Insect sting anaphylaxis; prospective evaluation of treatment with intravenous adrenaline and volume resuscitation.
OBJECTIVE
To assess a protocol for treatment of sting anaphylaxis.


METHODS
Prospective assessment of treatment with oxygen, intravenous infusion of adrenaline (epinephrine), and volume resuscitation with normal saline.


METHODS
Sub-study of a venom immunotherapy trial.


METHODS
21 otherwise healthy adults with systemic allergic reactions to diagnostic sting challenge.


METHODS
Response to treatment, total adrenaline dose and infusion duration, recurrence of symptoms after stopping the infusion, and additional volume resuscitation.


RESULTS
19 participants required intervention according to the protocol. All received adrenaline, and five received volume resuscitation. In nine cases, physical signs of anaphylaxis recurred after initial attempts at stopping adrenaline but resolved after recommencing the infusion. The median total dose and infusion duration were 590 micro g and 115 minutes respectively, but were significantly higher for eight patients who had hypotensive reactions (762 micro g and 169 minutes respectively). Hypotension was always accompanied by a relative bradycardia, which was severe and treated with atropine in two patients. Widespread T wave inversion occurred, before starting treatment with adrenaline, in one person with an otherwise mild reaction. All patients fully recovered and were fit for same day discharge, apart from the person with ECG changes who was observed overnight and discharged the following day.


CONCLUSIONS
Carefully titrated intravenous adrenaline combined with volume resuscitation is an effective strategy for treating sting anaphylaxis, however severe bradycardia may benefit from additional treatment with atropine. Cardiac effects of anaphylaxis, perhaps including neurocardiogenic mechanisms, may be an important factor in some lethal reactions.
Department of Emergency Medicine, Royal Hobart Hospital, Hobart, Australia. simon.brown@health.wa.gov.au <simon.brown@health.wa.gov.au>
S G A
SG
Brown
K E
KE
Blackman
V
V
Stenlake
R J
RJ
Heddle
D000328:Adult; D000707:Anaphylaxis / Q000188:drug therapy* / Q000209:etiology; D001794:Blood Pressure / Q000502:physiology; D001919:Bradycardia / Q000188:drug therapy / Q000209:etiology; D004334:Drug Administration Schedule; D004837:Epinephrine / Q000008:administration & dosage*; D006801:Humans; D007022:Hypotension / Q000188:drug therapy / Q000209:etiology; D007262:Infusions, Intravenous; D007299:Insect Bites and Stings / Q000150:complications*; D010102:Oxygen Inhalation Therapy / Q000379:methods; D011446:Prospective Studies; D012008:Recurrence; D012151:Resuscitation / Q000379:methods*; D016896:Treatment Outcome; D014662:Vasoconstrictor Agents / Q000008:administration & dosage*
D014662:Vasoconstrictor Agents; D004837:Epinephrine