1. Theme of practical lesson № 12: «Allergic rhinitis. Urticaria in children. Angioedema» - 2 h.

2. Background
Disease not always has the favorable forecast. Disease is characterized by presence of various
accompanying conditions and complications. Problem of treatment is widely discussed. Therapy of such
pathological condition includes a regimen, a diet, etiotropic, pathogenetic and symptomatic components.
It is important to carry out preventive maintenance of this disease in children age.
3. Purpose of the lesson
3.1. General purpose
Acquainted with the modern concepts of the etiopathogenesis, classification, clinical course and
additional methods of diagnosis of urticaria, angioedema, anaphylactic shock in children.
3.2. Educational goals
get acquainted with the works of the department staff on the problems of diagnosis and differentiated
therapy of atopic dermatitis, allergic dermatitis and hives in children. Have an idea of ecological,
technological and medical aspects of environmental protection to the human body. Know about the
deontological principles when dealing with a sick child and his parents.
3.3. Specific objective to know
1. Definition of AD, AR
2. Mortality and morbidity in children's blood pressure in the population.
3. Risk factors for the disease
4. Mechanisms of early and late allergic reactions constituting the pathogenesis of AD.
5. Modern classification of AD and AR.
6. Clinical disease
7. Age peculiarities of BP.
8. Hematological, immunological signs of the disease
9. Complex treatment.
3.4. On the basis of theoretical knowledge on the topic:
be able to:
1. Collect allergic history.
2. Find out the risk factors for AD.
3. Conduct the clinical examination of the patient.
4. Select the most informative methods to further investigation to determine the diagnosis and
differential diagnosis.
5. Evaluate the results of laboratory diagnostic methods.
6. Establish the diagnosis according to the classification.

4. Materials extracurricular self-study (interdisciplinary integration).

Discipline Know Be able to
1 2 3 4
Previous disciplines
1. Pat. Anatomy Morphologіcal changes Use knowledge of morphology for
of the skin diagnosis.

2. Pat. Physiology Pathogenesis of disease Use knowledge of pathogenesis for

the purpose of therapy.

3. Histology The building wall of the Use knowledge to explain the

skin in children of all clinical disease.
ages.

4. Microbiology The role of viruses and Verify the causative agent with
microorganisms in the additional methods.
occurrence of atopic
dermatitis, allergic
 rhinitis and hives in
children Possess the methods of inspection
5. Propadeutics Pediatrics. of the skin in children.Rate the
Anatomical and additional methods . Select the
physiological main pathological
characteristics of the symptoms(syndromes) lesions of
skin in children. the skin.
Next disciplines
2. 1. Hospital Pediatrics
Etio-pathogenesis, main Examine patients, prescribe
clinical forms, treatment, prevention, conduct
principles of treatment differential diagnosis with major
and prevention of atopic clinical forms.
dermatitis, allergic Conception of allergic disease’s
2. Hospital Therapy rhinitis, hives. gradual development (from atopic
dermatitis till bronchial asthma).
Atopic dermatitis. Examine, treat and prevent.
eczema, psoriasis in
adults
3. Interdisciplinary integration Groups of diseases Make differential diagnosis.
connected with skin Estimate severity of atopic
eruptions in dermatitis and square of the skin
children.(Children damage using SCORAD scale.
infectious diseases,
Quinke edema and
Utricaria)

5. Contents of theme.
"Urticaria" is the medical term for hives. Hives are raised areas of the skin that itch intensely and are
red with a pale center). Hives are a very common condition. About 20 percent of people have hives at
some time during their lives.
Hives develop when there is a reaction that activates immune cells in the skin called mast cells. When
activated, these cells release natural chemicals. One important chemical is histamine, which causes
itching, redness, and swelling of the skin in an area: a hive. In most cases, hives appear suddenly and
disappear within several hours.
Hives usually respond well to treatment, which includes medicines and avoiding whatever triggered the
hives.
More detailed information about hives is available by subscription.

HIVES SYMPTOMS
Skin appearance — Hives are raised areas that itch intensely and are sometimes red with a pale center.
In some cases, the raised areas enlarge and merge together. Itching is usually the most bothersome
symptom of hives, and it may be severe enough to interfere with work and sleep.
Severe pain, blood blister-like spots, and bruising of the skin are NOT typical of hives. Having hives
along with a fever and joint pains is also NOT typical. These symptoms suggest a different condition
called urticarial vasculitis, which requires a different treatment.
Angioedema — In up to one-half of people with hives, a condition called angioedema also develops.
Angioedema is similar to hives, but occurs in the deeper layers of skin. Symptoms of angioedema
include:
●Puffiness of the face, eyelids, ears, mouth, hands, feet, and genitalia
●Swelling that usually affects one side of the body or affects one side more than the other
●A sensation of fullness or discomfort in the area of the swelling
●Slight redness of the skin, although the skin may also be normal in color
Hives as part of a serious allergic reaction — Hives can also occur as part of a more serious allergic
reaction. You should see a doctor or nurse as soon as possible if you develop hives or angioedema
suddenly, along with other symptoms, such as:
●Trouble breathing
●Tightness in the throat
●Nausea or vomiting
●Cramping abdominal pain
●Passing out
TYPES OF HIVES
Hives are classified based upon how long you have the hives. Hives can be:
●Acute (brief)
●Chronic (long-standing)
●Physical (triggered by certain types of physical stimulation, such as heat, cold, or sun exposure)
Of course, when you first get hives, you cannot tell how long they will last, and so you cannot tell if you
have acute or chronic hives.
Although all types of hives look similar, they often have different triggers. Learning what triggers your
hives can help you to avoid the trigger.
Acute hives — Most cases of hives are acute and will not last beyond a few days to a week or two.
Triggers of acute hives can include the following:
●Infections – Infections can cause hives in some people. In fact, viral infections cause more than 80
percent of all cases of acute hives in children. A variety of viruses can cause hives (even routine cold
viruses). The hives seem to appear as the immune system begins to clear the infection, sometimes a
week or more after the illness begins. The hives usually persist for a week or two and then disappear.
●Drugs – Many types of drugs can trigger hives, including antibiotics and nonsteroidal anti-
inflammatory drugs (NSAIDs), such as aspirin, ibuprofen, or naproxen.
Painkillers (eg, codeine and morphine), muscle relaxants used in anesthesia, and intravenous (IV)
contrast dye used in imaging procedures can also trigger hives
●Insect stings – Stings from certain insects (bees, wasps, hornets, fire ants) can cause hives around the
area of the sting.
If you get hives all over your body after an insect sting, this may be a sign of a more serious reaction
called anaphylaxis. Anaphylaxis must be treated as soon as possible.
●Food allergies – Food allergy can cause acute hives in some people. Food-associated hives typically
appear within 30 minutes of eating the food. The foods most likely to cause hives in children include
milk, eggs, peanuts, other nuts, soy, and wheat. The foods most likely to cause hives in adults include
fish, shellfish, peanuts, and other nuts.
●Physical contact – Hives can occur after you touch certain substances if you are allergic to them. For
example, children who are allergic to dogs may get hives if a dog licks them. Other things that can cause
hives (if you are allergic) include plants, raw fruits and vegetables, and latex (found in balloons, latex
gloves, condoms, and other common items).
Chronic hives — Chronic hives occur daily or almost daily and last longer than six weeks, sometimes
for years. Chronic hives can be frustrating because they come and go and can interfere with sleep, work,
or school. Hives affect how you look and people may worry about being near you for fear that you have
a contagious infection.
However, it is important to remember that:
●Hives are not contagious
●Chronic hives are rarely permanent; almost 50 percent of people are hive-free within one year
●Chronic hives are rarely caused by allergies and are not life-threatening
●The bothersome symptoms of chronic hives are treatable in most people
In most cases of chronic hives, the cause is unknown. Researchers suspect that problems in the immune
system play a role.
Hives can be a sign of several other medical or autoimmune conditions, including thyroid or liver
diseases, chronic infections, or lupus. Most people with one of these conditions will have other
symptoms, apart from the hives.
Physical hives — Hives can be triggered by a variety of physical factors
●Exposure to cold – The hives often appear as the cold skin warms again.
●Changes in body temperature or sweating – These hives are often tiny and numerous and appear on
reddened skin.
●Vibration – Palms may become red, swollen, and itchy after holding onto the steering wheel of a car
while driving.
●Pressure – Hives on the palms or the soles of the feet can occur hours after carrying heavy objects or
walking long distances. Because the skin on the palms and soles is thick, these areas may appear
reddened and swollen without clear hives.
●Exercise – Hives that appear during exercise can be a sign of a dangerous condition called exercise-
induced anaphylaxis.
●Sunlight or water – This is rare.
Finally, there is a common condition called dermographism (literally "skin writing"). People with this
condition develop reddened, raised lines if the skin is stroked firmly or scratched.
Physical forms of hives tend to be long-lasting and are considered a type of chronic hives.
HIVES TESTING
Most people with hives do not need any testing. The diagnosis is usually based on their symptoms and a
physical examination. However, tests may be recommended if hives do not resolve within six weeks.
Testing — Skin testing for food and drug sensitivities may be recommended if there are concerns about
allergies as a cause of symptoms. This is usually done for people with acute hives. Chronic hives are
rarely caused by an allergy.
Blood tests are sometimes done if hives continue for several weeks. Blood tests can tell if there are signs
of underlying diseases, such as liver or thyroid problems or an autoimmune disease.
Skin biopsy — A skin biopsy (when a small sample of skin is removed) may help identify uncommon
causes of hives. A skin biopsy may be recommended for people who have chronic hives along with
other symptoms, such as persistent fever, painful hives, individual hives that last for days at a time, or
hives associated with bruising of the skin. A skin biopsy may also be recommended for people who
have other symptoms or abnormal blood tests.
HIVES TREATMENT
Hives are treated with a combination of avoiding things that cause or worsen the hives, plus the use of
medications.
Avoid triggers — The first treatment for hives is to figure out what is triggering the hives and then
avoid that trigger. Even if you cannot figure out the trigger, hives usually disappear over days or weeks.
Antihistamines — Antihistamines are medicines that can relieve itching. Most people with hives
respond to antihistamines. You may need a relatively high dose or more than one type of antihistamine
to control your symptoms.
There are two main types of antihistamines. They differ in side effects, cost, how long the medicine lasts,
and need for a prescription.
●Older antihistamines – Older antihistamines start to work quickly and work well to relieve symptoms.
The problem with older antihistamines is that you have to take a dose four to six times per day, and
many people have bothersome side effects. These can include drowsiness, dry mouth, double or blurred
vision, or difficulty urinating.
Some of these side effects interfere with driving and tasks requiring quick reactions, similar to the
effects of drinking alcohol. These medicines are therefore not recommended for people who plan to
drive, pilot aircrafts or boats, or operate heavy machinery, or for people whose job performance may be
otherwise affected. Starting the medicine at a low dose and gradually increasing the dose can help to
ease side effects. The side effects usually get better if you take the medicine regularly over a period of
days to weeks.
The older antihistamines include:
•Diphenhydramine (Benadryl and others)
•Chlorpheniramine (Chlor-Trimeton and others) – Chlorpheniramine appears to be safe in pregnant
women
•Hydroxyzine (Atarax, Vistaril, requires prescription)
•Cyproheptadine (Periactin, requires prescription)
●Newer antihistamines – Newer antihistamines have fewer side effects than older antihistamines. Also,
newer antihistamines have to be taken less often, usually once or twice per day. Examples include:
•Loratadine (Claritin and generic)
•Cetirizine (Zyrtec and generic)
•Fexofenadine (Allegra and generic)
•Desloratadine (Clarinex, requires prescription)
•Levocetirizine (Xyzal, requires prescription)
●Other antihistamines – There is another type of antihistamine that is commonly used to treat heartburn.
Your doctor or nurse might recommend one of these medicines in combination with another
antihistamine, if one medicine alone does not work for you. Examples of this type of antihistamine
include:
•Ranitidine (Zantac)
•Nizatidine (Axid)
•Famotidine (Pepcid)
•Cimetidine (Tagamet)
●Doxepin – Doxepin (Sinequan) can sometimes relieve hives that do not respond to other treatments.
However, doxepin causes significant drowsiness and is not recommended when driving or working.
Doxepin is sometimes taken at bedtime to help people with severe hives get a better night's sleep.
●Ketotifen – Ketotifen is a medicine sometimes used to treat hives. Ketotifen is not available in the
United States in pill form, but has been used for many years in Canada, Japan, and Europe.
Oral steroids — A high dose of antihistamines is usually recommended before trying other treatments.
However, oral steroids (glucocorticoids), such as prednisone, can help to relieve severe acute hives that
do not get better with antihistamines. Once the hives have improved, the steroid dose is gradually
lowered and then stopped.
Oral steroids may be used temporarily to relieve chronic hives, but they should not be used for long-
term treatment. This is because steroids can have serious side effects when taken for long periods of
time (months or years). If you are taking oral steroids for more than a month or two per year to control
your hives, you should see a specialist (an allergist or a dermatologist).
Other medicines — If your hives do not get better with the treatments discussed above, other
treatments are available. One example is montelukast, a medicine that helps with itching and hives in
some people when used together with antihistamines. If your hives are not responding to the treatments
you have been offered, you should see a specialist (an allergist or a dermatologist).
More detailed information about hives is available by subscription.

Anaphylaxis is a potentially fatal disorder that is under-recognized and undertreated. This may partly be
due to failure to appreciate that anaphylaxis is a much broader syndrome than "anaphylactic shock," and
the goal of therapy should be early recognition and treatment with epinephrine to prevent progression to
life-threatening respiratory and/or cardiovascular symptoms and signs, including shock.
IMMEDIATE MANAGEMENT — Prompt assessment and treatment are critical in anaphylaxis, as
respiratory or cardiac arrest and death can occur within minutes. It is also important to treat anaphylaxis
promptly because it appears to be most responsive to treatment in its early phases, based on the
observation that delayed epinephrine injection is associated with fatalities.
The tables provide rapid overviews of the initial assessment and emergency management of anaphylaxis
in adults and in children.
The cornerstones of initial management are the following:
●Removal of the inciting antigen, if possible (eg, stop infusion of a suspect medication).
●Call for help (summon a resuscitation team in a hospital setting, or call 911 or an equivalent
emergency medical services number in a community setting).
●Intramuscular (IM) injection of epinephrine at the earliest opportunity, followed by additional
epinephrine by IM or intravenous (IV) injection.
●Placement of the patient in the supine position with the lower extremities elevated, unless there is
prominent upper airway swelling prompting the patient to remain upright (and often leaning forward). If
the patient is vomiting, placement of the patient semi-recumbent with lower extremities elevated may be
preferable. Place pregnant patients on their left side.
●Supplemental oxygen.
●Volume resuscitation with IV fluids.
In a series of 164 fatalities due to anaphylaxis, the median time interval between onset of symptoms and
respiratory or cardiac arrest was 5 minutes in iatrogenic anaphylaxis, 15 minutes in stinging insect
venom-induced anaphylaxis, and 30 minutes in food-induced anaphylaxis]. A more detailed review of
fatal anaphylaxis is presented elsewhere.
Initial assessment and management — A number of critical components in the initial management
needs to be instituted concomitantly. Rapid overview tables that summarize important interventions in
the first few minutes of management are provided for adults and for infants and children:
●Initially, attention should focus on airway, breathing, and circulation, as well as adequacy of mentation.
The lips, tongue, and oral pharynx are assessed for angioedema, and the patient is asked to speak his or
her name to assess peri-glottic or glottic swelling. The skin is examined for urticaria or angioedema,
which (if present) is helpful in confirming the diagnosis.
●Epinephrine should be injected intramuscularly into the mid-outer aspect of the thigh. If symptoms are
severe, an IV epinephrine infusion should be prepared.
●If the upper airway is not edematous, the patient should be placed in the recumbent position with the
lower extremities elevated to maximize perfusion of vital organs (and pregnant patients on their left side
to minimize compression of the inferior vena cava by the gravid uterus). The recumbent position also
helps prevent severe hypotension, subsequent inadequate cardiac filling, and pulseless cardiac activity.
In this situation, death can occur within seconds. Individuals with respiratory distress or vomiting may
not tolerate the recumbent position and should be placed in a position of comfort, with lower extremities
elevated, if possible.
●Supplemental oxygen, initially using a nonrebreather mask at 15 liters/minute flow rate or commercial
masks providing at least 70 percent and up to 100 percent oxygen, should be administered.
●Two large-bore IV catheters (ideally 14 to 16 gauge for most adults) should be inserted in preparation
for rapid administration of fluids and medications. Intraosseous access should be obtained if IV access is
not readily obtainable.
●In normotensive adults, isotonic (0.9%) saline should be infused at a rate of 125 mL/hour to maintain
venous access. In normotensive children, isotonic saline should be infused at an appropriate
maintenance rate for weight in order to maintain venous access.
●Continuous electronic monitoring of cardiopulmonary status, including frequent measurements of
blood pressure (BP), heart rate, and respiratory rate, as well as monitoring of oxygen saturation by pulse
oximetry, is required for the duration of the episode.
Airway management — The initial steps in anaphylaxis management involve a rapid assessment of the
patient's airway:
●Intubation should be performed immediately if marked stridor or respiratory arrest is present.
●Preparations for early intubation should be made if there is any airway involvement or significant
edema of the tongue, oropharyngeal tissues, including the uvula, or if voice alteration has occurred,
especially if only a small amount of time has elapsed since the exposure. Early presence of upper airway
edema represents rapidly developing airway compromise, requiring prompt action.
●In a minority of cases, an emergency cricothyroidotomy may be required to secure the airway if upper
airway edema prevents access to the glottic aperture.
Intubation may be difficult in individuals in whom edema distorts the upper airway anatomical
landmarks. Early awake flexible scope intubation or awake intubation using a rigid video laryngoscope
with sedation and topical anesthesia/vasoconstriction are the methods of choice, unless intubation occurs
early when there is minimal disruption of upper airway anatomy. In this latter case a "double set-up"
rapid sequence intubation, preferably with a video laryngoscope and surgical airway backup are
reasonable alternatives. Failed attempts at intubation can lead to complete airway obstruction and
fatality. Therefore, upper airway closure in the setting of anaphylaxis should be managed by the most
proficient clinician available. This may require immediate collaboration between an emergency
medicine specialist and an anesthesiologist, otolaryngologist, or intensivist with training and experience
in the management of the difficult airway, but delay should not occur while seeking consultation. If
airway assistance is not immediately available, intubation should ensue.
Intravenous fluids — Intravenous (IV) access should be obtained in all cases of anaphylaxis. Massive
fluid shifts can occur rapidly due to increased vascular permeability, with transfer of up to 35 percent of
the intravascular volume into the extravascular space within minutes. Any patient whose hypotension
does not respond promptly and completely to IM epinephrine should receive large volume fluid
resuscitation. The following principles should guide therapy:
Fluid resuscitation should be initiated immediately in patients who present with orthostasis, hypotension,
or incomplete response to IM epinephrine.
●Adults should receive 1 to 2 liters of normal saline at the most rapid flow rate possible in the first
minutes of treatment. Large volumes of fluid (eg, up to 7 liters) may be required.
●Children should receive normal saline in boluses of 20 mL/kg, each over 5 to 10 minutes, and repeated,
as needed. Large volumes of fluid (up to 100 mL/kg) may be required.
Normal saline is preferred over other solutions in most situations because other solutions have potential
disadvantages:
●Lactated Ringer's (LR) solution can potentially contribute to metabolic alkalosis, although large
volumes of normal saline can cause hyperchloremic metabolic acidosis, so some clinicians change from
normal saline to LR if very large volumes are proving necessary.
●Dextrose is rapidly extravasated from the circulation into the interstitial tissues.
●Colloid solutions (eg, albumin or hydroxyethyl starch) confer no survival advantage in patients with
distributive shock and are more costly.
Patients should be monitored carefully and continuously for clinical response and for volume overload.
PHARMACOLOGIC TREATMENTS — The tables provide rapid overviews of the emergency
management of anaphylaxis in adults and children. The treatment recommendations in this section are
consistent with available practice parameters. Each pharmacologic therapy is discussed further below.
Anaphylaxis is variable and unpredictable. It may be mild and resolve spontaneously due to endogenous
production of compensatory mediators or it may be severe and progress within minutes to respiratory or
cardiovascular compromise and death. At the onset of an anaphylactic episode, it is not possible to
predict how severe it will become, how rapidly it will progress, and whether it will resolve promptly and
completely or not, because the factors that determine the course of anaphylaxis in an individual patient
are not fully understood. Because of these variables, it is important to administer intramuscular
(IM) epinephrine early to prevent the possible progression to life-threatening manifestations.
Epinephrine — Epinephrine is the first and most important treatment for anaphylaxis, and it should be
administered as soon as anaphylaxis is recognized to prevent the progression to life-threatening
symptoms. Delayed epinephrine injection is associated with fatalities. Epinephrine should also be
administered to patients who have symptoms or signs consistent with impending anaphylaxis, and the
clinical suspicion for anaphylaxis is high, even if formal diagnostic criteria are not met.
Dosing and administration — Epinephrine is commercially available in different concentrations. Great
care must be taken to use the correct dilution in order to avoid inducing cardiac complications.
Confusion persists among clinicians regarding the optimal epinephrine dose and route of administration
for the initial treatment of anaphylaxis.
Intramuscular epinephrine injection (preferred) — Intramuscular (IM) injection is the preferred
route for initial administration of epinephrine for anaphylaxis in most settings. IM injection is
recommended over subcutaneous injection because it consistently provides a more rapid increase in the
plasma and tissue concentrations of epinephrine. IM injection is also preferred over intravenous (IV)
bolus because it is faster in many situations and safer (ie, lower risk of cardiovascular complications,
such as severe hypertension and ventricular arrhythmias). The epinephrine dilution for IM injection
contains 1 mg/mL and ampules may also be labeled as 1:1000.
●IM dosing – For situations where an exact dose can be drawn up and administered, the recommended
dose of epinephrine for patients of any age is 0.01 mg/kg (maximum dose of 0.5 mg) per single dose,
injected intramuscularly into the mid-outer thigh (vastus lateralis muscle). The dose should be drawn up
using a 1 mL syringe using the 1 mg/mL formulation of epinephrine.
If the dose must be estimated:
•Infants and small children weighing <15 kg should be given an exact weight-based dose (not estimated),
whenever possible. However, if drawing up an exact dose is likely to cause a significant delay in a
rapidly deteriorating patient, the risks and benefits of administering 0.15 mg via an autoinjector must be
carefully considered. It is expected that the side effects of epinephrine would be mild and transient at the
plasma concentrations achieved.
•Children weighing between 15 and 29 kg can be given 0.15 mg (0.15 mL of the 1 mg/mL solution).
•Patients weighing between 30 and 50 kg can be given 0.3 mg (0.3 mL of the 1 mg/mL solution).
•Patients who weigh >50 kg can be given 0.5 mg (0.5 mL of the 1 mg/mL solution). If the patient is
obese, this can be administered using a 1.5 inch needle to penetrate the subcutaneous fat.
Epinephrine can also be administered intramuscularly using an autoinjector. These are available only in
0.15 mg and 0.3 mg doses. Children weighing between 10 and 29 kg should receive the 0.15 mg dose.
Patients weighing 30 kg or more should receive the 0.3 mg dose.
The needle used in adults and children should be long enough to penetrate the subcutaneous adipose
tissue over the vastus lateralis muscle. Realistically, however, IM injection into the thigh may be
impossible in some patients, especially those who are overweight or obese. Although the best approach
in this situation has not been studied, we suggest as deep an injection as possible into the muscle.
●Assessing response to IM epinephrine – Most patients respond to a single dose of IM epinephrine,
particularly if it is given promptly after the onset of symptoms. However, when epinephrine is
administered in an out-of-hospital area, emergency response (911 service or the equivalent) should be
activated, and the patient should be taken to a hospital for further evaluation. IM epinephrine may be
repeated at 5 to 15 minute intervals if there is no response or an inadequate response or even sooner if
clinically indicated. When additional IM doses are required, typically one or rarely two additional doses
are needed (eg, in patients with severe anaphylaxis and those who cannot access emergency care
promptly). Retrospective studies indicate that a second dose is necessary in 12 to 36 percent of cases.
Patients with a history of previous anaphylaxis and those presenting with flushing, diaphoresis, or
dyspnea were more likely to require multiple doses of epinephrine to control symptoms in an
observational study.
In patients who continue to be hypotensive after initial IM epinephrine, IV fluids should be administered.
It is also prudent to begin preparing an epinephrine solution for slow, continuous infusion early, so that
it is ready in case the patient fails to respond to IM epinephrine and IV fluids.
Intravenous epinephrine bolus (avoid or use only with caution) — Intravenous (IV)
bolus epinephrine is associated with significantly more dosing errors and cardiovascular complications
compared with slow continuous infusion and should be avoided whenever possible. Slow, continuous
infusion is preferred if patients have not responded to IM injections. In an observational study of 301
patients treated with epinephrine for anaphylaxis in the emergency department setting, there were four
overdoses, all of which occurred with IV bolus administration. Adverse cardiovascular events were
significantly more likely with IV bolus compared with slow IV infusion or IM injection (4 of 30, 0 of 4,
and 3 of 245, respectively).
Nonetheless, there may be situations in which a slow IV bolus of epinephrine is indicated, such as when
a patient is suffering cardiovascular collapse or impending cardiovascular collapse that is refractory to
IM epinephrine and volume resuscitation, and an epinephrine infusion is not yet available.
●In such cases in an adult or adolescent, this is accomplished by the slow administration of a 50 to 100
mcg (0.05 to 0.1 mg) IV bolus of epinephrine, ideally with hemodynamic monitoring. This is best
administered by slow push of 0.5 to 1 mL of 0.1 mg/mL (1:10,000) epinephrine solution ("cardiac"
epinephrine, available in 10 mL prefilled syringes, containing 1 mg of epinephrine, and stocked on
resuscitation carts). Note that for anaphylaxis, the dose is 1/10th or less of the IV epinephrine dose
used in cardiac arrest (Advanced Cardiac Life Support [ACLS]). The administration of 0.5 to 1 mL
(ie, maximum 1/10th of the total syringe volume) provides a dose of 50 to 100 mcg and is given over one
to three minutes, followed by at least three minutes of observation before considering repeat dosing.
Usually, a response is observed after a single dose, providing sufficient time to prepare an infusion. If
the patient remains severely hypotensive or has shown little response in either heart rate or blood
pressure to the first dose, a second dose is administered in the same way. As soon as infusion is
available, bolus injection is discontinued and replaced by titration of the solution.
●We avoid the use of IV epinephrine boluses in infants and children, because data are sparse on the
efficacy of safety of this approach and dosing is not well-established. Children who are not responding
to initial IM epinephrine and fluid resuscitation should be treated with a slow IV infusion of epinephrine.
Intravenous epinephrine continuous infusion and indications — Patients who do not respond to
several IM injections of epinephrineAND aggressive fluid resuscitation may not be adequately perfusing
muscle tissues, as most commonly occurs in individuals presenting with profound hypotension or
symptoms and signs suggestive of impending shock (dizziness, incontinence of urine and/or stool).
Such patients should receive epinephrine by SLOW intravenous (IV) infusion, with the rate titrated
according to response and the presence of continuous electronic hemodynamic monitoring. IV infusions
of epinephrine should preferably be given by clinicians who are trained and experienced in the
administration of vasopressors and can titrate the rate of infusion (and therefore the epinephrine dose)
using continuous noninvasive monitoring of blood pressure (BP), heart rate, and function.
●Preparing infusion solutions – Epinephrine is commercially available in several dilutions. Great care
must be taken to use the correct dilution in order to avoid overdosing the patient. To prepare an
epinephrine IV maintenance infusion, the commercially available epinephrine solution (eg, ampule,
syringe) must be further diluted. To reduce the risk of making a medication error, we suggest that
centers have a protocol available that includes steps on how to prepare and administer an epinephrine
infusion.
•A simple method for quickly preparing a solution of 1 mcg/mL for adults and adolescents is to add the
entire 10 mL contents of a 0.1 mg/mL (1:10,000) prefilled "cardiac" epinephrine syringe (1 mg) to a
1000 mL (1 liter) bag of normal saline. The resultant solution of 1 mcg/mL delivers 1 mcg/minute of
epinephrine for each 60 mL/hour of solution infused. Therefore, 120 mL/hour will deliver
2 mcg/minute and so forth.
•For adolescent/adult patients who have already received large quantities of IV fluids (four or more
liters), a more concentrated solution (4 mcg/mL) is preferable. Using a more concentrated solution
allows titration of epinephrine infusion and administration of bolus crystalloid solution to be done
independent of one another. To prepare a 4 mcg/mL solution, add the entire 10 mL contents of one
0.1 mg/mL (1:10,000) epinephrine syringe to a 250 mL bag of normal saline. The resultant solution
delivers 1 mcg/minute of epinephrine for each 15 mL/hour of infusion. Therefore, 30 mL/hour delivers
2 mcg/minute, 45 mL/hour delivers 3 mcg/minute, and so forth.
•For infants and children, a more concentrated solution of 10 mcg/mL is more appropriate to avoid
excessively large infusion volumes.
●Initial infusion rates:
•Infants and children – The dose for IV infusion of epinephrine is 0.1 to 1 mcg/kg/minute with use of
an infusion pump, titrated to effect on BP with continuous cardiac monitoring and frequent noninvasive
BP monitoring. To reduce the risk of making a medication error, we suggest that centers have a protocol
available that includes steps on how to prepare and administer epinephrine infusion. Examples of
pediatric infusions are provided.
Epinephrine is a vesicant, and central line administration is preferred, although central line insertion
should not delay the initiation of IV epinephrine infusion. When a patient does not have a central venous
catheter, epinephrine can be temporarily administered through an appropriately positioned, large bore,
peripheral venous catheter until a central venous catheter is inserted. Closely monitor the catheter site
throughout the infusion to avoid extravasation injury.
Epinephrine mechanisms of action — The pharmacologic actions of epinephrine address the
pathophysiologic changes that occur in anaphylaxis better than any other medication. It decreases
mediator release from mast cells, prevents or reverses obstruction to airflow in the upper and lower
respiratory tracts, and prevents or reverses cardiovascular collapse.
The therapeutic actions of epinephrine include the following:
●Alpha-1 adrenergic agonist effects – Increased vasoconstriction, increased peripheral vascular
resistance, and decreased mucosal edema (eg, in the upper airway).
●Beta-1 adrenergic agonist effects – Increased inotropy and increased chronotropy.
●Beta-2 adrenergic agonist effects – Increased bronchodilation and decreased release of mediators of
inflammation from mast cells and basophils.
Adverse effects — In patients of all ages, epinephrine administered in therapeutic doses by any route
often causes mild transient pharmacologic effects, such as anxiety, restlessness, headache, dizziness,
palpitations, pallor, and tremor. These symptoms and signs are similar to those occurring during the
physiologic "fight or flight" response due to endogenous epinephrine that occurs normally in sudden
frightening or life-threatening situations.
Rarely, epinephrine may lead to ventricular arrhythmias, angina, myocardial infarction, pulmonary
edema, sudden sharp increase in BP, and intracranial hemorrhage. However, anaphylaxis itself can lead
to angina, myocardial infarction, and cardiac arrhythmias in the absence of any exogenous epinephrine
or before exogenous epinephrine is administered.
Serious adverse effects occur most commonly after an IV bolus injection, particularly if an
inappropriately large dose is administered.
Situations requiring caution — There are NO absolute contraindications to epinephrine use in
anaphylaxis. The risk of death or serious neurologic sequelae from hypoxic-ischemic encephalopathy
due to inadequately treated anaphylaxis usually outweighs other concerns. Existing evidence clearly
favors the benefit of epinephrine administration in anaphylaxis. However, formal risk-benefit analyses
are not possible, and sound clinical judgment is essential.
Subgroups of patients might theoretically be at higher risk for adverse effects
during epinephrine therapy:
●Patients with cardiovascular diseases – Reluctance to administer epinephrine due to fear of adverse
cardiac effects should be countered by the awareness that the heart is a target organ in anaphylaxis. In
the healthy human heart, mast cells are present throughout the myocardium and in the intima of
coronary arteries. In patients with coronary artery disease, mast cells are found in atherosclerotic lesions
and contribute to atherogenesis. Anaphylaxis can unmask subclinical coronary artery disease, and
myocardial infarction and/or arrhythmias can occur during anaphylaxis, even if epinephrine is not
injected. Moreover, anaphylaxis itself can cause vasospasm, arrhythmias, and myocardial infarction in
patients, including children, with healthy hearts as confirmed by normal electrocardiograms,
echocardiograms, and coronary angiograms after resolution of anaphylaxis.
●Patients receiving monoamine oxidase inhibitors (which block epinephrine metabolism) or tricyclic
antidepressants (which prolong epinephrine duration of action).
●Patients with certain pre-existing conditions, such as recent intracranial surgery, aortic aneurysm,
uncontrolled hyperthyroidism or hypertension, or other conditions that might place them at higher risk
for adverse effects related to epinephrine.
●Patients receiving stimulant medications (eg, amphetamines or methylphenidate used in the treatment
of attention deficit hyperactivity disorder) or abusing cocaine that might place them at higher risk for
adverse effects from epinephrine.
Efficacy — Epinephrine is the best studied medication in anaphylaxis, although randomized, placebo-
controlled trials of epinephrine in humans experiencing anaphylaxis have never been performed for
ethical reasons. The evidence for its use comes from observational studies, randomized, controlled
clinical pharmacology studies in patients not experiencing anaphylaxis, studies of anaphylaxis in animal
models, and epidemiologic studies, including fatality studies. Several case series have implicated the
failure to administer epinephrine early in the course of treatment as a consistent finding in anaphylaxis
deaths.
●In a series of 13 fatal and near-fatal food-induced anaphylactic reactions in children and adolescents,
the six patients who died had symptom-onset within one to five minutes after ingestion of the culprit
food, but did not receive their first dose of epinephrine until 25, 60, 80, 90, 125, and 180 minutes after
the food was ingested. The authors concluded that the failure to recognize severity of the reactions and
to administer epinephrine promptly increased the risk of a fatal outcome.
●In a series of anaphylactic deaths occurring from 1992 to 1998, only 20 percent of 24 patients were
given epinephrine at any point in their treatment.
●In the fatality series described previously, only 14 percent of the 164 patients dying from anaphylaxis
received epinephrine before respiratory or cardiac arrest, although 62 percent of the 164 patients
eventually received it before demise.
In addition, anaphylaxis occurring during evaluation of venom immunotherapy has been investigated
prospectively. In one study, 68 patients with a history of anaphylaxis to insect stings were randomly
assigned to venom immunotherapy or placebo immunotherapy. Following this, all were stung in a
controlled, monitored setting and treated (if needed) with a standardized protocol of high flow
oxygen, epinephrine infusion, and normal saline rapid infusion. Nineteen of the 21 patients in the
placebo group developed anaphylaxis and received epinephrine. Symptoms responded within five
minutes in all but one patient. In nine patients, an initial attempt to stop the epinephrine infusion was
followed by a return of symptoms, which subsided again once the epinephrine infusion was restarted.
In a retrospective chart review of 234 children who received epinephrine for food-induced anaphylaxis,
treatment with epinephrine prior to arrival to the emergency department was associated with a
significantly lower risk of hospitalization. Although the time between food exposure and administration
of epinephrine could not be precisely determined, children who received epinephrine earlier (often
because they had an epinephrine autoinjector) were released from the emergency department sooner and
were less likely to require hospital admission compared with those who received it only after arrival (17
versus 43 percent).
Finally, there is extensive clinical experience among allergy practitioners with giving epinephrine to
treat anaphylaxis occurring in response to immunotherapy. This is a unique situation because allergy
clinic staff observe patients closely for the symptoms and signs of anaphylaxis and reactions are
detected at very early stages. Over the past few decades, consensus has been reached that even mild
systemic reactions are best treated immediately with epinephrine, as this appears to prevent progression
to more severe symptoms more effectively than any other available therapies. At the time the
autoinjector is used or epinephrine is administered in another form, 911 response should be initiated,
with the clear complaint of "anaphylaxis," without waiting to see if the reaction worsens. The 911 call
can always be aborted if the patient recovers or the patient can be assessed by paramedics and not
transported. As a result, successive guidelines for treatment of immunotherapy reactions have called for
epinephrine to be given as soon as a systemic reaction of any severity is detected. In studies in which all
or most patients who developed anaphylaxis after allergen immunotherapy were treated promptly with
epinephrine injections, symptoms were mild, and no additional injections of epinephrine were given,
even in the 10 to 23 percent of reactions that were biphasic.
Glucagon for patients taking beta-blockers — Patients receiving beta-blockers may be resistant to
treatment with epinephrine and can develop refractory hypotension. In this situation, glucagon should be
administered because it has inotropic and chronotropic effects that are not mediated through beta-
receptors.
●Adult dosing is 1 to 5 mg slow IV bolus over five minutes. May be followed by an infusion of 5 to
15 mcg/minute titrated to effect.
●Pediatric dosing is 20 to 30 mcg/kg (maximum 1 mg) slow IV bolus over five minutes. May be
followed by an infusion of 5 to 15 mcg/minutetitrated to effect (ie, not weight-based).
Rapid administration of glucagon can induce vomiting. Therefore, protection of the airway, for example,
by placement in the lateral recumbent position, is important in drowsy or obtunded patients.
Bronchodilators — For the treatment of bronchospasm not responsive to epinephrine, inhaled
bronchodilators (eg, albuterol, salbutamol), should be administered by mouthpiece (or facemask for
those whose age or condition requires) and nebulizer/compressor, as needed. Bronchodilators are
adjunctive treatment to epinephrine because they do not prevent or relieve mucosal edema in the upper
airway or shock, for which the alpha-1 adrenergic effects of epinephrine are required. The evidence for
the use of beta-2 adrenergic agonists in anaphylaxis is extrapolated from their use in acute asthma.
Adjunctive agents — Agents that may be given as adjunctive therapies to epinephrine in the treatment
of anaphylaxis include H1 antihistamines, H2 antihistamines, bronchodilators, and glucocorticoids.
None of these medications should be used as initial treatment or as sole treatment because they do not
relieve upper or lower respiratory tract obstruction, hypotension, or shock and are not life-saving.
H1 antihistamines — Epinephrine is first-line treatment for anaphylaxis, and there is no known
equivalent substitute. H1 antihistamines relieve itching and urticaria, and their use in anaphylaxis is
extrapolated from the studies of urticaria. A systematic review of the literature failed to retrieve any
randomized, controlled trials that meet current standards and support the use of H1 antihistamines in
anaphylaxis. Despite this, H1 antihistamines are the most commonly administered medications in the
treatment of anaphylaxis, which suggests over-reliance on these agents.
H1 antihistamines relieve itch and hives. These medications DO NOT relieve upper or lower airway
obstruction, hypotension or shock, and in standard doses, do not inhibit mediator release from mast cells
and basophils. It is probable that the improvement in noncutaneous symptoms that is sometimes
attributed to antihistamine treatment occurs instead because of endogenous production
of epinephrine and other compensatory mediators, including other catecholamines, angiotensin II, and
endothelin I. In addition, the onset of action of antihistamines, such as cetirizine or diphenhydramine,
takes 30 to 40 minutes and is too slow to provide any immediate benefit. Only first-generation H1
antihistamines are available in parenteral formulations, and rapid IV administration may increase
hypotension.
●For adults, diphenhydramine 25 to 50 mg can be administered intravenously over five minutes, which
may be repeated up to a maximum daily dose of 400 mg per 24 hours.
●For children weighing less than 50 kg, diphenhydramine 1 mg/kg (maximum 50 mg) can be
administered intravenously over five minutes, which may be repeated up to a maximum daily dose of
5 mg/kg or 200 mg per 24 hours.
For oral treatment, second-generation H1 antihistamines (eg, cetirizine) offer certain advantages over
first-generation agents (eg, diphenhydramine, chlorpheniramine, hydroxyzine, and promethazine).
Second-generation H1 antihistamines are less likely to impair cognition or psychomotor performance
(eg, the ability to drive safely) or to cause sedation. Orally-administered cetirizine acts within 30 to 40
minutes and lasts for 24 hours. However, second-generation H1 antihistamines are not available in
parenteral formulations.
H2 antihistamines — An H2 antihistamine given with an H1 antihistamine may provide some
additional relief of hives.
Although H2 antihistamines are sometimes administered in anaphylaxis treatment, H2 antihistamines
DO NOT relieve upper or lower airway obstruction or shock. Systematic reviews have not identified
any randomized, controlled trials that support the use of these agents in anaphylaxis or urticaria.
If used, ranitidine (50 mg in adults) (12.5 to 50 mg [1 mg/kg] in children), may be diluted in 5%
dextrose to a total volume of 20 mL and injected intravenously over five minutes.
Glucocorticoids — The onset of action of glucocorticoids takes several hours. Therefore, these
medications do not relieve the initial symptoms and signs of anaphylaxis. The rationale for giving them
is to theoretically prevent the biphasic or protracted reactions that occur in some cases of anaphylaxis.
However, a systematic review of the literature failed to retrieve any randomized, controlled trials in
anaphylaxis that confirmed the effectiveness of glucocorticoids]. In addition, a study of emergency
department patients with allergic reactions or anaphylaxis failed to find a decrease in return emergency
department visits or biphasic reactions among patients treated with glucocorticoids.
If given, a dose of methylprednisolone of 1 to 2 mg/kg/day is sufficient. If glucocorticoid treatment is
instituted, it should be stopped after one or two days without a taper.
REFRACTORY ANAPHYLAXIS — For patients who are not responding to initial measures,
admission to an intensive care unit should occur without delay. There are no published prospective
studies on the optimal management of refractory anaphylaxis.
Anaphylactic shock displays features of both distributive (vasodilatory) and hypovolemic shock. The
management of severe forms of these types of shock is discussed separately.

Other vasopressors — The addition of another vasopressor should be considered if the patient
continues to be hypotensive despite maximal epinephrine and fluid therapy. It is unclear if the addition
of other pressors is superior to epinephrine alone, but one theory about the pathogenesis of refractory
anaphylaxis proposes that the clinical manifestations may become refractory to further catecholamine
administration, perhaps due to saturation or desensitization of adrenergic receptors. The use of
nonadrenergic vasopressors, such as vasopressin, in the management of anaphylaxis refractory to
intravenous (IV) epinephrine in adults is discussed elsewhere. Other adrenergic vasopressors can also be
considered, such as norepinephrine and dopamine. An emergency medicine practice parameter states,
"Norepinephrine, vasopressin, and other pressors have been used with success in patients in anaphylaxis
with refractory hypotension".
Methylene blue — Vasoplegia (profound vasodilation) may be present in some cases of refractory
anaphylaxis. A few case reports and other publications support the use of methylene blue, an inhibitor of
nitric oxide synthase and guanylate cyclase, in severe anaphylaxis, mostly in perioperative settings. The
efficacy and ideal dose of methylene blue is unknown, but a single bolus of 1 to 2 mg/kg given over 20
to 60 minutes has been used in cardiac surgery. Improvement of vasoplegia (eg, increased systemic
vascular resistance, reduced vasopressor dose) has been observed within one to two hours in the setting
of cardiac surgery, but few data are available about anaphylaxis. This drug should not be given to
patients with pulmonary hypertension, underlying glucose-6-phosphate dehydrogenase deficiency
(G6PD), or acute lung injury. We also advise caution regarding potential drug interactions with
serotonergic agents. Methylene blue and other vital dyes are also rarely the cause of perioperative
anaphylaxis.

Extracorporeal membrane oxygenation — Patients suffering from refractory anaphylaxis have been
resuscitated with extracorporeal membrane oxygenation (ECMO) or operative cardiopulmonary bypass.
ECMO is becoming increasingly available in emergency departments and should be considered in
patients unresponsive to complete resuscitative efforts in institutions with experience in this technology.
The decision to initiate ECMO should be considered early in patients unresponsive to traditional
resuscitative measures, before irreversible ischemic acidosis develops. (See "Extracorporeal membrane
oxygenation (ECMO) in adults".)
TREATMENT ERRORS — Important errors in the treatment of anaphylaxis include failure to
administer epinephrine promptly and delay in epinephrine injection due to over-reliance on
antihistamines, albuterol (salbutamol), and glucocorticoids. (See 'Adjunctive agents' above.)
●Epinephrine should be administered as soon as possible once anaphylaxis is recognized or if
impending anaphylaxis is suspected, even if patients do not yet meet diagnostic criteria. Delayed
administration has been implicated in contributing to fatalities. A study of 13 fatal or near-fatal food-
induced anaphylactic reactions in children reported that six of the seven children who survived received
epinephrine within 30 minutes of ingesting the allergen, whereas only two of the six children who died
received epinephrine within the first hour.
●H1 antihistamines are useful for relieving itching and urticaria. They do NOT relieve stridor, shortness
of breath, wheezing, gastrointestinal symptoms and signs, hypotension or shock, and should not be
substituted for epinephrine .
●Bronchodilator treatment with nebulized albuterol (salbutamol) should be given in individuals with
severe bronchospasm as an adjunctive treatment to epinephrine. However, albuterol does NOT prevent
or relieve upper airway edema, hypotension, or shock, and should not be substituted for epinephrine in
the treatment of anaphylaxis.
CARE UPON RESOLUTION — To reduce the risk of recurrence, patients who have been
successfully treated for anaphylaxis subsequently require confirmation of the anaphylaxis cause as well
as anaphylaxis education. In a study of emergency department patients with suspected anaphylaxis who
followed up with an allergist/immunologist, 35 percent of patients had an alteration in the diagnosis or
suspected cause, underscoring the importance of follow-up evaluation.
Observation — There is no consensus regarding the optimal observation period for a patient who has
been successfully treated for anaphylaxis in a health care facility. We suggest the following:
●Patients with moderate anaphylaxis who do not respond promptly to epinephrine and all patients with
severe anaphylaxis should be admitted to an observation unit or hospital.
●We suggest a minimum observation period of four to eight hours for patients at risk for severe
anaphylaxis (ie, asthma, those for whom more than one dose of epinephrine was required to treat the
initial reaction, or if symptoms persist).
●For patients with anaphylaxis that resolved promptly and completely with treatment, we suggest that
observation times be customized based on the severity of the reaction and access to emergency care.
●Patients should be prescribed an epinephrine autoinjector and trained in its use. The importance of
filling the prescription immediately should be stressed. From 1 percent to 21 percent of patients may
experience a biphasic reaction.
Discharge care and referral — All patients who have experienced anaphylaxis should be sent home
with an anaphylaxis emergency action plan, one or more epinephrine autoinjectors, a plan for arranging
further evaluation, and printed information about anaphylaxis and its treatment.
Anaphylaxis emergency action plan — Before discharge, patients should be given a written
personalized anaphylaxis emergency action plan that lists the common symptoms and signs of
anaphylaxis and contains information about prompt recognition of anaphylaxis and self-injection
of epinephrine.
Anaphylaxis action plans specifically designed for patients with food allergy are available through the
organization Food Allergy Research & Education (FARE).
Epinephrine autoinjector — Patients should be instructed in how to use an epinephrine autoinjector
correctly, provided with a prescription for it, and advised to fill the prescription immediately. Ideally,
two epinephrine autoinjectors should be prescribed because up to 20 percent of patients require more
than one dose of epinephrine for the treatment of their anaphylactic reaction. Instructions in the proper
use of epinephrine autoinjectors should be reviewed verbally, and patients should be given a
DVD and/or written material or directed to a manufacturer's website video providing relevant
information. Patient information that can be printed or accessed online is provided. These steps prior to
discharge are often overlooked. In a survey of 1885 patients who survived anaphylaxis, 28 percent of
those who did not self-administer epinephrine reported that they had never received a prescription for an
autoinjector. Counseling — The mnemonic "SAFE" was developed to remind clinicians of the four
basic action steps suggested for patients with anaphylaxis who have been treated and are subsequently
leaving the emergency department or hospital. These steps are: Seek support, Allergen identification and
avoidance, Follow-up for specialty care, and Epinephrine for emergencies. The SAFE counseling is
outlined below and has been incorporated into printable patient information materials.
●Seek support – Advise the patient that:
•They have experienced anaphylaxis or "killer allergy," which is a life-threatening condition.
•Symptoms of the current episode may recur (without further exposure to the causal agent) up to three
days after the initial onset of symptoms.
•They should self-inject epinephrine and call emergency medical services or get to the nearest
emergency facility at the first sign of recurrence of symptoms.
•They are at risk for repeat episodes of anaphylaxis in the future.
•They should learn about anaphylaxis (refer the patient to resources).
●Allergen identification and avoidance
•Emphasize the importance of avoiding the suspected cause.
●Follow-up for specialty care
•Advise the patient to follow-up with his or her primary care clinician and obtain a referral to an
allergist (or to seek consultation directly with an allergist) for testing to confirm the cause and for
ongoing management. The evaluation of a patient following anaphylaxis is reviewed
separately. •Comorbidities, such as asthma, other chronic pulmonary disease, and cardiovascular disease,
should be optimally controlled.
●Epinephrine for emergencies
•Provide the patient with a prescription for two epinephrine autoinjectors and demonstrate proper use. In
addition, give the patient written information about how to recognize anaphylaxis and how to use an
epinephrine autoinjector, and provide directions to appropriate websites for video demonstrations of
autoinjector use.
-Explain the importance of carrying the epinephrine autoinjector at all times.
-Advise the patient to make sure that family and friends are aware of the risks of anaphylaxis, the causes,
and how to administer epinephrine. The correct injection technique is important to avoid unintentional
injection into fingers, thumbs, or other body parts.
RISK OF RECURRENCE — Patients who have experienced anaphylaxis are at risk for recurrent
episodes unless long-term risk reduction measures are implemented. Specifically, the cause for the
anaphylactic episode should be verified. Thirty-five percent of emergency department patients with
suspected anaphylaxis had an alteration to the diagnosis of suspected cause after evaluation with
an allergist/immunologist. In addition, anaphylaxis education is required in order to help patients
successfully avoid their confirmed cause(s) and self-inject epinephrine promptly and confidently in the
event of a recurrent anaphylactic episode. For these reasons, patients with anaphylaxis benefit from
referral to an allergy specialist.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from
selected countries and regions around the world are provided separately.

SUMMARY AND RECOMMENDATIONS

●Patients with anaphylaxis should be assessed and treated as rapidly as possible, as respiratory or
cardiac arrest and death can occur within minutes. Anaphylaxis appears to be most responsive to
treatment in its early phases, before shock has developed, based on the observation that
delayed epinephrine injection is associated with fatalities.
●Initial management is summarized in rapid overview tables for adults and children.
●Epinephrine is life-saving in anaphylaxis. It should be injected as early as possible in the episode in
order to prevent progression of symptoms and signs. There are no absolute contraindications to
epinephrine use, and it is the treatment of choice for anaphylaxis of any severity. We recommend
epinephrine for patients with apparently mild symptoms and signs (eg, a few hives and mild wheezing)
(Grade 1B), as well as for patients with moderate-to-severe symptoms and signs (Grade 1A).
●The route of epinephrine administration depends upon the presenting symptoms. For patients who
are not profoundly hypotensive or in shock or cardiorespiratory arrest, intramuscular (IM) injection
into the mid-outer thigh as the initial route of administration is advised, in preference to subcutaneous
administration or intravenous (IV) administration.
•When an exact dose can be drawn up and administered, 0.01 mg/kg (maximum of 0.5 mg) should be
administered in the mid-outer thigh every 5 to 15 minutes or more frequently if necessary.
•When an autoinjector is used, children weighing between 15 and 29 kg should receive the 0.15 mg dose,
and patients weighing 30 kg or over should receive the 0.3 mg dose administered to the outer thigh
every 5 to 15 minutes or more frequently if necessary. Autoinjector use must be carefully considered in
infants and children weighing under 15 kg. However, the benefits likely outweigh the risk if this is the
only source of epinephrine available.
●Massive fluid shifts can occur in anaphylaxis, and all patients with orthostasis, hypotension, or
incomplete response to epinephrine should receive large volume fluid resuscitation with normal saline.
Normotensive patients should receive normal saline to maintain venous access in case their status
deteriorates.
●Supplemental oxygen and bronchodilators should be administered to patients with respiratory signs or
symptoms.
●IV epinephrine is indicated for patients with profound hypotension or symptoms and signs suggestive
of impending shock (dizziness, incontinence of urine or stool) who do not respond to initial IM
injections of epinephrine and fluid resuscitation. For these patients, we suggest that epinephrine be
administered by continuous slow IV infusion rather than by intermittent IV bolus (Grade 2C). Slow IV
infusion is less likely to cause extreme hypertension or ventricular arrhythmias. Epinephrine infusion
should be accompanied by continuous electronic hemodynamic monitoring. Specific guidance for
creating the proper epinephrine solutions is provided.
●Patients successfully treated for anaphylaxis should be discharged with a personalized written
anaphylaxis emergency action plan, an epinephrine autoinjector, written information about anaphylaxis
and its treatment, and a plan for further evaluation.
●Patients should be evaluated further to confirm the cause, as specific avoidance measures are useful in
reducing the risk of recurrence. Additionally, for some allergens, immunomodulation is also available to
reduce the risk.

Hereditary angioedema (HAE) is a disease characterized by recurrent episodes of

angioedema, without urticaria or pruritus, which most often affect the skin or mucosal tissues of the
upper respiratory and gastrointestinal tracts. Although the swelling is self-limited, laryngeal
involvement may cause fatal asphyxiation. Prior to the availability of effective therapy, this disorder
was associated with a mortality rate of approximately 30 percent due to asphyxiation from laryngeal
swelling.
PATHOGENESIS
The swelling (ie, angioedema, sometimes called "giant" swelling) that occurs in hereditary angioedema
(HAE) results from excessive production of bradykinin, a potent vasodilatory mediator. Bradykinin also
has important vascular permeability-enhancing effects. During episodes of angioedema in patients with
HAE, plasma bradykinin levels have been shown to be sevenfold higher than normal. In bradykinin-
mediated angioedema, histamine and other mast cell mediators are not directly involved, which explains
the lack of response to antihistamines and distinguishes this form of angioedema from the histamine-
mediated angioedema that is seen in allergic reactions and urticaria.
Some forms of HAE arise from deficiency or dysfunction of C1 inhibitor (C1INH), while others do not.
In those that do not, specific mutations in the factor XII gene have been identified in some families,
while the etiopathogenesis of the disease in other families is unknown.
Functions of C1 inhibitor — C1 inhibitor (C1INH) is an acute-phase reactant and a member of the
"serpin" superfamily of serine protease inhibitors. C1INH is an inhibitor of two complement pathways
(classical and lectin), as well as of the intrinsic coagulation (contact system) fibrinolytic and kinin-
generating pathways. Within these different pathways, C1INH inhibits several plasma proteases: C1r
and C1s, mannose-binding lectin-associated serine proteases (MASP1 and MASP2), coagulation factor
XII (Hageman factor), coagulation factor XI, plasma kallikrein, and plasmin. The function of C1INH in
the kinin-generating pathway is most directly related to the pathogenesis of HAE.
6. Materials of methodological support classes
6.1. Methodological support of classes
Tests
1. 4 months old Olesya, after change into artificial feeding by formula on the basis of cow milk has
appeared intertrigo in unguentum and axilliary folds, warm hyperemia on cheeks’ skin. It is possible to
think of what condition?
A.Eczema
B. Nursing defect
+C. Exudative catarrhal diathesis
D. Infectious eczema
E. None of the above

2. Vadim is 5 months old, after introduction of carrot juice ,had a milky scab, gneiss, maculo-papular
rash. What changes from mucous membranes can be at the given condition?
А «Geographical tongue»
B.Rhinitis
C.Vulvitis
D.Conjuctivitis
+E. all of the above

3. Marina, 6 months old, after change into artificial feeding by formula on the basis of cow milk , has
appeared small macular rash in the abdomen and extremities, reddening of the skin of the cheeks with
peeling. What basic diet-therapy recommendations should the pediatrician give?
A. Feeding on mother’s breast milk
+B. Change in formula on a basis of only soy fibers
C. Feeding on adapted formula on the basis of cow milk
D. Feeding on products of cow milk
E .None of the above

4. The family doctor diagnosed 5 months old Elena with exudative catarrhal diathesis. Preparations of
what group are necessary at the given condition?
+A. Н1-histamine blockers
B. Н2-histamine blockers
C. M-cholenetics
Д. M-cholinomimetic
Е β2-adrenomimetic

5. Maxim 12 years old, the diagnosis atopic dermatitis is established. In the program of basic therapy are
appointed аntihistaminе preparations of 2nd generations. What preparations does not concern the given
group?
A.Loratadine
B.Cetirizine
+C.Clemastine
D.Azelastine
E. Ebastine

6. 11 years old Mikhail, has been diagnosed with allergic rhinitis. What groups of preparations are used
as therapy of the given disease?
A. Cromolyn acids derivates
B. Antihistamine preparations of 1st &2nd generations
C. Topical corticosteroids
+D. All the above
E. None of the above

7. 10 years old Margarita, who is ill with allergic rhinitis for 2 years, have been appointed topical
corticosteroids. What preparations are not included into the given group?
A. Fluticasone
B.Beclometasone dipropinate
C.Mometasone furoate
+D. Prednisolone
E. Triamcinolone acetonide

6.2. Information necessary for the formation of knowledge - skills can be found in the literature
 Basic educational literature
1. Captain T. Propedeutics of Childhood Diseases. 2008.
2. Tom Lissauer,Graham Clayden. Illustrated Textbook of Paediatrics. 2010.
3. O.P. Ghai “ Essential Pediatrics” 6th Edition. 2008.
4. Nelson Textbook of Pediatrics. 19th Edition. Robert Kilegman.
5. Current Diagnosis and Treatment in Pediatrics.18th Edition. William W. Hay, JR, Myron
J.Levin,- Denver 2007,- 1390 p.

 Additional scientific and methodological literature

1. The Harriet Lane Handbook. 19th Edition. 2011, -
2. Babiy I.L Propedeutic Pediatrics.- Odessa 2006, - 316 p.
3. Pieter –Jan Coenraads. Hand Eczema // N Engl J Med. 2012.-N 367.- P. 1829-1837
4. Alan. D. Irvine. Filaggrin Mutations Associated with Skin and Allergic Diseases // N Engl J
Med. 2011.- N365.- P. 1315-1327.

6.3. The estimated card for independent work with literature

N Main Task Recommendation Answers

1 2 3 4
1 Acquaint with Give information about
literature and epidemiology of the disease
educational Give the definition of the disease
goals studied.
2 Etiology Fill the scheme of etiological
factors
… … … …
% % % %
3 Pathogenesis Fill the scheme of pathogenetic
factors
Pathogenesis

4 Clinical data Make differential diagnosis of this

disease and similar to its condition

5 Diagnosis Make and explain diagnosis

according to the results of clinical,
laboratory and instrumental data.
6 Treatment Make program of treatment. Write
prescription of preparations which
is used for the treatment of this
disease
Rp Rp Rp Rp
… … … …
7 Prophylaxis and Fill the scheme of dispensary
rehabilitation control
N Specialist Time

7. Materials for self-control on the quality of training

1. anatomical and physiological of the skin of children of different age groups.
2. etiology and pathogenesis of atopic dermatitis in children.
3. clinical forms of atopic dermatitis.
4. clinical characteristics of atopic dermatitis.
5. principles of treatment of various forms of atopic dermatitis.
6. principles of rehabilitation of atopic dermatitis in children.

Tests
1. In 3 months old Alona, the local pediatrician diagnosed signs of exudative catarrhal diathesis.
Name the most significant group of causative allergens?
+A.Food
B.Pollen
C.Fungal
D.Epidermal
E.Household
2. 4 months old Olesya, after change into artificial feeding by formula on the basis of cow milk
has appeared intertrigo in unguentum and axilliary folds, warm hyperemia on cheeks’ skin. It is possible
to think of what condition?
A.Eczema
B. Nursing defect
+C. Exudative catarrhal diathesis
D. Infectious eczema
E. None of the above
3. Vadim is 5 months old, after introduction of carrot juice ,had a milky scab, gneiss,
maculo-papular rash. What changes from mucous membranes can be at the given condition?
А «Geographical tongue»
B.Rhinitis
C.Vulvitis
D.Conjuctivitis
+E. all of the above
4. Dennis, 5 months old, is on breast feeding. After mother gave chocolate and nuts to the
child, appeared macula-papular rash, intertrigo in unguentum and axillary folds. The local pediatrician
diagnosed exudative catarrhal diathesis. What is the doctor’s recommendations concerning the diet the
mother should be give?
A.Elimination of easily digested carbohydrates
+B. Elimination of food allergens
C.Elimination of products with the high levels of purine bases
D.Elimination of products with the high levels of calcium
E. Water loading
5. Ivan, 2 months old , after change into artificial feeding, had gneiss, a milky scab, maculo-
papular rash on the abdomen and back skin. The local doctor diagnosed exudative catarrhal diathesis.
What additional methods of investigations are necessary for diagnosis to be confirmed?
A. General blood analysis (level of eosinophils)
B.Allergen-test
C IgE level
D IgА lvel
+E. All of the above
6. Alexander, 3 months old, th pediatrician diagnosed signs exudative catarrhal diathesis. What
level of antibodies would be raised at the given condition?
+А IgE
В IgА
С IgМ
Д IgG
E. All listed
7. Marina, 6 months old, after change into artificial feeding by formula on the basis of cow
milk , has appeared small macular rash in the abdomen and extremities, reddening of the skin of the
cheeks with peeling. What basic diet-therapy recommendations should the pediatrician give?
A. Feeding on mother’s breast milk
+B. Change in formula on a basis of only soy fibers
C. Feeding on adapted formula on the basis of cow milk
D. Feeding on products of cow milk
E .None of the above
8. The family doctor diagnosed 5 months old Elena with exudative catarrhal diathesis.
Preparations of what group are necessary at the given condition?
+A. Н1-histamine blockers
B. Н2-histamine blockers
C. M-cholenetics
Д. M-cholinomimetic
Е β2-adrenomimetic

9. Parents of 4 years old Artem, have come to the pediatrician with complaints of occurrence in
their child on the flexors surfaces of elbow and knee joints, skin of eyelids, intensively itching areas,
hyperemia and infiltration with peeling. At examination: skin is dry, dark, skin drawing is strengthened,
in the areas of defect skin infiltration is expressed as lichenification, crusts and excretions are visualized.
Dermographism - white, proof. Mother specifies in presence in the anamnesis exudative catarrhal
diathesis. Hereditary allergic anamnesis is present: the father of the child - eczema, the uncle - bronchial
asthma. It is possible to think of what disease?
A. Exudative catarrhal diathesis
 +B. Atopic dermatitis
C .Microbic eczema
D. Lyell’s syndrome
E. .Urinary diathesis
10. Paul 14 years old, within 6 years was observed the widespread itching areas of defect
the skin localised on neck, extensor surfaces of extremities. The skin is dry and scaly. In the
pathological areas it is observed erythema without accurate borders, infiltration,lichenification, lichinoid
papules, hemorrhagic crusts. On lower eyelids «folds Dene-Morgan», behind ears - cracks are visualized
additional; cheilitis. The allergic anamnesis is burdened: the boy suffers on bronchial asthma, allergic
rhinitis. Mother of the child has bronchial asthma. What disease is the most probable?
A. Psoriasis
B. Exudative catarrhal diathesis
+C. Atopic dermatitis
D. Red flat deprivation
E. Herpes
11. In 5 years old Sergey, the children's allergist diagnosed atopic dermatitis. List obligatory
diagnostic criteria of the given disease:
A. Itching
B. Topical localisation of theareas of defect: flexor surfaces of extremities
C. Lichenification of the skin on flexor surfaces of extremities, strengthening of skin drawing
D. Chronic reccurent course, atopy in the anamnesis and in family
+E. All listed
12. After a trauma in 8 years old Olesya, on flexor surfaces of elbow and knee joints has
appeared intensively itching areas of hyperemia, papulo-vesicular elements, lichenification,
strengthening of skin drawing. The girl suffers from allergic rhinitis, mother of the child has pollen
allergy. The doctor has established the diagnosis - atopic dermatitis. For the estimation of the weight of
the disease ,index SСORAD has been calculated. The given indicator consists of what components?
+A. Volume of skin defect (in percentage), a score of subjective signs, a score of objective signs.
B. Subjective signs and a score of objective signs.
S. Volume of skin defect (in percentage)
D. Subjective signs
E. Objective signs.
13. Cyril 5 years old , is ill with atopic dermatitis for 2 years. What index pays off for the
estimation of the severity of the disease and efficiency of therapy?
A.. Chulitsky index
B.. Kettle index
+C. SCORAD index
D. Sokolov – Lajona index
E. All listed
14. Ice crust in a 3 years old, the diagnosis atopic dermatitis is established. What additional
methods of investigation are necessary for diagnosis confirmation?
A. Allergen-test
B. IgE level
C. Blood analysis (eosinophils level)
D. Ultrasonography of abdomen
+E. All listed
15. In 4 years old Sasha, suffering from atopic dermatitis, on the basic sum of the area of skin
defect (in percentage), scores of subjective and objective signs have been calculated by index of
SCORAD. What subjective criteria were used for calculation of the given index?
A. Erythema and hypostasis
B. Lichenification and dryness
C. Atopy in the anamnesis and recurrent course
+D. Itching and dream infringement
E. Level of IgE and eosinophils level in general analysis of blood.
 16. In 8 years old Vasya, the diagnosis atopic dermatitis is established. What preparations are
necessary for use in the basic therapy of disease?
A.Antihistamines
B. Membrane stabilizers
C.Hepatoprotectors
D.Eubiotic
+E. All listed
17. Angela 9 years old, has suffered atopic dermatitis for 3 years. The defect areas are localised
on the flexor surfaces of elbow and knee joints. Locally is expressed hyperemia, lichenification. The girl
is disturbed by the intensive itch amplifying at night. Index SCORAD makes 67 %. What preparations
areneeded for local therapy?
+A. Topical glucocorticoids
B. Inhalation glucocorticoids
C. Systematic glucocorticoids
D.Membrane stabilizers
E. Eubiotic
18. Maxim 12 years old, the diagnosis atopic dermatitis is established. In the program of basic
therapy are appointed аntihistaminе preparations of 2nd generations. What preparations does not concern
the given group?
A.Loratadine
B.Cetirizine
+C.Clemastine
D.Azelastine
E. Ebastine
19. Nikita 12 years old, suffers from atopic dermatitis the widespread form. The disease is
resistant to antihistamine preparations., So the boy was appointed systemic corticosteroids. Name the
basic pharmacological effects of these preparations of the given group?
A.Immunnosuppressants
B.Antiallergic
C.Resorbtive
D.Antiedematic
+E. All the above
20. Ruslan,14 years old, suffering from atopic dermatitis, has been appointed topical
corticosteroids. What kind of effects does these preparations possess?
A. Atrophy of a skin and hypodermic cells
B. Teleangioectasia
C.Hypertrichosis
D.Predisposition to infection
+E. All of the above
21. 7 years old, Maria's parent, give complaints to periodic episodes of nasal obstruction in their
child, nose itch. The given symptoms are connected with popular flowering. Exudative catarrhal
diathesis is observed in the anamnesis of the girl. Family allergic anamnesis is burdened: the
grandmother has pollen allergy. What disease is the most probable?
A. Bronchial asthma
B. Sinusitis
+C. Allergic rhinitis
D. Foreign body in nose
E. Acute rhinitis
22. In 12 years old Andrey, annually in April-May are marked the following symptoms:
obstruction of nasal breathing, itching of nose. The given symptoms decrease at night and increase in
the afternoon. Signs of conjuctivitis are typical. By rhinoscopcy: swelling of mucous membrane
of nasal partition; hypostasis of the bottom and average nasal bowls;
nasal mucous membrane is pale-grey with a bluish shade marble surface and brilliant drawing. The
presumable diagnosis is allergic rhinitis. What additional methods of investigation are needed for
diagnosis confirmation?
A. X-ray of additional comparmtents of nose
B.Allergen-test
C .Measuring level specific and nonspecific IgE.
D.Blood analysis
+E. All the above
23.Snegana 8 years old , have been established by the children's allergist the diagnosis allergic
rhinitis. What laboratory criteria is diagnostic for the given pathology?
+A. Determination of level of the general IgE and definition specific IgE to causing-significant
allergens in blood
B.Determination of level of the general and direct bilirubin in blood
C.Determination of level sial acids in blood
D. Decreasing of level of the general IgE in blood
E. Determination of level of uric acid in blood

24. 11 years old Mikhail, has been diagnosed with allergic rhinitis. What groups of preparations
are used as therapy of the given disease?
A. Cromolyn acids derivates
B. Antihistamine preparations of 1st &2nd generations
C. Topical corticosteroids
+D. All the above
E. None of the above
25. 10 years old Margarita, who is ill with allergic rhinitis for 2 years, have been appointed
topical corticosteroids. What preparations are not included into the given group?
A. Fluticasone
B.Beclometasone dipropinate
C.Mometasone furoate
+D. Prednisolone
E. Triamcinolone acetonide

Tasks
1. 3 months old, Ruslan’s parents, have come to the local pediatrician complaining of intertrigo and
rashes on the skin of the child. The given signs connected with changing into formula feeding. At
examination: skin is red in folds, on skin of cheeks is warm hyperemia with a shelled surface, on head -
gneiss elements, on abdominal skin - macular rash. From the family anamnesis: father has atopic
dermatitis.
1. What condition is most probable in the child?
2. What tissues are involved in the process of the given condition?
3. What skin disorders are typical for the given condition?
4. What groups of allergens is the causative factor?
5. Make the plan of additional investigations.

2. Masha, 6 months old, is on breast feeding. Maculo-papular rash on skin of body and the lower
extremities, intertrigo has appeared. Mother of the child connects the given signs with intake of
chocolate and oranges in food.
1. Establish the preliminary diagnosis
2. What mucous membranes injuires are typical for the given condition?
3. Make the plan of additional investigation.
4. Recommended diet-therapy.
5. What groups of preparations are applied in treatment of the given condition.

3. Veronica, 6 months old, after introduction of juice from red apples, had a small spotty-papular rash
on the body, milky scab on the skin of cheeks, «geographical tongue». In blood test - eosinophilia.
Results of allergen-test have revealed allergy to tangerines, chicken meat, red apples, carrots. Level IgE
is raised 2,5 times.
1. Establish the diagnosis
2. Make the treatment plan.
3. Name pathogenetic forms of the given diathesis.
4. What anatomo-physiological features contribute to the given diathesis?
5. What allergens are significant causative factors?

4. The rash, gneiss has appeared in Xenia, 4 months old, after changing into formula feeding (formula
on the basis of cow milk). Hereditary allergic anamnesis is burdened - mother has bronchial asthma,
elder brother-atopic dermatitis.
1. Establish the diagnosis
2. The plan of additional investigation
3. What system of bodies is involved in the process?
4. Give recommendations on diet therapy.
5. What local treatment is indicated for the child?

5. Denis, 10 years old, has marked itching foci of hyperemia, dryness of skin, crusts, lichenification on
flexor surfaces of joints has appeared. Skin drawing is expressed considerably. The itch amplifies at
night. The mother of the child has bronchial asthma, the uncle has eczema.
1. Establish the diagnosis
2. Name obligatory diagnostic criteria of the given disease.
3. What risk factors are present at the anamnesis in the boy?
4. Make the investigation plan
5. What changes in immunogram are probable?

6. Tatyana, 12 years old, has been ill for 3 years. She complains to the foci of intensive itching on
elbow joints, skin of eyelids, neck. Objectively: skin is dry, dim, skin drawing is increased. It is marked
with erythema, infiltration, crusts, lichenification. Dermographism is white, proof. Den’e - Morgan folds
on the lower extremities are revealed. The anamnesis data - exudative-catarrhal diathesis, allergic to
tangerines, sweet cherry, fish, beets. The father of the child has bronchial asthma.
1. Establish the diagnosis.
2. Make the plan of additional inspection.
3. What changes in the blood test are probable?
4. Criteria of course severity estimation.
5. Recommended regimen and a diet.

7. 7 years old, Paul’s parents complains to occurrence in the boy of the itching foci on face, skin and
elbow joints after a trauma. The local status: hyperemia, hypostasis, lichenification, dryness. In the
anamnesis - a food allergy, urticaria.
1. Formulate the presumable diagnosis.
2. Make the plan of additional investigation.
3. What is index SСORAD?
4. What preparations group are used in disease therapy?
5. Recommended climatic resorts

8. 5 years old Daniel has been ill for 1 year. Mother has noticed occurrence on skin of neck and knee
joints, itching red centers. Objectively: the skin is dry, skin drawing is sharply expressed, lichenoid
papules. From 1 month of age the child had exhudative-catarrhal diathesis after changing into formula
feeding.
1. Establish the diagnosis.
2. What data of the anamnesis show the atopic origin of the disease?
3. Compose the treatment plan.
4. What local therapy is indicated for the patient?
5. Side effects of topical corticosteroids.
9. 8 years old ,Anton's parents, have complaints to difficult nasal breathing, itch in the child. The given
signs are accompanied by conjunctivitis. Parents connect it with pollen blossoming. Objectively: the boy
is pale, dark shadow under eyes, nasal breathing is complicated, hyperemic nasal skin, nasal discharge -
mucous, watery. From the anamnesis - mother has pollinosis, uncle has atopic dermatitis.
1. Make the presumable diagnosis.
2. What data of the anamnesis confirms atopic origin of the disease?
3. What allergens are causally-significant?
4. Make the investigation plan.
5. The treatment plan.

10. Vladimir, 15 years old, complaints to disorder of nasal breathing, mucous discharge from nose,
itching of nose. The given symptoms repeat annually in spring - summer period. The elder brother of the
boy suffers from bronchial asthma, mother has eczema. In blood test - eosinophilia. Level IgE is raised
1,5 times. Results of allergen-test have revealed a sensitisation to popular pollen, peach, tangerines,
chicken meat, potato.
1. Establish the diagnosis
2. With what diseases it is necessary to differentiate this problem?
3. What kind of clinico-anamnestic data point out the allergic origin of disease?
4. Recommendations about a regime and a diet.
5. Make the treatment plan.

11. Nazar, 12 years old, on the basis of complaints on itching on the elbow joints, the given anamnesis
of disease (he has been ill for 2 years with aggravation and remission periods), data of the family
anamnesis (the father has eczema), results of objective investigation (hypostasis signs, infiltration,
lichenification in the defect pathologic foci) have been made the preliminary diagnosis atopic dermatitis.
1. Make the plan of additional investigation of the patient.
2. What methods of research are necessary for definition of disease severity?
3. What changes are probable in the general analysis of blood?
4. Calculation of index SСORAD
5. Make the treatment plan

12. Vadim, 8 years old, on the basis of complaints on seasonal nasal obstruction, rhinorrea, itching of
nose, data of the anamnesis of disease (2 years of been ill, disease connects with blossoming of
аmbrosia in august), the family anamnesis (mother has pollen allergy, bronchial asthma), objective data
(nasal breathing is difficult, serous discharge from nose, hyperemia of nose, conjunctivitis) has been
made the diagnosis allergic rhinitis.
1. Make the plan of additional investigation.
2. What immunological criteria prove allergic disease origin?
3. Name clinico-diagnostic criteria of an allergic rhinitis
4. Name main principle of medicamentous therapy of an allergic rhinitis
5. What medicamentous preparations are used in therapy of an allergic rhinitis?

13. Elizabeth, 6 months old, after introduction of mashed vegetable; intertrigo, reddening, peeling of the
skin of cheeks have appeared. After exclusion of the given dish these signs are disappeared.
1. Name the presumable diagnosis.
2. What allergens are causally-significant at the given condition?
3. What another injurement of a skin are tipical for the given condition?
4. Make the investigation plan.
5. Diet-therapy. An exception of a diet obligate and facultative food allergens.

14. Nadya, 10 years old, complaints to intensive itching, rash in the thigh, neck, cheeks. The allergic
anamnesis is burdened: exudative catarrhal diathesis from 1 year. Mother of the girl suffers bronchial
asthma. Objectively: hyperemia, crusts, lichenification in the foci. The skin is dry, skin drawing is
expressed.
1. Establish the diagnosis.
2. The plan of laboratory-instrumentally investigation.
3. What subjective symptoms of disease used for calculation of index SСORAD?
4. What anamnesis data point out on atopic origin of the disease?
5. What preparations are appointed for local therapy of given disease.

8. Classroom materials for self-study.

8.1. List of educational practical tasks that must be completed during the practical exercises:
1. Collect history, provide data that indicate an allergic nature of the disease.
2. Identify the most informative features of the disease during objective and laboratory and instrumental
examination of the patient.
3. Clinical diagnosis by modern classification.
9. Instructional materials for learning professional skills.
9.1. Methods of work Stages of the possible
List of educational practical tasks that must be completed during the practice session:
1. Non-pharmacological treatments in the program rehabilitation of children with bronchial asthma.
2. Emergency treatment of asthma in children.
3. Nebulized therapy practice in the treatment of bronchial asthma in children.

10. Materials for self study,

10.1. Tests
In 3 months old Alona, the local pediatrician diagnosed signs of exudative catarrhal diathesis. Name the
most significant group of causative allergens?
+A.Food
B.Pollen
C.Fungal
D.Epidermal
E.Household
2. 4 months old Olesya, after change into artificial feeding by formula on the basis of cow milk has
appeared intertrigo in unguentum and axilliary folds, warm hyperemia on cheeks’ skin. It is possible to
think of what condition?
A.Eczema
B. Nursing defect
+C. Exudative catarrhal diathesis
D. Infectious eczema
E. None of the above
3. Vadim is 5 months old, after introduction of carrot juice ,had a milky scab, gneiss, maculo-
papular rash. What changes from mucous membranes can be at the given condition?
А «Geographical tongue»
B.Rhinitis
C.Vulvitis
D.Conjuctivitis
+E. all of the above
4. Dennis, 5 months old, is on breast feeding. After mother gave chocolate and nuts to the child,
appeared macula-papular rash, intertrigo in unguentum and axillary folds. The local pediatrician
diagnosed exudative catarrhal diathesis. What is the doctor’s recommendations concerning the diet the
mother should be give?
A.Elimination of easily digested carbohydrates
+B. Elimination of food allergens
C.Elimination of products with the high levels of purine bases
D.Elimination of products with the high levels of calcium
E. Water loading
 5. Ivan, 2 months old , after change into artificial feeding, had gneiss, a milky scab, maculo-papular
rash on the abdomen and back skin. The local doctor diagnosed exudative catarrhal diathesis. What
additional methods of investigations are necessary for diagnosis to be confirmed?
A. General blood analysis (level of eosinophils)
B.Allergen-test
C IgE level
D IgА lvel
+E. All of the above

11. Topic of the next lesson: Atopic dermatitis.

11.1 Task for research work:

 Evaluation of skin damage according to SCORAD
 Study the role of protein-flaggrin in atopic dermatitis in children.
 Features of topic cytokine status in atopic dermatitis in children.

The study guide was prepared by M.D. Stoeva T.V.