 For the evening session is Dr. Harshita Sridhar, our head department of emergency medicine. She is going to speak on anaphylaxis, how to prepare ourselves to handle patients who come with anaphylaxis. Good evening everyone, I am Dr. Harshita. So today's session is held by Manipal groups talking about common emergencies. So I started off with a question to say, are we prepared to handle common emergencies? So I'm, I head the emergency department at Manipal Millers Road and today I want to talk about one part of that emergency, medical emergency that is anaphylaxis. And the question is, are we prepared to handle anaphylactic reactions? So what is anaphylaxis? So this is a severe allergic reaction. You know that it is a very rapid onset, it progresses fast. In many cases we have heard about death due to anaphylaxis and this requires an emergent diagnosis and treatment. So what kind of a response is this? It's a type 1 hypersensitivity reaction, it's an immune mediated reaction. As you can see in the image, the antigens, these are, could be any common harmless antigens that can activate the B-cells, releasing the immunoglobulin IgE. This goes and coats the mast cells and when the allergen is again exposed in the body, they bind these IgEs and releases the degranulation of the mast cells, releasing the histamines and the other mediators. These mediators increase the permeability of the vessels causing all the reactions that we see. And these reactions can anywhere be from mild to severe reactions. So I want to start with a case report. So there was a 40-year-old healthy woman, no apparent medical condition. She was admitted for an abdominal hysterectomy. She denied any drug allergies and passed adverse reactions to any anesthetic drugs. Her physical examination was normal, vitals were normal. She was taken up to the OT and 20 minutes after induction, she was given properful lidocaine fentanyl and rockuronium. She suddenly developed a hypotension response and a bronchospasm. She required ventilatory support, fluids, epinephrine and after 48 hours, she was extubated and then she was retaken to the OT. During the process, they had done a skin test and they found that she was probably allergic to fentanyl. So the whole purpose of telling you this case report is that we always plan something for our patients and we say, yeah, we're going to give this drug and this is how it's going to go and lead to. But suddenly they can be a U-turn, they could be another response or a reaction which we need to be aware and we need to know how to deal here. So taking this forward, what are the common causes of anaphylaxis? Food allergies are common, milk, soya, egg, fish allergies are common, insect bites. And medication, technically you name any medication, the person can be allergic, but common antibiotics are penicillin and betalactam groups, NSAIDs, aspirins are common medications that the patient can be allergic to, latex, exercises and a good chunk of it comes under the unknown causes or the idiopathic causes. So there was an Asian study which identified the etiology spread, 34% is food allergy but 37% were the unknown causes. Then you had 20% come because of the drugs, 7% came from exercise and 2% came from other rubber and insect bites and so on. So here is another case report of an unusual anaphylactic reaction, a 34-year-old man he presented to the emergency room with aortic area, hypotension and shortness of breath and all that he could say is he went in for a cold, I mean he went in for a shot and then after a hot shot he came out and the weather was extremely cold, he got exposed to a cold weather and then he comes to the emergency room in a crashing situation. So here this patient did not respond to two intramuscular adrenaline, then he required adrenaline infusion to get his hypotension settled, he was admitted in the ICU for some time, he was found to have a positive ice cube test and then this probably confirmed that exposure to cold caused the anaphylactic reaction. So again here I want to insist that things can present very unusual to us. So the common science and symptoms of anaphylaxis from conjunctival swelling to tearing of the eye, angioedema, lip swelling, tongue swelling which can present to us with significant airway compromises, heart situations where the patient can have high heart rate, low heart rate, hypotension, skin rashes which is commonly seen all the aortic area rashes that you are all aware. Pelvic pain to loss of bladder control to abdominal cramps, vomiting, shortness of red stridor, these are all the presentations of allergic reactions. So what is the clinical criteria for identifying or diagnosing anaphylaxis in your setup? So a patient comes with aortic area crash but also can have respiratory distress or hypotension or associated symptoms of other organ dysfunction. So aortic area with any of these can indicate anaphylaxis. Another way to look at it is you have four signs and any two present you can think of anaphylaxis that can be skin involvement, respiratory compromise, hypotension or persistent GI symptoms. So what is the treatment? Its emergencies always we talk about airway stabilization, breathing and circulation. So watch for the airway compromise, any striders, spot the patient on oxygen, ensure the patient's saturation is above 94%. And the drug of choice in anaphylaxis is adrenaline. So after adrenaline you have the other choices that's fluids, antihistamines, bronchodilators and hydrocortisone we will discuss that in the next slides. So adrenaline is as I said the drug of choice, why is it the natural antidote to an anaphylactic reaction in your body is to release the adrenaline. This helps to combat the reaction released you through all the histamine and other mediators that are causing the problem in your anaphylactic reaction. So we inject this adrenaline so that it assists the body's natural response. But unfortunately many observation studies have shown that we use adrenaline, we under use adrenaline and often dozed it suboptimally and when we discharge patients also we do not advise for the potential future use. Over here we are talking more about use of EpiPen but unfortunately we don't have that access at the moment but we should probably start talking about it and start utilizing adrenaline.