Rosen & Barkin's 5-Minute Emergency Medicine Consult (748 page)

• Cautions:
  
  • Systemic allergic reactions can rapidly progress if not treated with early epinephrine
    
• Severe reaction:
  
  • Manage airway, oxygen
    
  • IM epinephrine
    
  • Parenteral or inhaled β-agonist for bronchospasm
    
  • IV crystalloid and vasopressors as needed
    

Remove offending agent if possible

• Largely symptomatic except in severe reactions
  
• Treatment aimed at stimulus, effector cells, inflammatory mediators, and target receptors
  
• β-Agonist (parenteral or inhaled):
  
  • Severe hives, angioedema, systemic features
    
• H
  ₁
  -receptor antagonist (1st or 2nd generation):
  
  • Mainstay of treatment
    
• H
  ₂
  -receptor antagonist:
  
  • May be beneficial as adjunct to H
    ₁
    blocker when no response to H
    ₁
    blocker alone
    
• Corticosteroid (oral):
  
  • S
    evere or refractory cases
    
• Avoid NSAIDs and opiates:
  
  • May exacerbate condition
    
• Concurrent use of ketoconazole or macrolides alters hepatic metabolism of antihistamine; use with caution
  

• β-Agonists:
  
  • Epinephrine (1:1,000 solution): 0.1–0.5 mg IM q10–15min PRN (peds: 0.01 mg/kg, IM [max. single dose not to exceed 0.3 mg] q15min PRN)
    
  • IV epinephrine 0.1–0.25 mg (1:10,000 sol) IV over 5–10 min q5–15min then 1–4 μg/min IV ONLY if anaphylactic shock
    
  • Albuterol (0.5% solution): 0.5 mL nebulized q20min PRN (peds: 0.01–0.05 mL/kg per dose [max. 0.5 mL/dose] nebulized q20min PRN bronchospasm)
    
  • Terbutaline: 0.25 mg SC q15–30min PRN (max. 0.5 mg q4h); (peds: <12 yr old; 0.005–0.01 mg/kg [max. 0.4 mg/dose] SC q15–20min × 3 PRN bronchospasm)
    
• H
  ₁
  -receptor antagonist (1st generation—lipophilic and sedating)
  
  • Diphenhydramine: 25–50 mg PO, IV, or IM q6h (peds: 1 mg/kg q6h [max. 300 mg/24 h])
    
  • Hydroxyzine: 25–50 mg PO or IM q6h (peds: 2 mg/kg/24 h PO div. q8h or 0.5–1 mg/kg IM q4–6h PRN)
    
• H
  ₁
  -receptor antagonist (2nd generation—less sedating and preferred):
  
  • Cetirizine: Adult and peds ≥6 yr old: 5–10 mg PO QD (peds 2–6 yr old: 2.5 mg QD to BID)
    
  • Loratadine: 10 mg PO BID (peds 2–6 yr old: 5 mg PO QD
    
  • Fexofenadine: 60 mg PO BID or 180 mg PO QD (peds 6–12 yr old: 30 mg PO BID)
    
• H
  ₂
  -receptor antagonist (suggested dosage):
  
  • Famotidine: 20 mg IV q12h or 20–40 mg PO QHS (peds: 1 mg/kg/d div. QID [max. 40 mg/24 h])
    
  • Ranitidine: 150 mg PO BID (peds: Neonate: 2–4 mg/kg/24 h PO div. q8–12h or 2 mg/kg/24 h IV div. q6–8h; infants and children: 4–5 mg/kg/24 h PO div. q8–12h or 2–4 mg/kg/24 h IV or IM div. q6–8h)
    
• Corticosteroid:
  
  • Methylprednisolone: 125 mg IV (peds: Start at 2 mg/kg × 1)
    
  • Prednisolone: 50 mg PO QD for 3 days (peds: 0.5–2 mg/kg/24 h [max. 80 mg/24 h] div. QD to BID for 3–5 days)
    
  • Prednisone: 40 mg PO QD or 20 mg PO BID for 3–5 days (peds: 1–2 mg/kg/24 h [max. 80 mg/24 h] div. QD to BID for 3–5 days)
    
• Antileukotrienes:
  
  • Montelukast: 10 mg PO QD
    
  • Zafirlukast: 20 mg PO BID
    

• H
  ₁
  -receptor antagonist, 2nd generation
  
• Corticosteroids
  
• β-Agonists:
  
  • Albuterol if bronchospasm present
    
  • Epinephrine for severe or systemic signs
    

• Antileukotrienes
  
• H
  ₁
  -receptor antagonist, 1st generation
  
• H
  ₂
  -receptor antagonist, data weak
  

FOLLOW-UP

• Systemic allergic reaction with:
  
  • Respiratory distress or failure
    
  • Refractory hypotension or shock
    
• Severe case with dysfunction of health-related quality of life
  
• Other comorbidities
  

• Normal vitals
  
• Absence of other condition requiring admission
  
• Adequate ability of caregivers at home to monitor for further exacerbations
  

Follow with PCP, especially if lasting >6 wk

• If severe presentation, there is often a biphasic course. Rebound may occur in 4–6 hr
  
• Chronic urticaria often has a systemic cause
  

• Kropfl L, Mauer M, Zuberbier T. Treatment strategies in urticaria.
  Expert Opin. Pharmacother.
  2010;11:1445–1450.
  
• Nichols K, Cook-Bolden F. Allergic skin disease: Major highlights and recent advances.
  Med Clin N Am.
  2009;93:1211–1224.
  
• Ricci G, Giannetti A, Belotti T, et al. Allergy is not the main trigger of urticaria in children referred to the emergency room.
  J Eur Acad Dermatol Venereol.
  2010;24:1347–1348.
  
• Wolfson AB, Hendey GW, Ling LJ, et al. (eds)
  Harwood-Nuss’ Clinical Practice of Emergency Medicine.
  5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010.
  
• Zuberbier T. A summary of the new international EAACI/GA(2)LEN/EDF/WAO guidelines in urticaria.
  WAO J.
  2012;5(suppl 1):S1–S5.
  
• Zuberbier T, Asero R, Bindslev-Jensen C, et. al. EAACI/GA2LEN/EDF/WAO guideline: definition, classification, and diagnosis of urticaria.
  Allergy.
  2009;64:1417–1426.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Angioedema
  
• Erythema Multiforme
  
• Vasculitis
  

CODES

• 708.0 Allergic urticaria
  
• 708.1 Idiopathic urticaria
  
• 708.9 Unspecified urticaria
  

BASICS

Uvulitis refers to any inflammatory condition involving the uvula. Uvulitis can be separated into 2 broad categories:

• Infectious:
  
  • Bacterial
    
  • Viral
    
  • Candidal
    
• Traumatic or noninfectious
  

• Exact incidence is unknown owing to limited reporting
  
• Once thought to be rare but may in fact be more common (e.g., viral etiologies)
  
• Children (age 5–15) more often affected than adults due to prevalence of group A streptococcal infections in this age group
  
• Noninfectious causes more common than infectious causes in adult population
  

• Infectious:
  
  • Bacterial:
    
    • Group A streptococcal infection (GAS), most common
      
    • Haemophilus influenzae
      type b (Hib)
      
    • Other bacterial infections (
      Fusobacterium nucleatum, Provetella intermedia, Streptococcus pneumonia
      )
      
  • Viral:
    
    • Not well reported but suspected in mild/transient cases
      
    • Known to cause uvular lesions however rare in isolation
      
    • Coxsackie virus (other enteroviruses)
      
    • Herpes simplex virus
      
    • Varicella-zoster virus
      
    • Epstein–Barr virus
      
  • Candidal infections
    
• Noninfectious:
  
  • Trauma/procedure related
    
  • Inhalation/ingestion of chemical or thermal irritants
    
  • Vasculitis
    
  • Allergic
    
  • Angioedema:
    
    • Hereditary
      
    • Medication induced (e.g., Angiotensin-converting enzyme inhibitor [ACEi], Angiotensin receptor blocker [ARB])
      

DIAGNOSIS