Anaphylaxis in Anaphylaxis in the Radiology the Radiology DepartmentDepartment

Anita Pozgay, MD, FRCPC Emergency Anita Pozgay, MD, FRCPC Emergency Medicine,Medicine,

Dip. Sport Med & Tropical Med.Dip. Sport Med & Tropical Med.

Case OneCase One

A 7 year old comes in to the ED after A 7 year old comes in to the ED after an possible exposure to peanut butteran possible exposure to peanut butter

He has a severe nut allergy for which He has a severe nut allergy for which he was prescribed an EpiPenhe was prescribed an EpiPen

He was recently admitted to PICU for a He was recently admitted to PICU for a severe asthma attack but was not severe asthma attack but was not intubatedintubated

Mom gave him some oral Benadryl and Mom gave him some oral Benadryl and he is no longer itchy but still has lip he is no longer itchy but still has lip swellingswelling

Case One continuedCase One continued

He is sent for a CXR due to He is sent for a CXR due to decreased air entry in the lower decreased air entry in the lower lobeslobes

While in radiology, he becomes While in radiology, he becomes acutely SOB and his lip becomes acutely SOB and his lip becomes more swollenmore swollen

What do you do now?What do you do now?

Case TwoCase Two

A 45 y o woman involved in a MVC A 45 y o woman involved in a MVC needs a CT abdo after she is needs a CT abdo after she is stabilized in the EDstabilized in the ED

She received 2 L NS for a hypotensive She received 2 L NS for a hypotensive episode and her BP is now 120/70episode and her BP is now 120/70

She has a positive FAST U/SShe has a positive FAST U/S Although her CXR is normal she has Although her CXR is normal she has

palpable lower rib fractures & a palpable lower rib fractures & a distended abdomendistended abdomen

Case Two continuedCase Two continued

She is given both oral and IV She is given both oral and IV contrast for her CTcontrast for her CT

She becomes hypotensive again!She becomes hypotensive again! What do you do now?What do you do now? There is no rashThere is no rash

Case ThreeCase Three

A 67 y o man is stung by an insect A 67 y o man is stung by an insect while gardeningwhile gardening

He developed pruritus, dizziness, He developed pruritus, dizziness, and SOB 20 min later so he called and SOB 20 min later so he called 911911

He self-treated with Benadryl po and He self-treated with Benadryl po and was given another 50 mg IV by EMS was given another 50 mg IV by EMS due to persistent sx and rashdue to persistent sx and rash

He is now asymptomatic and He is now asymptomatic and refusing transport to hospitalrefusing transport to hospital

Case Three: Do you Case Three: Do you transport?transport?

EMS convinced him to get “checked EMS convinced him to get “checked out” in the hospitalout” in the hospital

On arrival, he becomes hypotensive, On arrival, he becomes hypotensive, and his hives reappeared, along with and his hives reappeared, along with facial edemafacial edema

An ECG shows T wave inversion in An ECG shows T wave inversion in his lateral leadshis lateral leads

PHx: MI, HTN, IV contrast allergyPHx: MI, HTN, IV contrast allergy Meds: ASA, metoprolol, lisinoprilMeds: ASA, metoprolol, lisinopril

Management Questions?Management Questions?

What is the first line of therapy?What is the first line of therapy? When do you give epi? Type? Route?When do you give epi? Type? Route? Do all patients need Epinephrine? Do all patients need Epinephrine?

Corticosteroids?Corticosteroids? What is the role of combined H1 & What is the role of combined H1 &

H2 blockers?H2 blockers? Who needs to be monitored? Who needs to be monitored?

Referred?Referred? Who needs an EpiPen?Who needs an EpiPen?

EpidemiologyEpidemiology

Likely under reported due to lack of Likely under reported due to lack of recognition or self treatment in the recognition or self treatment in the fieldfield

in Ontario: 4 cases/ 1 millionin Ontario: 4 cases/ 1 million in Germany: 10 cases/100 000in Germany: 10 cases/100 000 in Minnesota, U.S.A.: 17/19,122 visitsin Minnesota, U.S.A.: 17/19,122 visits in Brisbane, Australia: 1/440 visitsin Brisbane, Australia: 1/440 visits

Common Causative Common Causative AgentsAgents

DrugsDrugs: Antibiotics, ASA, NSAIDS, : Antibiotics, ASA, NSAIDS, sulfa, opioids, IV contrast dyesulfa, opioids, IV contrast dye

FoodsFoods:: Peanuts, Seafood, Eggs, Peanuts, Seafood, Eggs, milkmilk

Latex glovesLatex gloves Insect StingsInsect Stings Physical Factors: Exercise (FDEIA), Physical Factors: Exercise (FDEIA),

Cold/HeatCold/Heat

DefinitionsDefinitions

AnaphylaxisAnaphylaxis: “against protection”, a : “against protection”, a severe severe systemicsystemic allergic reaction in a allergic reaction in a previously sensitized person; must previously sensitized person; must include respiratory difficulty or include respiratory difficulty or vascular collapsevascular collapse

* * hives/angioedema NOT universally present!hives/angioedema NOT universally present!

Allergic reactionsAllergic reactions: : localizedlocalized urticaria, angioedema, contact urticaria, angioedema, contact dermatitis, rhinoconjunctivitisdermatitis, rhinoconjunctivitis

PathophysiologyPathophysiology

Sensitization occurs when IgE Sensitization occurs when IgE adheres to the mast celladheres to the mast cell

Ag (allergen)Ag (allergen)

IgE specific IgE specific

Degranulation of mast cellDegranulation of mast cell

mediatorsmediators

Anaphylactic vs. Anaphylactic vs. AnaphylactoidAnaphylactoid

Anaphylactoid has the same clinical Anaphylactoid has the same clinical features as anaphylaxis but is not features as anaphylaxis but is not IgE mediated IgE mediated

Instead it is due to direct mast cell Instead it is due to direct mast cell degranulation and thus, does not degranulation and thus, does not require prior sensitizationrequire prior sensitization

Clinical FeaturesClinical Features

CAPILLARY LEAKCAPILLARY LEAK urticariaurticaria angioedemaangioedema laryngeal edemalaryngeal edema hypotension/syncopehypotension/syncope

SMOOTH MUSCLE SMOOTH MUSCLE CONTRACTIONCONTRACTION

abdominal crampsabdominal cramps nauseanausea rhinitisrhinitis conjunctivitisconjunctivitis

MUCOSAL SECRETIONSMUCOSAL SECRETIONS bronchospasm bronchospasm diarrhoeadiarrhoea vomitingvomiting

Urticaria versus Urticaria versus AngioedemaAngioedema

Both characterized by transient, Both characterized by transient, pruritic, red wheals on raised pruritic, red wheals on raised serpiginous bordersserpiginous borders

urticaria due to edema of dermisurticaria due to edema of dermis angioedema due to edema of angioedema due to edema of

subcutaneous tissuessubcutaneous tissues

DDx: AnaphylaxisDDx: Anaphylaxis MI/arrhythmia/cardiogenic shockMI/arrhythmia/cardiogenic shock Airway obstruction due to other Airway obstruction due to other

causes: FB aspiration, asthma, causes: FB aspiration, asthma, COPD, epiglottitis, peri-tonsillar COPD, epiglottitis, peri-tonsillar abscess, etc.abscess, etc.

Flushing syndromes (eg: carcinoid)Flushing syndromes (eg: carcinoid) Vasovagal syncopeVasovagal syncope Panic attackPanic attack Scombroid poisoningScombroid poisoning Hereditary angioedemaHereditary angioedema

Management Questions?Management Questions?

What is the first line of therapy?What is the first line of therapy? When do you give IV vs IM epi?When do you give IV vs IM epi? Do all patients need Epinephrine; Do all patients need Epinephrine;

corticosteroids?corticosteroids? What is the role of combined H1 & What is the role of combined H1 &

H2 blockers?H2 blockers? Who needs to be monitored? Who needs to be monitored?

Referred?Referred? Who needs an EpiPen?Who needs an EpiPen?

Key Management of Key Management of AnaphylaxisAnaphylaxis

11stst line of therapy: line of therapy:

AWARENESSAWARENESS RECOGNITIONRECOGNITION TREAT QUICKLYTREAT QUICKLY CALL FOR BACK-UP!CALL FOR BACK-UP!

Anaphylaxis Algorithm

Anaphylaxis:(Hypotension with/without respiratory obstruction)Eg: SBP<90 +/ - stridor, tongue/ laryngeal swelling

• 0.1 mg epinephrine in 10 ml NS IV over 10 minutes! (Dilute 0.1 ml of 1:1,000 f rom 1mg/ ml amp in 10 ml NS or 1 ml of 1:10,000 f rom 1mg/ 10 ml in 10 ml NS & run @ 1 mcg/ min; total 10 mcg)

• Benadryl 50 mg IV/PO &• Ranitidine 50 mg IV or 150 mg PO &• Prednisone 50 mg PO (or Solumedrol 125 mg IV)• +/- Ventolin 2cc nebulized q 5 min X 3 prn

Systemic Allergic Reaction:(angioedema or bronchospasm)

Simple Allergic Reaction:(urticaria, GI upset, contact dermatitis)

0.3 mg (0.3 ml) 1: 1,000 epinephrine IM* (1mg/ml amp)

Cardiac Monitor + 1 L NS bolus

Repeat 1L NS bolus, if no response

Repeat IM epinephrine & add ventolin 2 cc via neb

ABCs

Least severeMost severe

All three groups of patients receive the following:

Hypotension persists No or inadequate response * never use SC due to inconsistent absorption•I n pts on Bblockersbeware of poor response to epi; use Glucagon 1 mg IV/ IM instead.CALL FOR BACK-UP!

Anita Pozgay, MD.

Management: Adult Epi Management: Adult Epi dosingdosing

Epinephrine:Epinephrine:

0.3 mg (0.3 ml) 1:1000 0.3 mg (0.3 ml) 1:1000 solution IMsolution IM

(NOT SC or IV)(NOT SC or IV)

may repeat in 5 min X 1may repeat in 5 min X 1

(empirical only but safe)(empirical only but safe)

EPI cautions: Co-EPI cautions: Co-morbiditiesmorbidities

Thyroid diseaseThyroid disease Cocaine addictsCocaine addicts CAD on BBlockers, ACEiCAD on BBlockers, ACEi Depression using MAOIs or Depression using MAOIs or

TCAsTCAs

Mechanisms of Mechanisms of EpinephrineEpinephrine

Alpha agonist effects increase Alpha agonist effects increase peripheral resistance, BP, reduce peripheral resistance, BP, reduce vascular leakagevascular leakage

Beta agonist effects cause Beta agonist effects cause bronchodilation, positive cardiac bronchodilation, positive cardiac inotropy/chronotropy (caution in inotropy/chronotropy (caution in CAD pts!)CAD pts!)

Dangers of Epinephrine Dangers of Epinephrine IVIV

Only use IV Epi if patient has refractory Only use IV Epi if patient has refractory shock not responding to fluid bolus firstshock not responding to fluid bolus first

dose 0.1 mg (10 ml) 1:100,000 dose 0.1 mg (10 ml) 1:100,000 dilution over 10 minutesdilution over 10 minutes

must be on cardiac monitormust be on cardiac monitor caution in elderly or those with CADcaution in elderly or those with CAD may cause supraventricular/ventricular may cause supraventricular/ventricular

dysrhythmias!dysrhythmias!

ManagementManagementDo all patients need Epi?Do all patients need Epi?

Epinephrine reverses mediator Epinephrine reverses mediator release while antihistamines (H1) do release while antihistamines (H1) do notnot

Epinephrine should be used for all Epinephrine should be used for all systemic signs of allergy: airway systemic signs of allergy: airway edema (includes tongue/lips), SOB, edema (includes tongue/lips), SOB, cyanosis, hypotensioncyanosis, hypotension

Grading of AnaphylaxisGrading of AnaphylaxisGradGrad

eeSkinSkin GI tractGI tract RespResp CVCV NeurNeur

oo

11 Local Local pruritus, pruritus, hives, mild hives, mild lip swellinglip swelling

Oral Oral “tingling”, “tingling”, prurituspruritus

22 Generalized Generalized pruritus, pruritus, hives, hives, flushing, flushing, angioedemaangioedema

Above plus Above plus nausea +/- nausea +/- emesisemesis

Nasal Nasal congestion/congestion/

sneezingsneezing

Activity Activity changechange

33 Any of aboveAny of above Any of Any of above + above + repetitive repetitive vomitingvomiting

RhinorrheaRhinorrhea, , sensation sensation of throat of throat tightnesstightness

TachyTachy

( > 15 ( > 15 bpm)bpm)

Above Above plus plus anxietyanxiety

44 Any of aboveAny of above Any of Any of above + above + diarrheadiarrhea

HoarsenesHoarsenesss

dysphagiadysphagia, SOB, , SOB, cyanosiscyanosis

Above + Above + arrhythmiarrhythmia +/- dec a +/- dec BPBP

dizzinessdizziness

Feeling Feeling of of impendinimpending doomg doom

55 Any of aboveAny of above Any above Any above + stool + stool incont.incont.

Any above Any above + + resp resp arrestarrest

Brady +/- Brady +/- card card arrestarrest

LOCLOC

Management: Do all Management: Do all patients need patients need

Corticosteroids?Corticosteroids? Corticosteroids take 4-6 hours to workCorticosteroids take 4-6 hours to work theoretically blunt the multi-phasic theoretically blunt the multi-phasic

reaction of anaphylaxisreaction of anaphylaxis the quicker the onset of anaphylaxis the the quicker the onset of anaphylaxis the

worse the reaction/quicker resolution worse the reaction/quicker resolution less likely to relapseless likely to relapse

Caution in IV steroids esp if given in Caution in IV steroids esp if given in bolus doses; case reports of anaphylaxis!bolus doses; case reports of anaphylaxis!

Oral form preferred if possibleOral form preferred if possible

Histamine ClassesHistamine Classes

H1 receptorH1 receptor: stimulates bronchial, : stimulates bronchial, intestinal, smooth muscle contraction, intestinal, smooth muscle contraction, vascular permeability, coronary artery vascular permeability, coronary artery spasmspasm

H2 receptorH2 receptor: increase rate & force of : increase rate & force of ventricular & atrial contraction, gastric ventricular & atrial contraction, gastric acid secretion, airway secretions, acid secretion, airway secretions, vascular permeability, bronchodilation, vascular permeability, bronchodilation, & inhibition of histamine release& inhibition of histamine release

Management: What is Management: What is the role of combined H1 the role of combined H1

& H2 Antagonists?& H2 Antagonists? RCT, N=91 w/ allergic syndromesRCT, N=91 w/ allergic syndromes 50 mg Benadryl (H1) & saline vs. 50 mg 50 mg Benadryl (H1) & saline vs. 50 mg

Benadryl & 50 mg Ranitidine (H2) IVBenadryl & 50 mg Ranitidine (H2) IV Endpoints of resolution of urticaria, Endpoints of resolution of urticaria,

angioedema, or erythemaangioedema, or erythema also measured subjective improvement & also measured subjective improvement &

vitals vitals

Lin et al., Lin et al., Improved outcomes in patients with acute allergic syndromes who Improved outcomes in patients with acute allergic syndromes who

areare tretreated with combined H1 & H2 antagonists,ated with combined H1 & H2 antagonists, Annals of Emergency Annals of Emergency Medicine 36(5) 2000.Medicine 36(5) 2000.

Histamines: ResultsHistamines: Results

Statistically significant diminution of Statistically significant diminution of angioedema and/or urticaria with angioedema and/or urticaria with addition of H2 blockeraddition of H2 blocker

study too small to determine if H2 study too small to determine if H2 blockers helpful in anaphylaxis blockers helpful in anaphylaxis (those with respiratory compromise (those with respiratory compromise &/or hypotension)&/or hypotension)

also significant decrease in HR in Rx also significant decrease in HR in Rx groupgroup

Back to Cases: Back to Cases: Management Case 1Management Case 1

Case One: Peanut allergy Case One: Peanut allergy in asthmaticin asthmatic

A 7 year old comes in to the ED after A 7 year old comes in to the ED after an possible exposure to peanut butteran possible exposure to peanut butter

He has a severe nut allergy for which He has a severe nut allergy for which he was prescribed an EpiPenhe was prescribed an EpiPen

He was recently admitted to PICU for a He was recently admitted to PICU for a severe asthma attack but was not severe asthma attack but was not intubatedintubated

Mom gave him some oral Benadryl and Mom gave him some oral Benadryl and he is no longer itchy but still has lip he is no longer itchy but still has lip swellingswelling

Case One continuedCase One continued

He is sent for a CXR due to He is sent for a CXR due to decreased air entry in the lower decreased air entry in the lower lobeslobes

While in radiology, he becomes While in radiology, he becomes acutely SOB and his lip becomes acutely SOB and his lip becomes more swollenmore swollen

What do you do now?What do you do now?

Case 1 ConclusionCase 1 Conclusion

He needs IM Epi!He needs IM Epi!

(He weighs 30 kg and thus 0.3 mg (He weighs 30 kg and thus 0.3 mg IM is fine.)IM is fine.)

O2, IV fluids, cardiac monitoringO2, IV fluids, cardiac monitoring Consider Ventolin neb (esp if Consider Ventolin neb (esp if

concurrent asthma)concurrent asthma)

Case Two : MVC Case Two : MVC ManagementManagement

A 45 y o woman involved in a MVC A 45 y o woman involved in a MVC needs a CT abdo after she is needs a CT abdo after she is stabilized in the EDstabilized in the ED

She received 2 L NS for a hypotensive She received 2 L NS for a hypotensive episode and her BP is now 120/70, HR episode and her BP is now 120/70, HR 100100

She has a positive FAST U/SShe has a positive FAST U/S Although her CXR is normal she has Although her CXR is normal she has

palpable lower rib fractures & a palpable lower rib fractures & a distended abdomendistended abdomen

Case Two continuedCase Two continued

She is given both oral and IV She is given both oral and IV contrast for her CTcontrast for her CT

She becomes hypotensive again!She becomes hypotensive again! What do you do now?What do you do now? There is no rashThere is no rash

Case 2: ConclusionCase 2: Conclusion Is she in hypovolemic shock or anaphylactic? Is she in hypovolemic shock or anaphylactic?

doesn’t matter b/c both require IV doesn’t matter b/c both require IV crystalloids!crystalloids!

There may be no rash initiallyThere may be no rash initially Look for airway compromise/swelling: Look for airway compromise/swelling:

intubate?intubate? IV contrast reactions are anaphylactoid and so IV contrast reactions are anaphylactoid and so

prior sensitization not necessary (thus may be prior sensitization not necessary (thus may be no prior hx of anaphylaxis)no prior hx of anaphylaxis)

If no response to fluids give IV epi 1If no response to fluids give IV epi 1st st via slow via slow infusion, except if pulseless then may give IV infusion, except if pulseless then may give IV bolus bolus

Anaphylaxis Algorithm

Anaphylaxis:(Hypotension with/without respiratory obstruction)Eg: SBP<90 +/ - stridor, tongue/ laryngeal swelling

• 0.1 mg epinephrine in 10 ml NS IV over 10 minutes! (Dilute 0.1 ml of 1:1,000 f rom 1mg/ ml amp in 10 ml NS or 1 ml of 1:10,000 f rom 1mg/ 10 ml in 10 ml NS & run @ 1 mcg/ min; total 10 mcg)

• Benadryl 50 mg IV/PO &• Ranitidine 50 mg IV or 150 mg PO &• Prednisone 50 mg PO (or Solumedrol 125 mg IV)• +/ - Ventolin 2cc nebulized q 5 min X 3 prn

Systemic Allergic Reaction:(angioedema or bronchospasm)

Simple Allergic Reaction:(urticaria, GI upset, contact dermatitis)

0.3 mg (0.3 ml) 1: 1,000 epinephrine IM* (1mg/ml amp)

Cardiac Monitor + 1 L NS bolus

Repeat 1L NS bolus, if no response

Repeat IM epinephrine & add ventolin 2 cc via neb

ABCs

Least severeMost severe

All three groups of patients receive the f ollowing:

Hypotension persists No or inadequate response * never use SC due to inconsistent absorption•I n pts on Bblockersbeware of poor response to epi; use Glucagon 1 mg IV/ IM instead.CALL FOR BACK-UP!

Anita Pozgay, MD.

Case 3: Gardener Case 3: Gardener ManagementManagement

Case ThreeCase Three

A 67 y o man is stung by an insect A 67 y o man is stung by an insect while gardeningwhile gardening

He developed pruritus, dizziness, He developed pruritus, dizziness, and SOB 20 min later so he called and SOB 20 min later so he called 911911

He self-treated with Benadryl po and He self-treated with Benadryl po and was given another 50 mg IV by EMS was given another 50 mg IV by EMS due to persistent sx and rashdue to persistent sx and rash

He is now asymptomatic and He is now asymptomatic and refusing transport to hospitalrefusing transport to hospital

Case Three: Do you Case Three: Do you transport?transport?

EMS convinced him to get “checked EMS convinced him to get “checked out” in the hospitalout” in the hospital

On arrival, he becomes hypotensive, On arrival, he becomes hypotensive, and his hives reappeared, along with and his hives reappeared, along with facial edemafacial edema

An ECG shows T wave inversion in An ECG shows T wave inversion in his lateral leadshis lateral leads

PHx: MI, HTN, IV contrast allergyPHx: MI, HTN, IV contrast allergy Meds: ASA, metoprolol, lisinoprilMeds: ASA, metoprolol, lisinopril

Case 3 Management: Case 3 Management: Refractory AnaphylaxisRefractory Anaphylaxis

Biphasic (multi?) reactions can occur typically Biphasic (multi?) reactions can occur typically after 3-4 hours but as late as 72 hours later! after 3-4 hours but as late as 72 hours later!

Beware of the patient with increased age and Beware of the patient with increased age and co-morbidities (eg. CAD) b/c anaphylaxis can co-morbidities (eg. CAD) b/c anaphylaxis can cause cardiac ischemiacause cardiac ischemia

B-Blockers & ACEi blunt the catecholamine B-Blockers & ACEi blunt the catecholamine responseresponse

Management Refractory Management Refractory Anaphylaxis: GlucagonAnaphylaxis: Glucagon

Glucagon: increases Glucagon: increases inotropy/chronotropy & causes inotropy/chronotropy & causes smooth muscle relaxation smooth muscle relaxation independent of B receptorsindependent of B receptors

Dose: 1-5 mg in adults (0.5 - 1 mg in Dose: 1-5 mg in adults (0.5 - 1 mg in kids) kids) IV/IMIV/IM

Management: Management: Disposition & Follow-upDisposition & Follow-up

Inquire about possible antigen exposureInquire about possible antigen exposure Those with systemic reactions require a Those with systemic reactions require a

prescription for and instruction on how prescription for and instruction on how to use a EpiPen to use a EpiPen

A Medic Alert Bracelet is usefulA Medic Alert Bracelet is useful Follow-up with an allergist for skin Follow-up with an allergist for skin

testing should be arranged particularly testing should be arranged particularly if the allergen is unknownif the allergen is unknown

EpiPenEpiPen

SummarySummary

Acute anaphylaxis is often poorly Acute anaphylaxis is often poorly recognized & treated due to the protean recognized & treated due to the protean clinical features and variation in the speed clinical features and variation in the speed of onsetof onset

a trigger is often not founda trigger is often not found Pruritis is a universal feature and should Pruritis is a universal feature and should

differentiate anaphylaxis from asthmadifferentiate anaphylaxis from asthma Expedious treatment w/ epi is necessary & Expedious treatment w/ epi is necessary &

thus patient education on its use is thus patient education on its use is essentialessential

Anaphylaxis Algorithm

Anaphylaxis:(Hypotension with/without respiratory obstruction)Eg: SBP<90 +/ - stridor, tongue/ laryngeal swelling

• 0.1 mg epinephrine in 10 ml NS IV over 10 minutes! (Dilute 0.1 ml of 1:1,000 f rom 1mg/ ml amp in 10 ml NS or 1 ml of 1:10,000 f rom 1mg/ 10 ml in 10 ml NS & run @ 1 mcg/ min; total 10 mcg)

• Benadryl 50 mg IV/PO &• Ranitidine 50 mg IV or 150 mg PO &• Prednisone 50 mg PO (or Solumedrol 125 mg IV)• +/ - Ventolin 2cc nebulized q 5 min X 3 prn

Systemic Allergic Reaction:(angioedema or bronchospasm)

Simple Allergic Reaction:(urticaria, GI upset, contact dermatitis)

0.3 mg (0.3 ml) 1: 1,000 epinephrine IM* (1mg/ml amp)

Cardiac Monitor + 1 L NS bolus

Repeat 1L NS bolus, if no response

Repeat IM epinephrine & add ventolin 2 cc via neb

ABCs

Least severeMost severe

All three groups of patients receive the f ollowing:

Hypotension persists No or inadequate response * never use SC due to inconsistent absorption•I n pts on Bblockersbeware of poor response to epi; use Glucagon 1 mg IV/ IM instead.CALL FOR BACK-UP!

Anita Pozgay, MD.