions or anaphylaxis, failed to find a decrease in return emergency department visits or biphasic reactions among patients treated with glucocorticoids [79,80]. In addition, more general systematic reviews of the literature have failed to retrieve any randomized-controlled trials in anaphylaxis that confirmed the effectiveness of glucocorticoids [81,82].
2018-10-29 from Medscape.
腎上腺素是第一線用藥. 成人. 每 3-5 分鐘 肌肉注射 0.3-0.5 cc (但2010 AHA ACLS 指引建議 10-15 分鐘打一次). 在使用 epipen 注射大腿肌肉時. 不需要脫褲子. 靜脈注射腎上腺素. 一隻 1mg epinephrine 稀釋一百倍. 抽 10cc(內含 0.1mg epinephrine), 靜脈注射 10 分鐘. 持續監測血壓. 底下是關於類固醇和抗組織胺的敘述.
Administration of Antihistamines and Corticosteroids
過敏性休克標準的治療應包含抗組織胺及類固醇, 然而, 抗組織胺生效速率比腎上腺素慢, 對於血壓的影響很輕微, 不可以僅使用抗組織胺作為單一治療, 抗組織胺的角色主要是輔助腎上腺素.
The standard treatment of anaphylaxis should also include antihistamines and corticosteroids. However, antihistamines have a much slower onset of action than epinephrine, they exert minimal effect on blood pressure, and they should not be administered alone as treatment. Antihistamine therapy thus is considered adjunctive to epinephrine.
給予 H1 blocker (H1B一般稱為抗過敏的藥物, 組織胺第一型拮抗劑) 及 H2 blocker (H2B可抑制胃酸分泌, 通常當成胃炎的治療用藥), 兩個一起給, 對於緩解組織胺媒介的症狀, 效果優於單獨給予 H1 blocker. 例如可以同時給予 diphenhydramine(屬於H1B, 醫護人員常稱 vena) 加上 ranitidine (H2B), 靜脈注射能確保藥物都有進入血管, 因為過敏性休克的病患, 血液循環可能不足, 口服或肌肉注射較難預測有多少進入血中(進入血中才能產生全身性作用), 但對於輕度的過敏性休克, 口服或肌肉注射抗組織胺可能就足夠了.
Administer an H1 blocker and an H2 blocker, because studies have shown the combination to be superior to an H1 blocker alone in relieving the histamine-mediated symptoms. Diphenhydramine and ranitidine are an appropriate combination. IV administration ensures that effective dosing is not impaired by hemodynamic compromise, which adversely affects gastrointestinal (GI) or IM absorption. However, oral or IM administration of antihistamines may suffice for milder anaphylaxis.
類固醇對於過敏性休克沒有立即的療效, 但早期給予類固醇能避免遲發性過敏性休克(或雙相性過敏性休克, 意思是給藥已經穩定的病患, 藥效過了又休克), 氣喘病患或因其他疾病已經在使用類固醇治療的病患, 一但出現過敏性休克, 可能會增加嚴重或致死性過敏性休克的機率 (已經服用類固醇還過敏, 表示過敏太嚴重, 應該不是說類固醇會增加嚴重度), 這類病患給予額外的類固醇會有助益, 因此建議所有過敏性休克病患都給予類固醇, 如果擔心口服或肌肉注射吸收不良, 應使用靜脈注射.
Corticosteroids have no immediate effect on anaphylaxis. [74] However, administer them early to try to prevent a potential late-phase reaction (biphasic anaphylaxis). Patients with asthma or other conditions recently treated with a corticosteroid may be at increased risk for severe or fatal anaphylaxis and may receive additional benefit if corticosteroids are administered to them during anaphylaxis. The authors recommend corticosteroid treatment for all patients with anaphylaxis. If absorption is a concern, IV preparations should be used.
多數病患經過抗組織胺及類固醇治療, 會完全緩解, 之後可以慢慢減少類固醇劑量, 有些嚴重過敏的可能需要長期服用 H1B
Most patients treated with antihistamines and steroids have complete remission following tapering of steroids. Others require long-term prophylaxis with high doses of H1 antihistamines.
病患離院的時候, 應給予口服抗組織胺, 類固醇應繼續服用數日, 但這些都只是理論上會有幫忙, 無足夠的研究證實
Outpatient medications are the oral forms of antihistamines and corticosteroids that should be continued for a short time (a few days) following an episode. The benefit of these drugs is more theoretical because no studies exist that prove their benefit in this setting.
prednisolone 是相當方便取得的口服類固醇. 但應該給到多少劑量比較好, 目前還不清楚, 通常成人每天每公斤可以給 1mg. 分兩次或三次服用, 小兒可以給予每天每公斤 0.5-1 mg. 除非是需要長期服用, 一般不需要逐漸減量.
A convenient oral corticosteroid is prednisone. No proven best dose exists. In adults, a dose of 1 mg/kg/d in divided doses is probably adequate; in children, a dose of 0.5-1 mg/kg/d in divided doses is appropriate. Tapering is not necessary unless the patient has been taking steroids chronically.
底下的處方是醫師經常使用的, 但沒有強力的資料佐證. 因此也不要將下面的數據當成治療的唯一處方或標準療法, 關於H2B的效果證據尤其稀少.
The following regimens are used commonly by clinicians, though very little hard data concerning the natural history of anaphylaxis treated in the ED exists. In light of this, do not construe the following as an unqualified recommendation or as a standard of care. Evidence for efficacy of H2 -blocker antihistamines is particularly sparse.
H1 -blocker antihistamine treatment is as follows:
Diphenhydramine (Benadryl) - Adults: 25 mg PO q6h for 2-5 d; Children: 1 mg/kg PO q6h for 2-5 d
Hydroxyzine (Atarax) - Adults: 25 mg PO q8h for 2-5 d; Children: 1 mg/kg PO q8h for 2-5 d
Corticosteroid treatment is as follows:
Prednisone - Adults: 20-80 mg PO daily for 2-5 d; Children: 0.5-1 mg/kg PO daily for 2-5 d
Many other glucocorticoid preparations may be used.
H2 -blocker antihistamine treatment is as follows:
Cimetidine - 300 mg PO qid for 2-5 d; Children: Not recommended
Patients with frequent idiopathic anaphylaxis may benefit from daily antihistamine therapy (both H1 antagonists and H2 antagonists) or, in rare circumstances, daily corticosteroid therapy.
每天服用抗組織胺, 通常選 diphenhydramine 或 hydroxyzine, 如果想減少嗜睡的副作用, 也可以選二代抗組織胺, 例如艾來 allegra 每天可以給 180 mg. 或 loratadine(claritin)每天 10mg. 或 cetirizine 每天 10 mg. 或 desloratadine (clarinex) 每天 5 mg. 或 levocetirizine (xyzal) 每天 5mg. 但以上藥物對於過敏性休克的預防, 沒有一種有足夠的評估, 如果病患可以忍受副作用, 有些專家會給更大劑量的抗組織胺以控制症狀
For daily antihistamine therapy, diphenhydramine or hydroxyzine is often used first. Second-generation, less-sedating agents may be preferable because of decreased adverse effects. In their adult doses, these include fexofenadine (Allegra) at 180 mg/d, loratadine (Claritin) at 10 mg/d, cetirizine (Zyrtec) at 10 mg/d, desloratadine (Clarinex) at 5 mg/d, and levocetirizine (Xyzal) at 5 mg/d. However, none has been specifically evaluated in anaphylaxis prevention. Some specialists prescribe extra doses of antihistamines as needed and as tolerated to control symptoms.
2016-12-19 from 張志華醫師
http://www.emnote.org/emnotes/anaphylaxis
References:
1. http://daniellesbrainbits.blogspot.tw/
2. http://www.totalem.org/
3. http://iconpediatrics.com/
4. http://emergencymedicinecases.com/
2016-05-28 修改
BOX 119-7
Emergency Measures (taken simultaneously)
移除造成過敏的來源, 如果是蜂螫或注射藥物, 可在近端綁上止血帶. 將患肢位置放低於心臟.
讓病患頭低腳高
接上生理監視器. 給予 NRM 氧氣. 打上大號點滴. 抽血. 做 ECG. 照 CXR.
保持呼吸道通暢. 必要時插管. 視情況使用其他設備輔助插管.
給予消旋腎上腺素 或左旋腎上腺素, 2.25% 0.5cc + NS 2.5cc 噴霧吸入
大量注射生理食鹽水
Remove any triggering agent. If the patient had a sting or immunization injection, place a loose tourniquet proximal to the site; if the reaction site is on an extremity, place the extremity in dependent position.
Place patient in the Trendelenburg position if hypotensive.
Begin cardiac monitoring, pulse oximetry, and blood pressure autonomic monitoring; apply oxygen non-rebreather mask, establish large-bore intravenous lines, draw blood, obtain stat electrocardiogram and portable chest radiograph.
Establish a patent airway.
Open the airway by head tilt/chin lift or jaw thrust as clinically appropriate.
Be prepared for endotracheal intubation with or without rapid sequence intubation.
Be prepared to use adjunct airway technique (laryngeal mask airway, fiberoptic, jet ventilation, surgical airway) as per local custom.
Administer racemic epinephrine (L-epinephrine acceptable) 0.5 mL of 2.25% solution in 2.5 mL of NS by nebulizer while awaiting definitive airway management.
Start rapid infusion of isotonic crystalloid (NS): 500 mL in the first 5 minutes in the adult; several liters of NS may be required.
跟第五版相同. 腎上腺素是第一線用藥. 成人. 每 3-5 分鐘 肌肉注射 0.3-0.5 cc. 在使用 epipen 注射大腿肌肉時. 不需要脫褲子.
靜脈注射腎上腺素. 一隻 1mg epinephrine 稀釋一百倍. 抽 10cc(內含 0.1mg epinephrine), 靜脈注射 10 分鐘. 持續監測血壓.
VENA. 成人 50mg IV STAT. 或口服 150 mg(通常一顆 10mg. 一次可吃 15顆)
Ranitidine: intravenous ==Adult: 50 mg IV
噴霧藥物 Albuterol 2.5mg + NS 2cc.
類固醇劑量往下調了. Methylprednisolone =Adult: 125-250 mg IV
Corticosteroids 類固醇作用時間約需要 4-6 小時. 所以在緊急處理幫忙不大. 但可以治療頑固性過敏. 避免治療過後又再次惡化, 極少數病患可能對類固醇過敏.
Along with epinephrine and antihistamines, systemic corticosteroids are commonly administered in the treatment of anaphylaxis. A typical regimen involves an initial intravenous loading dose of methylprednisolone (Solu-Medrol, 125 to 250 mg) or oral prednisone (0.5-1 mg/kg). Steroids have an onset of action of approximately 4 to 6 hours after administration and therefore are of limited benefit in the acute treatment. They are most useful for
protracted symptoms and may confer theoretic benefits in preventing the biphasic reaction. Rare cases of deterioration after corticosteroid administration may be the result of the patient’s hypersensitivity reaction to steroid.
Antianaphylactic Drugs
Epinephrine is the first-choice drug, to be given simultaneously with the above general emergency measures, at the first suspicion of an anaphylactic reaction.
Intramuscular (1 : 1000 concentration)
==Adult: 0.3-0.5 mL every 5 minutes, more often as clinically indicated, titrated to effects
==Pediatric: 0.01 mL/kg, every 5 minutes as necessary, titrated to effects
Alternatively, epinephrine (EpiPen, 0.3 mL; or EpiPen Jr, 0.15 mL) can be administered into anterolateral thigh.
Removal of clothing is unnecessary.
Intravenous (1 : 100,000 concentration; 0.1 mL of 1 : 1000 epinephrine in 10 mL of NS)
Continuous hemodynamic monitoring required 10 mL of 1 : 100,000 during 10 minutes, titrated to effects; repeat as necessary
Antihistamines 效果比較慢.. 屬於輔助用藥. 所有病患都建議使用. 可同時給予 H1 & H2 blocker.
Diphenhydramine: intravenous (intramuscular acceptable)
==Adult: 50 mg, up to 400 mg/24 hr, titrated to effects
==Pediatric: 1 mg/kg, up to 300 mg/24 hr, titrated to effects
Ranitidine: intravenous
==Adult: 50 mg IV (150 mg oral)
==Pediatric: 1 mg/kg IV or oral
Aerosolized beta-agonists
==Adult
==Albuterol: 2.5 mg, diluted to 3 mL of NS; may be given continuously
==Levalbuterol: 0.625-1.25 mg, diluted to 3 mL of NS; may be given continuously
==Ipratropium: 0.5 mg in 3 mL of NS; repeat as necessary
==Pediatric
==Albuterol: 2.5 mg, diluted to 3 mL of NS; may be given continuously
==Levalbuterol: 0.31-0.625 mg, diluted to 3 mL of NS; may be given continuously
==Ipratropium: 0.25 mg in 3 mL of NS; repeat as necessary
Methylprednisolone
==Adult: 125-250 mg IV
==Pediatric: 1-2 mg/kg IV
Special Situations
Refractory Hypotension
Consider continuous epinephrine drips
Dilute 1 mg (1 mL 1 : 1000) in 250 mL D5W to yield a concentration of 4 μg/mL
Infuse this diluted solution at 1 to 4 μg/min, up to 10 μg/min, titrated to effects
Glucagon: 1-5 mg IV during 5 minutes, followed by 5-15 μg/min continuous infusion
Consider vasopressors:
Dopamine, 5-20 μg/kg/min continuous infusion and/or
dobutamine 5-20 μg/kg/min continuous infusion, titrated to effects
Norepinephrine: 8-12 μg/min (2-3 mL/min; 4 mg added to 1000 mL of D5W provides a concentration of 4 μg/mL), titrated to effects
Phenylephrine, 40-180 μg/min, titrated to effects
Vasopressin, 2-4 IU/hr, titrated to effects
Patients Receiving Beta-Blockade
Glucagon: 1-5 mg IV during 5 minutes, followed by 5-15 μg/min
continuous infusion
Transcutaneous pacing for bradycardia
Atropine for bradycardia
Adult: 0.3-0.5 mg IV or subcutaneous, to a maximum of 3 mg
Pediatric: 0.02 mg/kg IV or subcutaneous, to a maximum of 2 mg
==END
2018-10-11 from uptodate
組織胺第一型拮抗劑(第一型抗組織胺) H1B. 需 30-40 分鐘出現效果(例如CETIRIZINE或diphenhydramine). 無法立即改善症狀, 可止癢及緩解蕁麻疹. 對於上呼吸道或下呼吸道阻塞無效, 對低血壓或休克也無效.
目前僅有第一代 H1B 有注射劑型. 但靜脈快速注射抗組織胺反而可能引起低血壓.
成人可以給 vena 25-50 mg.五分鐘滴完. 24 小時內最大劑量可以給 400 mg.
H1B 無法緩解上下呼吸道阻塞, 低血壓或休克. 在常規劑量無法抑制肥大細胞及嗜鹼性球釋放出媒介物,
H1 antihistamines — Epinephrine is first-line treatment for anaphylaxis, and there is no known equivalent substitute. H1 antihistamines relieve itching and urticaria, and their use in anaphylaxis is extrapolated from the studies of urticaria. A systematic review of the literature failed to retrieve any randomized-controlled trials that support the use of H1 antihistamines in anaphylaxis [11]. Despite this, H1 antihistamines are the most commonly administered medications in the treatment of anaphylaxis, which suggests over-reliance on these agents [72-75].
H1 antihistamines relieve itch and hives. These medications do not relieve upper or lower airway obstruction, hypotension or shock, and in standard doses, do not inhibit mediator release from mast cells and basophils. It is probable that the improvement in noncutaneous symptoms that is sometimes attributed to antihistamine treatment occurs instead because of endogenous production of epinephrine and other compensatory mediators, including other catecholamines, angiotensin II, and endothelin I [34]. In addition, the onset of action of antihistamines, such as cetirizine or diphenhydramine, takes 30 to 40 minutes and is too slow to provide any immediate benefit [76]. Only first-generation H1 antihistamines are available in parenteral formulations, and rapid IV administration may increase hypotension [77].
●For adults, diphenhydramine 25 to 50 mg can be administered IV over five minutes, which may be repeated up to a maximum daily dose of 400 mg per 24 hours.
●For children weighing less than 50 kg, diphenhydramine 1 mg/kg (maximum 50 mg) can be administered IV over five minutes, which may be repeated up to a maximum daily dose of 5 mg/kg or 200 mg per 24 hours.
For oral treatment, second-generation H1 antihistamines (eg, cetirizine) offer certain advantages over first-generation agents (eg, diphenhydramine, chlorpheniramine, hydroxyzine, and promethazine). Second-generation H1 antihistamines are less likely to impair cognition or psychomotor performance (eg, the ability to drive safely) or to cause sedation [11,15,78]. Orally administered cetirizine acts within 30 to 40 minutes and lasts for 24 hours. However, second-generation H1 antihistamines are not available in parenteral formulations.
同時給 H1 和 H2 抗組織胺對於舒緩麻疹有額外效果.
H2 antihistamines — An H2 antihistamine given with an H1 antihistamine may provide some additional relief of hives.
Although H2 antihistamines are sometimes administered in anaphylaxis treatment, H2 antihistamines do not relieve upper or lower airway obstruction or shock. Systematic reviews have not identified any randomized-controlled trials that support the use of these agents in anaphylaxis or urticaria .
If used, ranitidine (50 mg in adults) (12.5 to 50 mg [1 mg/kg] in children) may be diluted in 5 percent dextrose to a total volume of 20 mL and injected IV over five minutes.
類固醇劑量. methylprednisolone 每天每公斤 1-2 mgX 1-2 天.
Glucocorticoids — Glucocorticoids are commonly given in the treatment of anaphylaxis, although there is little evidence of clear benefit. The onset of action of glucocorticoids takes several hours. Therefore, these medications do not relieve the initial symptoms and signs of anaphylaxis. The rationale for giving them, theoretically, is to prevent the biphasic or protracted reactions that occur in some cases of anaphylaxis. However, a review of 31 publications, as well as a study of emergency department patients with allergic reactions or anaphylaxis, failed to find a decrease in return emergency department visits or biphasic reactions among patients treated with glucocorticoids [82,83]. In addition, more general systematic reviews of the literature have failed to retrieve any randomized-controlled trials in anaphylaxis that confirmed the effectiveness of glucocorticoids.
In the absence of conclusive data or consensus, our approach is not to administer glucocorticoids routinely to patients who respond well to epinephrine and other measures and in whom discharge is anticipated. On the other hand, there appears to be no evidence that glucocorticoids are harmful in patients with anaphylaxis, and they may well be beneficial for patients with severe symptoms requiring hospitalization or for those with known asthma and significant bronchospasm that persists after other anaphylaxis symptoms and signs have abated.
If given, a dose of methylprednisolone of 1 to 2 mg/kg/day for one to two days is sufficient. Glucocorticoids can be stopped after that without a taper.
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底下是舊的資料
anaphylaxis 過敏性休克 全身性過敏反應 (from Rosen 5th edition p 1619) 寫於 2011年11月12日 22:42
anaphylaxis rosen p 1619
ana=against
phylax=guard or protect
定義：在先前已經有暴露於過敏原的病患，發生全身性過敏反應，可以有很多種不同臨床症狀
definition: severe systemic allergic reaction in a previously sensitiazed patient, a syndrome associated with variable clinical features.
和一般過敏反應作區分的主要特徵：急性呼吸困難與休克（低血壓、血管衰竭）
the distinguishing features are acute respiratory difficulty and vascular collapse, within seconds to minutes after exposure to the offending agent.
其他症狀包括：
PRUTIRIC ERYTHEMATOUS RASH 搔癢性紅疹
CONJUNCTIVITIS 結膜炎
URTICARIA 蕁麻疹
ANGIOEDEMA 血管性浮腫
LARYNGEAL EDEMA 喉頭水腫
RHINITIS 流鼻水
NAUSEA/VOMITING 噁心 嘔吐
ABDOMINAL PAIN 腹痛
PALPITATION 心悸
LIGHTHEADEDNESS 頭重腳輕
SYNCOPE 暈厥
治療：P 1632
1. EPINEPHRINE：第一線藥物（最重要的藥物）
皮下注射：用於血壓正常症狀輕微的病患（有呼吸道黏膜腫脹但血壓還好）
肌肉注射：如果全身皮膚蕁麻疹很嚴重的病患不適合打皮下，此時應打肌肉
使用方式, 1支1mg的腎上腺素＝1CC，每公斤打0.01CC。50公斤重成人一次給半支。最大劑量半支 0.5CC。
應將總量的0.1～0.2CC打入接觸過敏原的部位（例如被蜜蜂螫傷處、打藥物造成過敏處）
原文：A fraction of the total dosage (0.1 to 0.2 mL) should be administered at the site of antigenic exposure if accessible (such as a bee sting or antigen injection in an extremity)
靜脈注射：用於嚴重呼吸道阻塞、急性呼吸衰竭、休克（收縮壓小於80mmHg)且沒有VT的病患。
靜脈注射可能導致：SVT、VT、心肌缺血、STUNNED HEART SYNDROME
避免不良反應的措施：稀釋+緩慢給藥
1支＝1mg EPINEPHRINE 稀釋一百倍，抽10CC靜脈滴注 10 分鐘。
如果單次給予沒有效果，需考慮連續靜脈滴注
1支＝1mg EPINEPHRINE泡D5W 250CC （每CC＝4ug)，每小時 15～60CC（用PUMP給藥）
嬰幼兒給的劑量 0.1 ug/kg/min(每小時每公斤 6 ug)，最大給到 1.5 ug/kg/min （每小時每公斤 90 ug）
如果無法建立靜脈管路，可考慮從舌下注射、骨內注射、經氣管蒸汽吸入。這些途徑的藥物劑量與靜脈注射相同（跟ACLS教的不一樣喔）
2. 氣管擴張劑
3. 抗組織胺：所有病患都應該使用（雖然在嚴重過敏反應的角色比較有限）
vena(H1 BLOCKER) 25-50mg q4h~q6h (台灣通常一支30mg)
兒科劑量 vena 5 mg/kg/day 分次給予 （10公斤兒童一天給50mg = 1.6CC ==> 0.4cc q6h)
可同時給予H1和H2阻斷劑，持續有症狀的病患應考慮給予cimitidine
cimetidine 300mg iv stat , then 300mg po q6h x 2 days
4. 類固醇：作用時間要4-6小時，比較慢，但可以持續作用比較久
LOADING DOSE：solu-cortef 250mg~1000mg iv stat 或 solu-medrol 125~500mg iv stat
然後給予口服PREDNISOLONE 7-10天
Glucocorticoids 類固醇屬於二線用藥. 不可取代腎上腺素的使用.
Glucocorticoids switch off transcription of a multitude of activated genes that encode proinflammatory proteins. Extrapolating from their use in acute asthma, the onset of action of systemic glucocorticoids takes several hours. Although they potentially relieve protracted anaphylaxis symptoms and prevent biphasic anaphylaxis, these effects have never been proven (Table 8). A Cochrane systematic review failed to identify any evidence from randomized, controlled trials to confirm the effectiveness of glucocorticoids in the treatment of anaphylaxis, and raised concerns that they are often inappropriately used as first-line medications in place of epinephrine.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3500036/
5. 昇壓劑：
CVP 小於 12mmHg 時要灌水（也可以給膠體溶液，例如 5％ ALBUMIN）+ DOPAMINE 5 ug/kg/min
CVP 大於 12mmHg 時要給予DOPAMINE。
如果合併肺高壓，要給予過渡換氣、高濃度氧氣、大劑量類固醇
如果所有治療都沒效果，可以給NOREPINEPHRINE、METARAMINOL
6. glucagon 昇糖劑（我們醫院沒有進）
服用BETA阻斷劑的病患可考慮使用
傳統治療無效的病患也可以考慮使用
成人 1mg iv/im/sc 之後連續靜脈注射 1-5mg/hr
小兒 0.5mg iv/im/sc
副作用：噁心嘔吐、低血鉀、高血糖
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