Author: Gcplive
Source: Center for Drug Evaluation< /p>Severe allergic reactions are distributed in various clinical departments, and all patients who use drugs may have allergic reactions. Severe allergic reactions occur suddenly and progress rapidly. If they are not handled in time, they can easily lead to death and medical disputes. Referring to the domestic and foreign guidelines for the diagnosis and treatment of severe allergic reactions, the rescue procedures for severe allergic reactions are drawn for your reference.. 
I. Severe allergic reaction rescue procedure when severe allergic reaction occurs1. Cut off allergensThe most common drugs that cause severe allergic reactions are β-lactam antibiotics, traditional Chinese medicine injections and biological products. The route of administration was the highest incidence rate of intravenous administration, accounting for about 78.22%. In the event of anaphylactic shock, remove the allergen immediately. If the patient is taking intravenous medication, stop the infusion, replace the infusion set and tubing, do not pull out the needle, and keep the venous access. 2. Injection of epinephrineOnce a severe allergic reaction is diagnosed, epinephrine should be injected as soon as possible. 2.1 Intramuscular injectionThe best way to use epinephrine is intramuscular injection of the medial lateral thigh. Concentration: 1:1000 epinephrine injection (specification: 1ml:1mg); Dose: calculated at 0.01mg/kg, the maximum dose for adults is 0.5ml (0.5mg) , children do not exceed 0.3ml (0.3mg). Epinephrine can be repeated, but at least 5 minutes apart, until the patient’s condition stabilizes. Special reminder:Subcutaneous injection of epinephrine absorbs slowly, and it takes 6 to 15 minutes to take effect. Subcutaneous injection is not recommended by domestic and foreign guidelines, and it is hoped that this usage will never be seen again in clinical practice. 2.2 IntravenousIntravenous epinephrine should be administered if cardiac/respiratory arrest has occurred or is imminent. Concentration: 1:10000Epinephrine injection (0.1mg/ml); Preparation: take epinephrine injection with a specification of 1ml:1mg 1ml, diluted 10 times with 0.9% sodium chloride injection. Dosage: Inject 1:10000 epinephrine by intravenous injection of 5ml~10ml and slowly push it intravenously for at least 5 minutes. 2.3 Intravenous infusionAfter 2 to 3 injections of intravenous/intramuscular epinephrine, symptoms improved but not In complete remission, considerintravenous epinephrine. Concentration: 1:10 000～1:250000 (concentration 0.1~0.004mg/ml)Preparation: 1ml epinephrine injection (1ml: 1mg)+5% glucose solution in 250ml intravenous drip, the drip rate is 1~4ug/min. Special reminder:patients receiving intravenous epinephrine require full monitoring ECG, blood pressure, pulse oxygen, in case of hypertensive crisis and ventricular fibrillation. Even in CPR, high-dose epinephrine is no longer recommended because it is not good for long-term survival. 3. Fluid resuscitationPatients with unstable circulatory system need both epinephrine and fluid support. Because epinephrine is ineffective without circulating blood volume efficiently. Crystalline or colloidal solution can be used, usually 0.9% sodium chloride injection. The initial dose is 20ml/kg in 10 to 20 minutes. Can be reused if necessary. If the infusion volume exceeds 40ml/kg, vasopressor support such as dopamine or epinephrine should be considered. 4. Glucocorticoids and Antihistamines4.1 GlucocorticoidsEarly High-dose intravenous glucocorticoids, such as hydrocortisone (200-400 mg) or methylprednisolone (120-240 mg) intravenously, may reduce the risk of advanced respiratory disease. However, corticosteroids should not be used as first-line treatment for severe allergic reactions. The onset of hormones is not fast enough to fully demonstrate their ability to reduce the risk of late reactions. 4.2 AntihistaminesAntihistamines such as diphenhydramine and chlorpheniramine may be given intravenously or intramuscularly , to relieve skin-related symptoms. Special reminder:The commonly used antihistamine in China is promethazine. However, promethazine can cause children under 2 years of ageChildren under the age of 2 should be banned from respiratory depression or even death. Neither domestic or foreign guidelines recommend 10% calcium gluconate injection for the rescue of severe allergic reactions and cardiopulmonary resuscitation; only hyperkalemia and hypocalcemia Or calcium channel blocker poisoning, calcium treatment is effective, other cases without calcium treatment. 5. GlucagonSevere allergic disease is not effective for epinephrine-resistant patients, especially those In patients on beta-blockers, intravenous glucagon may be effective. 6. MonitoringSevere allergic reactions need to be observed after treatment improves, but there is no evidence to suggest how long. After the patient is out of danger after treatment, he should be monitored in the hospital for at least 12 hours, monitoring the patient’s heart, blood pressure, respiration, blood oxygen saturation and urine. quantity. Second, wrong cases of severe allergic reaction rescueError one: subcutaneous injection of epinephrine Patient, female, 52 years old. On February 27, 2015, due to elevated transaminase, he was prescribed magnesium isoglycyrrhizinate 150mg+10% glucose injection 500ml, intravenously. About 2 minutes after the infusion, the patient developed cyanotic lips, sigh-like breathing, cold limbs, and unpalpable carotid artery pulse. The drug was stopped immediately, chest compression, sputum suction, oxygen inhalation, Sodium Lactated Ringer’s Injection 500ml, intravenous drip; Epinephrine 1mg, subcutaneous injection. Eventually rescue failed and died. Mistake 2: Taking glucocorticoids as the first-choice drugPatient, female, 84 years old, diagnosed with “chronic gastritis, pulmonary Infect”. After admission, he was given comprehensive treatment such as acid-suppressing and stomach-protecting drugs, anti-infective drugs, cough-relieving and phlegm-relieving drugs, and rehydration support. On December 21, 2009, 500ml of low molecular weight dextran amino acid injection was intravenously infused. About 1 minute after the infusion, the patient suddenly experienced chest tightness, shortness of breath, cyanosis, difficulty breathing, and undetectable blood pressure. Immediately stop the drug, perform tracheal intubation, sputum suction, ventilator-assisted ventilation, inotrope, blood pressure, cardiac compression, intravenous dexamethasone 15mg anti-allergic treatment, a few minutes later die. Error three: IV or infusion of 10% calcium gluconate injectionPatient, female, 48 years old. Because the chest X-ray showed bronchial inflammation, cefoperazone/sulbactam sodium 3g+0.9% sodium chloride injection 250ml was given intravenously. About 10 minutes after the infusion, the patient developed dyspnea, cyanotic lips, unmeasured blood pressure, disappearance of pulse, and loss of consciousness. The drug was discontinued immediately, oxygen inhalation was given, epinephrine 1.5 mg intramuscularly, dexamethasone 10 mg slowly intravenously and 10% calcium gluconate plus 5% glucose Injection 250ml intravenous drip. In the end, the rescue failed.
Main references:
1.2019 Recommendations of the Guidelines for First Aid for Severe Anaphylaxis
2. Luo Jia; Wu Yi; Cao Lizhi; Yang Liping. A case of death from anaphylactic shock caused by Jing infusion of magnesium isoglycyrrhizinate[J].Chinese Medicine, 2015, 18(12): 2125
3. Xu Shuxia, Li Shuan’e. Comparison of clinical efficacy between methylprednisolone and dexamethasone in the treatment of anaphylactic shock [J]. Jilin Medicine, 2014, 35(32): 7138
4. Chen Zhihong, Chen Bing.A case of death from anaphylactic shock caused by low molecular weight dextran amino acids[J].Modern Medicine and Clinic, 2010, 25 (6 ): 472
5. Gao Ling, Yang Xiaoqing. Death from anaphylactic shock caused by intravenous infusion of cefoperazone/sulbactam sodium[J]. Journal of Reactions, 2008, 10(6): 445
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