Critical Care Emergencies 27Anaphylaxis
6 These four lists may seem daunting, but aim to build up a picture of the
events as follows.
History:
(i) Any clues from relatives, passers-by or ambulance crew?
(ii) Witnessed fit, trauma, alcohol or drug ingestion?
(iii) Prior medical or surgical conditions?
(iv) Known drug therapy or abuse?
(v) Recent travel abroad?
7 Further examination:
(i) Search the clothing for a diabetic card, steroid card or outpatient
card.
(ii) Look particularly for signs of trauma, needle puncture marks, or
petechiae on the skin.
(iii) Repeat the vital signs, including the temperature.
(iv) Reassess the neurological state, including the level of
consciousness using the GCS score (see Table 1.1, p. 30), the
pupil responses, eye movements and fundi. Assess the muscle
power, tone and reflexes including the plantar responses. Exclude
any neck stiffness.
(v) Examine the front of the chest, feel the abdomen and examine the
back, inspect the perineum and perform a rectal examination.
8 Arrange:
(i) CXR and pelvic X-ray in trauma (see p. 221).
(ii) Head computed tomography (CT) scan with cervical spine if
intracranial pathology is suspected or cannot be excluded, which
is frequently the case.
9 Refer the patient to the medical (or surgical) team, or ICU if they are not
already involved, having stabilized the cardiorespiratory status, treated any
urgent conditions and built up a list of the likely causes of unconsciousness.
DIAGNOSIS
1 IgE-mediated allergic anaphylaxis is an immunological, multi-system
reaction that may rapidly follow drug ingestion, particularly parenteral
penicillin, a bee or wasp sting, or food such as nuts and seafood.
(i) Non-IgE-mediated, non-allergic anaphylaxis (previously termed
an anaphylactoid reaction) is a clinically identical reaction most
commonly seen following radio-contrast media or aspirin or
NSAID exposure, but which is not triggered by IgE antibodies.