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Author: Richard S Krause, MD, Senior Faculty, Department of Emergency Medicine, State University of New York at Buffalo School of Medicine
Updated: Sep 2, 2009
Anaphylaxis is a severe allergic reaction that is rapid in onset and may cause death. There are usually prominent dermal and systemic signs and symptoms. The full-blown syndrome includes urticaria (hives) and/or angioedema with hypotension and bronchospasm. The classic form, described in 1902, involves prior sensitization to an allergen with later re-exposure, producing symptoms via an immunologic mechanism. An anaphylactoid reaction produces a very similar clinical syndrome but is not immune-mediated. Treatment for both conditions is similar, and this article uses the term anaphylaxis to refer to both conditions unless otherwise specified. A recent consensus report reviewed the definition and management of anaphylaxis.1
For additional information, see Medscape's Allergy & Immunology Resource Center.
Rapid onset of increased secretion from mucous membranes, increased bronchial smooth muscle tone, decreased vascular smooth muscle tone, and increased capillary permeability occur after exposure to an inciting substance. These effects are produced by the release of mediators, which include histamine, leukotriene C4, prostaglandin D2, and tryptase.
In the classic form, mediator release occurs when the antigen (allergen) binds to antigen-specific immunoglobulin E (IgE) attached to previously sensitized basophils and mast cells. The mediators are released almost immediately when the antigen binds. In an anaphylactoid reaction, exposure to an inciting substance causes direct release of mediators, a process that is not mediated by IgE. Increased mucous secretion and increased bronchial smooth muscle tone, as well as airway edema, contribute to the respiratory symptoms observed in anaphylaxis. Cardiovascular effects result from decreased vascular tone and capillary leakage. Histamine release in skin causes urticarial skin lesions.
The most common inciting agents in anaphylaxis are parenteral antibiotics (especially penicillins), IV contrast materials, Hymenoptera stings, and certain foods (most notably, peanuts). Oral medications and many other types of exposures also have been implicated. Anaphylaxis also may be idiopathic.
The true incidence of anaphylaxis is unknown, partly because of the lack of a precise definition of the syndrome. Some clinicians reserve the term for the full-blown syndrome, while others use it to describe milder cases. Fatal anaphylaxis is relatively rare; milder forms occur much more frequently. The frequency of anaphylaxis is increasing, and this has been attributed to the increased number of potential allergens to which people are exposed. Up to 500-1,000 fatal cases of anaphylaxis per year are estimated to occur in the United States. A recent review concluded that the lifetime prevalence of anaphylaxis is 1-2% of the population as a whole.2
Reactions to insects and other venomous plants and animals are more prevalent in tropical areas because of the greater biodiversity in these areas.
Approximately 1 in 5000 exposures to a parenteral dose of a penicillin or cephalosporin antibiotic causes anaphylaxis. More than 100 deaths per year are reported in the United States. Fewer than 100 fatal reactions to Hymenoptera stings are reported each year in the United States but this is considered to be an underestimate. One to 2% of people receiving IV radiocontrast experience some sort of reaction. The majority of these reactions are minor, and fatalities are rare. Low molecular weight contrast causes fewer and less severe reactions.
Well-described racial differences in the incidence or severity of anaphylaxis do not exist. Cultural and socioeconomic differences may influence exposure rates.
Differences have been reported in the incidence and prevalence of anaphylactic reactions between men and women. Overall, women have a higher incidence of anaphylaxis than men, but, in some series of children, males predominate.2
Anaphylaxis occurs in all age groups. Food allergies are more common in the young, whereas more drug reactions occur in adults, possibly due to greater exposure. Although prior exposure is essential for the development of true anaphylaxis, reactions occur even when no documented prior exposure exists. Thus, patients may react to a first exposure to an antibiotic or insect sting. Elderly persons have the greatest risk of mortality from anaphylaxis due to the presence of preexisting disease.
- Anaphylactic reactions almost always involve the skin or mucous membranes. More than 90% of patients have some combination of urticaria, erythema, pruritus, or angioedema.
- The upper respiratory tract commonly is involved, with complaints of nasal congestion, sneezing, or coryza. Cough, hoarseness, or a sensation of tightness in the throat may presage significant airway obstruction.
- Eyes may itch and tearing may be noted. Conjunctival injection may occur.
- Dyspnea is present when patients have bronchospasm or upper airway edema. Hypoxia and hypotension may cause weakness, dizziness, or syncope. Chest pain may occur due to bronchospasm or myocardial ischemia (secondary to hypotension and hypoxia).
- GI symptoms of cramplike abdominal pain with nausea, vomiting, or diarrhea also occur but are less common, except in the case of food allergy.
- In a classic case of anaphylaxis, the patient or a bystander provides a history of possible exposures that may have caused the rapid onset of skin and other manifestations. This history often is partial; exposure may not be recalled, or it may not be considered significant by the patient or health care provider. For example, when queried about medications, a patient may not mention over-the-counter (OTC) products. The clinician may not realize that, while reactions are usually rapid in onset, they also may be delayed.
- For reasons that are not well understood, a lack of dermal findings is more common in children than in adults.
- General
- Physical examination of patients with anaphylaxis depends on affected organ systems and severity of attack. Vital signs may be normal or significantly disordered with tachypnea, tachycardia, and/or hypotension.
- Place emphasis on determining the patient's respiratory and cardiovascular status.
- Frank cardiovascular collapse or respiratory arrest may occur in severe cases. Anxiety is common unless hypotension or hypoxia causes obtundation. Shock may occur without prominent skin manifestations or history of exposure; therefore, anaphylaxis is part of the differential diagnosis for patients who present with shock and no obvious cause.
- General appearance and vital signs vary according to severity of attack and affected organ system(s). Patients commonly are restless due to severe pruritus from urticaria. Anxiety, tremor, and a sensation of cold may result from compensatory endogenous catecholamine release. Severe air hunger may occur when the respiratory tract is involved. If hypoperfusion or hypoxia occurs, the patient may exhibit a depressed level of consciousness or may be agitated and/or combative. Tachycardia usually is present, but bradycardia may occur in very severe reactions.
- Skin
- The classic skin manifestation is urticaria (ie, hives). Lesions are red and raised, and they sometimes have central blanching. Intense pruritus occurs with the lesions. Lesion borders usually are irregular and sizes vary markedly. Only a few small or large lesions may become confluent, forming giant urticaria. At times, the entire dermis is involved with diffuse erythema and edema. Hives can occur anywhere on the skin.
- In a local reaction, lesions occur near the site of a cutaneous exposure (eg, insect bite). The involved area is erythematous, edematous, and pruritic. If only local skin reaction (as opposed to generalized urticaria) is present, systemic manifestations (eg, respiratory distress) are less likely. Local reactions, even if severe, are not predictive of systemic anaphylaxis on reexposure.
- Lesions typical of angioedema also may manifest in anaphylaxis. The lesions involve mucosal surfaces and deeper skin layers. Angioedema usually is nonpruritic and associated lesions are nonpitting. Lesions most often appear on the lips, palms, soles, and genitalia.
- Pulmonary
- Upper airway compromise may occur when the tongue or oropharynx is involved. When the upper airway is involved, stridor may be noted. The patient may have a hoarse or quiet voice and may lose speaking ability as the edema progresses. Complete airway obstruction is the most common cause of death in anaphylaxis.
- Wheezing is common when patients have lower airway compromise due to bronchospasm or mucosal edema.
- In angioedema, due to ACE inhibitors, marked edema of the tongue and lips may obstruct the airway.
- Cardiovascular
- Cardiovascular examination is normal in mild cases. In more severe cases, compensatory tachycardia occurs due to loss of vascular tone.
- Intravascular volume depletion may take place as a consequence of capillary leakage. These mechanisms also lead to development of hypotension.
- Relative bradycardia has been reported.
- A wide variety of substances can cause anaphylaxis. Drugs and foods are the most common causes. Peanuts, tree nuts, and shellfish are the most commonly implicated foods, while antibiotics (especially penicillins) and nonsteroidal anti-inflammatory drugs (NSAIDs) are the most common drugs. Anaphylaxis also may be idiopathic.
- In the classic form of anaphylaxis, a foreign protein is the inciting agent (eg, antigen). On initial exposure, the antigen elicits generation of an IgE antibody. The antibody residue binds to mast cells and basophils. On reexposure, the antigen binds to the antibody, and the receptors are activated. Clinical manifestations result from release of immune response mediators such as histamine, leukotrienes, tryptase, and prostaglandins. The same mechanism occurs when a nonimmunogenic foreign substance binds as a so-called hapten to a native carrier protein, creating an immunogenic molecule. Factors influencing severity of a reaction include degree of host sensitivity and dose, route, and rate of administration of the offending agent.
- Parenteral exposures tend to result in faster and more severe reactions. Most severe reactions occur soon after exposure. The faster a reaction develops, the more severe it is likely to be. While most reactions occur within hours, symptoms may not occur for as long as 3-4 days after exposure.
- Penicillin and cephalosporin antibiotics are the most commonly reported medical agents in anaphylaxis. This prevalence is a function of the immunogenicity and frequent use of these agents. Although concern for cross-sensitivity has been present because of their molecular and immunologic similarity, there is growing evidence that this association is not significant and is based on historic data with early cephalosporins.
- Prior reports, based on skin testing, indicated that about 10% of patients allergic to a penicillin antibiotic are allergic to cephalosporins.
- One report suggested that the actual incidence of clinical cross-reactivity is lower (perhaps 1%), with most reactions considered mild.3 Another paper indicated that patients with a history of allergy to penicillin seem to have a higher risk (by a factor of about 3) of subsequent reaction to any drug and that the risk of an allergic reaction to cephalosporins in patients with a history of penicillin allergy may be up to 8 times as high as the risk in those with no history of penicillin allergy (ie, at least part of the observed "cross reactivity" may represent a general state of immune hyperresponsiveness, rather than true "cross-reactivity").4
- One retrospective study evaluated 606 hospitalized patients with a history of penicillin allergy who were given a cephalosporin. Only one patient (0.17%) had a reaction, and it was minor.5
- A review of the topic of penicillin and cephalosporin "cross-reactivity" concluded that the widely quoted 10% "cross-reactivity" is a myth.6
- In penicillin-allergic patients, cephalothin, cephalexin, cefadroxil, and cephazolin are more likely to precipitate an allergic reaction than cefprozil, cefuroxime, ceftazidime, or ceftriaxone. This increased reactivity with the older agents is due to greater antigenic similarity of the side chain not present with the newer second- and third-generation agents.
- Patients with a history of positive skin tests for penicillin allergy are at high risk of subsequent reactions. However, approximately 85% of patients with a history of penicillin allergy have negative skin tests and a low risk of reactions.
- When a drug in either class is the drug of choice for a patient with a life-threatening emergency, a number of options exist. When the history is indefinite, the drug may be administered under close observation; however, when possible, obtain the patient's informed consent. Immediate treatment measures for anaphylaxis should be available. Alternatively, when the history is more convincing, a desensitization or prophylactic pretreatment protocol may be instituted or another agent selected.
- Prior reports, based on skin testing, indicated that about 10% of patients allergic to a penicillin antibiotic are allergic to cephalosporins.
- Reactions to medications tend to be more severe and rapid in onset when the antibiotic is administered parenterally.
- A drug reaction may occur in a patient with no prior history of drug exposure.
- Aspirin and NSAIDs commonly are implicated in allergic reactions and anaphylaxis. Bronchospasm is common in patients with reactive airway disease and nasal polyps. Cross-reactivity often occurs between aspirin and the various NSAIDs.
- ACE inhibitors, widely used in the treatment of hypertension, are associated with angioedema in 0.5-1.0% of patients who take them. Systemic anaphylaxis is rarely associated with these agents. The reaction is thought to be mediated by bradykinin and is more common in African Americans.
Intravenous radiocontrast media
- IV administered radiocontrast media causes an anaphylactoid reaction that is clinically similar to true anaphylaxis and is treated in the same way. The reaction is not related to prior exposure. Shellfish or iodine allergy is not a contraindication to use of IV contrast and does not mandate a pretreatment regimen. As with any allergic patient, give consideration to use of low molecular weight (LMW) contrast.
- The term iodine allergy is a misnomer. Iodine is an essential trace element present throughout the body. No one is allergic to iodine. Patients who report iodine allergy usually have had either a prior contrast reaction, a shellfish allergy, or a contact reaction to povidone-iodine (Betadine). Manage these patients as indicated earlier.
- Approximately 1-3% of patients who receive hyperosmolar IV contrast experience a reaction. Use of LMW contrast decreases incidence of reactions to approximately 0.5%. Personnel, medications, and equipment needed for treatment of allergic reactions always should be available when these agents are administered. Obtain consent before administration.
- Reactions to radiocontrast usually are mild (most commonly urticarial), with only rare fatalities reported. Risk of a fatal reaction has been estimated at 0.9 cases per 100,000 exposures.
- Mucosal exposure (eg, GI, genitourinary [GU]) to radiocontrast agents has not been reported to cause anaphylaxis; therefore, a history of prior reaction is not a contraindication to GI or GU use of these agents.
- Pretreatment with antihistamines or corticosteroids and use of LMW agents lead to lower rates of anaphylactoid reactions to IV contrast. Consider these measures for patients who have prior history of reaction, since rate of recurrence is estimated at 17-60%. Some institutions use only LMW agents. Patients who are atopic and/or asthmatic also are at increased risk of reaction. In addition, allergic reaction is more difficult to treat in those taking beta-blockers.
Hymenoptera stings
- Hymenoptera stings are a common cause of allergic reaction and anaphylaxis. An uncertain but enormous number of exposures occur; accurate reaction rates are therefore difficult to estimate. In the United States, Hymenoptera envenomations result in fewer than 100 reported deaths per year.
- Local reaction and urticaria without other manifestations of anaphylaxis are much more common than full-blown anaphylaxis. Generalized urticaria is a risk factor for subsequent anaphylaxis; but a local reaction, even if severe, is not a risk factor for anaphylaxis.
- Caution patients treated and released from the ED after an episode of anaphylaxis or generalized urticaria from Hymenoptera envenomation to avoid future exposure when possible. Consider referral to an allergist for desensitization, particularly when further exposure is likely. Additionally, consider prescribing a treatment kit with an epinephrine auto-injector and oral antihistamine. Both are effective measures in preventing or ameliorating future reactions.
Food and environmental allergies
- Food allergy is common. Symptoms usually are mild and limited to the GI tract, but full-blown anaphylaxis can occur. Fatalities are rare compared to number of exposures; however, the number of exposures is so high that foods may be the commonest cause of anaphylaxis. Anaphylaxis due to foods may be an underrecognized cause of sudden death and an unappreciated cause of diagnosed anaphylaxis. Commonly implicated foods include peanuts, tree nuts, legumes, fish and shellfish, milk, and eggs. Reports of severe allergic reactions to peanuts are increasing.
- Latex allergy is an increasingly recognized problem in medical settings, where use of gloves and other latex products is ubiquitous. Most reactions are cutaneous or involve the mucous membranes. Anaphylactic reactions occur and have been reported with seemingly benign procedures (eg, Foley catheter insertion, intraperitoneal exposure to gloves during surgery).
Anaphylaxis: Differential Diagnoses & Workup
Other Problems to Be Considered
Globus hystericus
Hereditary angioedema
Monosodium glutamate poisoning (ie, Chinese restaurant syndrome)
- The diagnosis of anaphylaxis is clinical and does not rely on laboratory testing. When typical symptoms are noted in association with a likely exposure, diagnosis is virtually certain. Ancillary testing may help assess severity of reaction, although this is primarily a clinical judgment. When unclear, ancillary testing may help establish the diagnosis.
- The only potentially useful test at the time of reaction is measurement of serum mast cell tryptase, though the test's availability and slow turnaround time greatly limit its clinical utility. Tryptase is released from mast cells in both anaphylactic and anaphylactoid reactions. Levels are usually raised in severe reactions. Mast cell tryptase is raised transiently with blood levels reaching a peak approximately an hour after reaction onset.
- Tryptase levels may aid in later diagnosis and treatment.
- Consider the test in cases for which diagnosis of anaphylaxis is uncertain.
- The utility of this test awaits full evaluation.
- Cardiac monitoring in patients with severe reactions and in those with underlying cardiovascular disease is important, particularly when adrenergic agonists are used in treatment. Pulse oximetry also is useful.
- Imaging studies are not generally useful in the diagnosis and management of anaphylaxis, although they may be used as diagnostic aids when diagnosis is unclear.
- Sensitivity testing
- Testing for sensitivity to penicillin antibiotics may be useful when a penicillin or cephalosporin antibiotic is the drug of choice for a serious infection in a patient who has a history of severe allergic reaction. Obtain informed consent, and ensure that resuscitative equipment is immediately available. Protocols for acute testing for allergy to penicillin or cephalosporin antibiotics involve administration of increasing IV doses of the chosen antibiotic, while observing the patient for pruritus, flushing, urticaria, dyspnea, hypotension, or other manifestations of anaphylaxis. If no manifestations are observed, a full dose of the antibiotic may be administered safely.
- A suggested protocol for IV testing begins with 0.001 mg of the chosen drug. At 10-min intervals, incrementally increase the dose (eg, 0.001 mg, 0.005 mg, 0.01 mg, 0.05 mg, 0.1 g, 0.5 mg, 1 mg, 10 mg, 50 mg, 100 mg, full dose), while observing the patient. Many other protocols exist. In most circumstances, perform desensitization on an inpatient basis. If the necessary resources are available, desensitization may be performed in the ED.
- Intravenous contrast reaction prevention
- Patients with a history of severe reactions to IV contrast material may require use of contrast in an urgent or emergency situation. Alternatives (eg, noncontrast spiral CT scan for ureteral stone, Doppler ultrasonography for deep venous thrombosis [DVT], nuclear scans for pulmonary embolism) should be considered but are not always feasible. In these circumstances, a prophylactic regimen of corticosteroids and antihistamines may be used. The precise efficacy of these regimens is difficult to evaluate, but they generally are considered effective. One author states that the recurrence rate for patients with a previous reaction was reduced from 17-60% to 9% when conventional contrast material was used; the rate was reduced to less than 1% when low osmolality material was employed after a pretreatment regimen.
- The use of H2 blockers has not been shown to decrease the risk of reaction to IV contrast. One study suggests H2 blockers actually appear to increase the risk.
- A widely quoted protocol for prevention of reactions to IV contrast suggests the following:
- Use low osmolality contrast.
- Administer hydrocortisone (200 mg IV); wait 2 hours if clinically appropriate.
- Administer diphenhydramine (50 mg IM) immediately before the procedure.
- Desensitization regimens
- Desensitization regimens for penicillin and cephalosporin antibiotic allergy have been shown effective. Because these regimens are lengthy (approximately 6 h), they have limited applicability to the ED. When patients wait for long periods in the ED or in an observation unit, consider desensitization regimens.
- A typical desensitization regimen involves administering the antibiotic of choice in an initial dose of 0.01 mg. While observing the patient, double the dose every 10-15 minutes until a full dose has been administered.
- Desensitization regimens do not protect against non-IgE-mediated reactions that may be severe or even life threatening (eg, Stevens-Johnson syndrome).
- While theoretically attractive, premedication regimens have not been clinically shown to decrease incidence or severity of IgE-mediated allergic reactions to antibiotics.
Anaphylaxis: Treatment & Medication
Prehospital Care
- Prehospital patients with symptoms of severe anaphylaxis should first receive standard interventions. Interventions include high-flow oxygen, cardiac monitoring, and IV access. These measures are appropriate for an asymptomatic patient who has a history of serious reaction and has been re-exposed to the inciting agent. Additional treatment depends upon the condition of the patient and the severity of the reaction. Measures beyond basic life support (BLS) are not necessary for patients with purely local reactions.
- Immediately assess airway patency due to the potential for compromise secondary to edema or bronchospasm. Active airway intervention may be difficult due to laryngeal or oropharyngeal edema. In this circumstance, it may be preferable to defer intubation attempts, and instead ventilate with a bag/valve/mask apparatus while awaiting medications to take effect. In extreme circumstances, cricothyrotomy or catheter jet ventilation may be lifesaving. Inhaled beta-agonists are used to counteract bronchospasm and should be administered to patients who are wheezing.
- The IV line should be of large caliber due to the potential requirement for large-volume IV fluid resuscitation. Isotonic crystalloid solutions (ie, normal saline, Ringer lactate) are preferred. A keep vein open (KVO) rate is appropriate for patients with stable vital signs and only cutaneous manifestations. If hypotension or tachycardia is present, administer a fluid bolus of 20 mg/kg for children and 1 L for adults. Further fluid therapy depends on patient response. Large volumes may be required in the profoundly hypotensive patient.
- Administer epinephrine to patients with systemic manifestations of anaphylaxis. With mild cutaneous reactions, an antihistamine alone may be sufficient, thus the potential adverse effects of epinephrine can be avoided. Patients on beta-blocker medications may not respond to epinephrine. In these cases, glucagon may be useful. The Medication section describes dosage, routes of administration, and contraindications for medications discussed in this section. Antihistamines (eg, H1 blockers), such as diphenhydramine (Benadryl) are important and should be administered for all patients with anaphylaxis or generalized urticaria.
- Corticosteroids are used in anaphylaxis primarily to decrease the incidence and severity of delayed or biphasic reactions. Corticosteroids may not influence the acute course of the disease; therefore, they have a lower priority than epinephrine and antihistamines.
Emergency Department Care
- ED care begins with standard monitoring and treatment, including oxygen, cardiac monitoring, and a large-bore IV with isotonic crystalloid solution. Further intervention depends on severity of reaction and affected organ system(s).
- Rapidly assess airway patency in patients with systemic signs or symptoms. If required, intubation may be difficult to achieve because of upper airway or facial edema. Standard rapid sequence induction (RSI) techniques can be used but may cause loss of the airway in a patient whose airway anatomy is altered by edema. Epinephrine may rapidly reverse airway compromise, and bag/valve/mask ventilation may be effective in the interim when intubation is not possible. Surgical airway intervention using standard cricothyrotomy is an option when orotracheal intubation or bag/valve/mask ventilation is not effective.
- Wheezing or stridor indicates bronchospasm or mucosal edema. Treatment with epinephrine and inhaled beta-agonists is effective for these indications.
- Recommendations to treat refractory bronchospasm with corticosteroids have been made because of their effectiveness in reactive airway disease. As in asthma therapy, onset of action is delayed for several hours. Aminophylline also has been recommended for bronchospasm in anaphylaxis and may be more rapidly effective than corticosteroids.
- Hypotension in anaphylaxis usually is due to vasodilatation and capillary fluid leakage. Epinephrine is the primary pharmacologic treatment for these findings. H1-blocking antihistamines also may have a role in reversing hypotension. Some authors also recommend H2-blocking agents. Large volume fluid resuscitation with isotonic crystalloid often is needed to support the circulation in patients with cardiovascular manifestations of anaphylaxis.
- Refractory hypotension first should be treated with large volumes of crystalloid and repeated doses of epinephrine or a continuous epinephrine infusion. If this is not effective, other pressors with alpha-adrenergic activity, such as levarterenol (Levophed) or dopamine, may be considered. Cases of effective use of military antishock trousers (MAST) for refractory hypotension have been reported.
- Mediators of anaphylaxis are not considered to have direct myocardial toxicity. In patients with preexisting heart disease, ischemic myocardial dysfunction may occur due to hypotension and hypoxia. Epinephrine still may be necessary in patients with severe anaphylaxis, but remember the potential for exacerbating ischemia. If pulmonary congestion or evidence of cardiac ischemia is present, fluid resuscitation should be approached more cautiously.
- Patients taking beta-blockers may be resistant to the effects of epinephrine. Larger than usual doses may be needed. Glucagon may be effective in this circumstance, because it increases intracellular cyclic adenosine monophosphate (cAMP) levels by a mechanism that does not depend upon beta-receptors.
- Cutaneous effects of anaphylaxis are uncomfortable but not life threatening. Patients often respond promptly to epinephrine and H1 antihistamines. Some authors state that corticosteroids help prevent recurrence of symptoms (both cutaneous and systemic) that may occur 6-8 hours after successful treatment (so-called biphasic reaction). H2 blockers may have an added effect.
- GI symptoms in anaphylaxis respond to H1 antihistamines and epinephrine.
- Disposition: Disposition of patients with anaphylaxis depends upon the severity of the initial reaction and the response to treatment. Patients with non–life-threatening symptoms may be observed for 4-6 hours after successful treatment and then discharged. Patients who have refractory or very severe anaphylaxis (with cardiovascular and/or severe respiratory symptoms) should be admitted or treated and observed for a longer period in the ED or an observation area.
- After discharge care: Patients with cardiovascular and/or respiratory symptoms who have an environmental trigger likely to be encountered after discharge should carry self-injectable epinephrine after discharge. Referral to an allergist should be considered.
Diagnosis and management guidelines are available from the American Academy of Allergy, Asthma, and Immunology; American College of Allergy, Asthma, and Immunology; and Joint Council of Allergy, Asthma, and Immunology.7
- Acute manifestations of anaphylaxis usually respond to ED treatment. In refractory cases, consult with an allergist, cardiologist, pulmonologist, or other intensivist.
- Consultation with an allergist (when available) is appropriate when desensitization to an antibiotic is contemplated.
- When a patient at high risk for contrast reaction is under consideration for a contrast study, consultation with the radiologist regarding pretreatment and choice of contrast agent is appropriate.
- Refer patients who are treated and released from the ED after an episode of anaphylaxis or generalized urticaria to their primary care provider or to an allergist for follow-up. At that time, consideration can be given to skin testing and possible desensitization.
The primary drug treatments for acute anaphylactic reactions are epinephrine and H1 antihistamines. Epinephrine is the drug of choice for life-threatening reactions. When the intravenous route is not indicated, the intramuscular route is preferable to the subcutaneous route due to more rapid and reliable absorption. The anterolateral thigh is the preferred site, especially in children.
Epinephrine is clearly effective for the most serious effects and H1-blockers are also effective; do not delay or defer their use in favor of other treatments. Inhaled beta-agonists lack some of the adverse effects of epinephrine and are useful for cases of bronchospasm, but they may not have additional effects when optimal doses of epinephrine are used. Corticosteroids are potentially effective in preventing biphasic (ie, recurrent) reactions. Due to their delayed effect, corticosteroids are not first-line treatments. H2-blocking antihistamines theoretically are attractive agents for dermal and GI manifestations, but evidence supporting their clinical effectiveness is less than that for H1-blocking agents. Some evidence suggests that combining H1 and H2 blockers may be more effective than H1 blockers alone. Glucagon may be useful in treating refractory cardiovascular effects in patients taking beta-blockers.
Parenteral adrenergic agents
Reverse cardiovascular, cutaneous, GI, and pulmonary manifestations of anaphylaxis.
Epinephrine (EpiPen, Adrenalin)
DOC for shock, angioedema, airway obstruction, bronchospasm, and urticaria in severe anaphylactic reactions. Administer IM (preferred) or SC, except for patients in extremis for whom it is administered IV. May be administered SL or via ET when no IV access available. Continuous infusion may be administered in cases of refractory shock.
0.3-0.5 mL 1:1000 soln SC or IM q15min
0.5-1 mL 1:10,000 soln IV; slow administration; repeat prn
0.3-0.5 mL 1:1000 soln SL q15min
1 mL 1:1000 soln ET in approximately 10 mL NS
IV infusion: 0.1-1 mcg/kg/min
0.01 mL/kg (minimum 0.1 mL) 1:1000 soln IM (preferred) or SC q15min
0.1 mL/kg 1:10,000 soln IV prn slow administration; repeat prn
0.01 mL/kg (minimum 0.1 mL) 1:1000 soln SL q15min
0.01 mL/kg (minimum 0.1 mL) 1:1000 soln ET in approximately 1-3 mL NS
IV infusion: 0.1-1 mcg/kg/min
Sympathomimetics cause additive effects; beta-blockers antagonize therapeutic effects of epinephrine; digitalis potentiates proarrhythmic effect of epinephrine; TCAs and MAOIs potentiate cardiovascular effects of epinephrine; phenothiazine causes a paradoxical decrease in BP
May be administered in life-threatening anaphylactic reactions, even when the following relative contraindications are present: (1) coronary artery disease, (2) uncontrolled hypertension, (3) serious ventricular arrhythmias, and (4) second stage of labor
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Adverse effects include cardiac ischemia or arrhythmias, fear, anxiety, tremor, and hypertension with subarachnoid hemorrhage; use with caution in elderly and in patients that have diabetes mellitus, hyperthyroidism, prostatic hypertrophy, hypertension, cardiovascular disease, and cerebrovascular insufficiency; rapid IV infusions also may cause death from cerebrovascular hemorrhage or cardiac arrhythmias
Inhaled beta-agonists
Used to treat bronchospasm. Doses are identical to those used in the treatment of asthma.
Albuterol (Proventil, Ventolin)
Numerous inhaled beta-agonists are used for treatment of bronchospasm; albuterol is the most commonly used preparation.
0.5 mL 0.5% soln in 2.5 cc NS nebulized q15min
0.03-0.05 mL/kg 0.5% soln in 2.5 cc of NS via nebulizer q15min
Sympathomimetics cause additive effects; beta-blockers antagonize therapeutic effects; digitalis potentiates proarrhythmic effects; TCAs and MAOIs potentiate cardiovascular effects; phenothiazine causes a paradoxical decrease in BP
In a life-threatening anaphylactic reaction, albuterol may be administered even in the presence of (1) severe coronary insufficiency or (2) uncontrolled, severe hypertension
Significant effects are much less likely than with parenteral sympathomimetics
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Inhaled beta-agonists are relatively well-tolerated; beta 2-agonists, such as albuterol, have relatively few cardiovascular adverse effects when compared with agents that also have beta 1-agonist activity or with parenteral sympathomimetics
H1-receptor blockers (Antihistamines)
Primarily effective against cutaneous effects of anaphylaxis. Also may help antagonize cardiac and respiratory effects; should be used routinely in most cases of anaphylaxis. IV administration is preferable when a rapid effect is desired. IM dosing also is effective but has a slower onset than IV and may cause local tissue irritation. PO doses must be larger than parenteral doses because of 50% first-pass metabolism in the liver. Most recommendations for use of antihistamines state that they should be continued for 2-3 days after treatment of the acute anaphylactic event.
Diphenhydramine (Benadryl)
Many effective H1 blockers exist; diphenhydramine is effective and widely available.
25-50 mg IV/IM q4-6h
50 mg PO q4-6h
1-2 mg/kg IV/IM q4-6h
2 mg/kg PO q4-6h
Potentiates effect of CNS depressants; due to alcohol content, do not give syrup dosage form to patient taking medications that can cause disulfiramlike reactions
Documented hypersensitivity, MAOIs
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
May exacerbate angle closure glaucoma, hyperthyroidism, peptic ulcer, and urinary tract obstruction
H2-receptor blockers (Antihistamines)
H2 blockers are used commonly by clinicians in treatment of allergic reactions and urticaria. Evidence of additive effect with H1-blocker anaphylaxis exists, but they should not be considered first-line therapy.
Cimetidine (Tagamet)
Many H2 blockers are available. Cimetidine is the prototype drug; other agents have much less evidence of effectiveness in anaphylaxis.
300 mg PO/IV/IM q6h
5-10 mg/kg PO/IV/IM q6h
Multiple drug interactions are related to inhibition of hepatic microsomal enzymes; cimetidine is known to increase blood concentration of (1) warfarin, (2) benzodiazepines, (3) lidocaine, (4) TCAs, (5) terfenadine, (6) phenytoin, and (7) theophylline
Documented hypersensitivity
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Cimetidine carries relatively few serious adverse effects, particularly when only short-term acute use is considered; in the acute setting consider important adverse effects to include (1) headache and confusion and (2) cardiac arrhythmias and hypotension from rapid IV administration
These agents have a role in reversing bronchospasm and cutaneous effects of anaphylaxis. Corticosteroids have a delayed onset of action and do not reverse the cardiovascular effects of anaphylaxis. These agents should be used in severe reactions, but the use of epinephrine and H1 antihistamines has a higher priority. Some authors state that corticosteroids help prevent or ameliorate recurrent (biphasic) anaphylaxis, but the true incidence of this condition has not been determined, and recurrences are usually less severe than the initial attack.
While corticosteroids usually are administered IV in patients with anaphylaxis for presumed rapidity of effect, PO and IV corticosteroids are equally efficacious in asthma therapy. When administered acutely, corticosteroids commonly are continued for 2-3 days. In asthma treatment, large parenteral doses customarily are administered acutely, followed by lower PO dosing for varying periods. Long-acting parenteral preparations may be administered as an alternative and have been shown effective in asthma therapy. Optimal dosage range for corticosteroids has not been established; thus, a range of dosages is provided based on published recommendations.
Methylprednisolone (Solu-Medrol, Adlone, Medrol, Depo-Medrol)
A multitude of corticosteroid preparations are available. Methylprednisolone is widely available in the ED because of other uses (ie, acute asthma, spinal cord injury). Supplied in both parenteral and oral formulations. Discussed here as typical drug of this class.
40-250 mg IV/IM q6h
2-60 mg PO qd
1-2 mg/kg IV/IM q6h
1 mg/kg PO qd
The most important interactions in the acute setting are (1) ulcerogenesis with NSAIDs, (2) increased weakness in patients who have MyG with anticholinesterases, and (3) possible viral dissemination with live virus vaccines
Other than a previous severe reaction to the drug, there are no absolute contraindications to the use of corticosteroids for treatment of severe anaphylaxis
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Short-term use of corticosteroids, even in large doses, has minimal harmful effects; multiple adverse effects from chronic usage; benefits and risks should be considered in pregnant females; patients who are immunosuppressed and are receiving corticosteroids are at risk for dissemination or activation of certain infections
Antidote, Hypoglycemia
Glucagon appears to benefit by stimulating the release of endogenous catecholamines.
Has inotropic, chronotropic, and vasoactive effects that are independent of beta-receptors. Glucagon also causes endogenous catecholamine release. Patients taking beta-blocking agents may be resistant to effects of epinephrine or other adrenergic agents used to treat the cardiovascular effects of anaphylaxis. Glucagon may be effective in these patients. Should be used in addition to epinephrine, not as a substitute. Reports of effectiveness of glucagon in anaphylaxis are anecdotal; therefore, it is difficult to specify a dose. Smaller doses are effective in elevating blood sugar in patients with hypoglycemia, but larger doses have been recommended in beta-blocker overdose. Given parenterally. IV route is preferable.
1-10 mg IV/IM/SC; typically 1-2 mg q5min to effect
Not established; adult dose is approximately equivalent to 0.02 mg/kg
Anaphylaxis: Follow-up
- Most patients with anaphylaxis may be treated successfully in the ED and then discharged. Treatment success operationally may be defined as complete resolution of symptoms followed by a short period of observation. The purpose of observation is to monitor for recurrence of symptoms (ie, biphasic anaphylaxis).
- Hospital admission is required for patients who (1) fail to respond fully, (2) have a recurrent reaction or a secondary complication (eg, myocardial ischemia), (3) experience a significant injury from syncope, or (4) need intubation. As with many other conditions, consider a lower admission threshold when patients are at age extremes or when they have significant comorbid illness.
- The presenting manifestation(s) of anaphylaxis dictate inpatient care. Essentially, this care consists of continuing the care initiated in the ED.
- Consider ICU admission for patients with persistent hypotension. The primary means of support are adrenergic agents (eg, epinephrine, dopamine) and fluid resuscitation. Persistent hypotension in the face of pressors and fluid resuscitation is an indication for invasive hemodynamic monitoring with evaluation of cardiac function and peripheral vascular resistance. Use of these parameters provides the basis for objective decisions regarding the use of fluids and pressors.
- Inpatient management of airway compromise consists of continuation of parenteral and inhaled adrenergic agents and corticosteroids that were initiated in the ED.
- Cutaneous manifestations of anaphylaxis are treated with repeated doses of antihistamines.
- Discharged patients who have been successfully treated for anaphylaxis usually should continue antihistamines for 2-5 days to prevent recurrence. When corticosteroids have been used as part of the initial treatment, common practice continues that treatment for a short period.
Inpatient & Outpatient Medications
- Inpatient medications are identical to those listed for ED care (see Medication).
- Outpatient medications
- Outpatient medications primarily consist of oral forms of the medications used in ED treatment. Adrenergic medications are not listed in this chapter, as it is assumed that patients who require these on an on-going basis will be admitted.
- Consider patients who experience severe reactions to bites, stings, food, or other possibly unavoidable causes, as candidates for an epinephrine auto-injector prescription. These injectors may be packaged as kits that also contain an oral antihistamine.
- The following regimens are used commonly by clinicians, though very little hard data concerning the natural history of anaphylaxis treated in the ED exists. In light of this, do not construe the following as an unqualified recommendation or as a standard of care. Evidence for efficacy of H2-blocker antihistamines is particularly sparse. The newer nonsedating antihistamines have not been studied in the context of treatment for anaphylaxis.
- H1-blocker antihistamines
- Diphenhydramine (Benadryl) - Adults: 25 mg PO q6h for 2-5 d; Children: 1 mg/kg PO q6h for 2-5 d
- Hydroxyzine (Atarax) - Adults: 25 mg PO q8h for 2-5 d; Children: 1 mg/kg PO q8h for 2-5 d
- Corticosteroids
- Prednisone - Adults: 20-80 mg PO qd for 2-5 d; Children: 1-2 mg/kg PO qd for 2-5 d
- Many other glucocorticoid preparations may be used.
- H2-blocker antihistamines
- Cimetidine - 300 mg PO qid for 2-5 d; Children: Not recommended
- Epinephrine auto-injectors prefilled syringes: A number of forms are available. Instructions for self-administration are included.
- Ana-Kit (Bayer): This product is a syringe with 0.3 mL 1:1000 epinephrine solution packaged with four 2-mg chewable chlorpheniramine tablets. The syringe has 0.1 mL gradations, allowing the injection of smaller doses for pediatric patients.
- EpiPen and EpiPen Jr. Auto-Injector (Center): This product is an auto-injecting syringe containing 0.3 mL 1:1000 epinephrine solution (EpiPen) or 0.3 mL 1:2000 solution (EpiPen Jr).
- Requirements for treating a patient with anaphylaxis are likely to exist in most hospitals within the United States and Canada; therefore, transfer of patients with anaphylaxis would be a very unusual occurrence in these locations.
- Preventive therapy for anaphylaxis depends on identification of the inciting agent. When the agent has been identified, the key to prevention is avoidance. Certain prophylactic or preventative therapies may be employed when re-exposure cannot be avoided. When the inciting agent is not obviously known from the history, allergy testing may help identify it. When the allergen is a therapeutic agent for which subsequent usage is medically necessary, desensitization or pretreatment protocols may be employed.
- Desensitization therapy for reactions to Hymenoptera venom is partially effective in preventing or ameliorating subsequent severe reactions.
- At minimum, patients discharged from the ED after a severe reaction to Hymenoptera venom should be informed of the availability of this treatment. Referral to the patient's primary care source or directly to an allergist also may be appropriate.
- Complications from anaphylaxis are rare, and most patients completely recover. Myocardial ischemia may result from hypotension and hypoxia, particularly when underlying coronary artery disease exists. Ischemia or arrhythmias may result from treatment with pressors. Prolonged hypoxia also may cause brain injury. At times, a fall or other injury may occur when anaphylaxis leads to syncope.
- Anaphylaxis may occur following re-exposure to the inciting agent. Rates of recurrence vary with the nature of the inciting agent and host factors. Other than the possibility of recurrence or the occurrence of complications, anaphylaxis carries no long-term effects.
- As described above, caution patients who are discharged after an episode of anaphylaxis to avoid exposure to an inciting agent. When no inciting agent has been identified, consider referral to an allergist to identify the cause of anaphylaxis.
- Inform patients who react to Hymenoptera venom of the availability of desensitization therapy, and consider a self-administered epinephrine prescription.
- Sting avoidance is important for hypersensitive persons. Patients must be educated concerning steps they can take to reduce the risk of insect stings.
- Caution patients to avoid use of perfumes or hygiene products that include perfumes, particularly floral scents, as these attract flying Hymenoptera.
- Brightly colored clothing attracts bees and other pollinating insects.
- Avoid locations of known hives or nests, and avoid using equipment that disturbs the hive.
- Persons who are sensitive to Hymenoptera and who must be outdoors should carry a sting kit.
- On discharge, warn patients of the possibility of recurrent symptoms, and instruct them to seek further care if this occurs.
- For excellent patient education resources, visit eMedicine's Allergy Center and Allergic Reaction and Anaphylactic Shock Center. Also, see eMedicine's patient education article Severe Allergic Reaction (Anaphylactic Shock).
- Claims of medical negligence related to the emergency treatment of anaphylaxis are not common. Potential pitfalls are as follows:
- Failure to consider the diagnosis in patients with unexplained syncope or shock
- Failure to warn the patient of avoidance or preventive measures
- Prescription or administration of a drug to which the patient is known allergic
- Failure to appreciate the potentially serious nature of symptoms, such as syncope or throat tightness, in a patient with an allergic reaction
- Complications of epinephrine administration in patients without clear indication


text:
Hello this is my second novel which is individual and not directly or indirectly linked to my other novels. It tells the story of two police officers who find a mutual attraction to one another but one day end up living outside the law for a crime they did not commit. I hope you enjoy the story!
Hello my name is Richard, I'm 22 years old and I am currently working in the police force as a regular policeman which can be exciting but you do get treated like dirt. It was all worthwhile though because of my boss. His name is Mark and he is slightly older then me at 30 years old and he has that dominant masculine side which I love.
But to continue describing myself I stand at 6 ft 1, muscular build but not over excessively I have known about my sexuality from an early age and I would constantly get guys wanting a piece of my 10" cock. But nobody really got my loins burning until I met Mark.
Mark stands slightly shorter at 5 ft 7 and he has a muscular build but has some fat on his belly which I think looks pretty sexy. Anyways me and Mark were called into duty for attempted robbery at a shop and ran to our vehicle and swiftly drove quickly to the location.
We arrived at the shop to see the suspect foolishly walking to his car with bags of cash. We slammed the robber down on the boot of the car and handcuffed him as we told him the arrest notice and his rights.
We thrown him on the backseat of the car and drove back to the station and then locked him up in the cell.
"Another successful arrest boss" I said as I gave him a formal handshake and I noticed his grip was really strong
"Yeah we got the bastard, he'll think twice before doing that again" He said in a satisfied tone.
Mark then motioned me to come into his private office and asked me to sit down and I looked at him in a confused manner
"Richard I have been working in this police force for 12 years and my judgement has always been spot on, so i want you to be honest with me do you find me sexually attractive?" he asked me
I look at him desperately trying to cover up my obvious attraction to him but left with no choice I simply reply with: "Yes I am attracted to you and I always have been from the first day" I admitted
Suddenly Mark got up from his seat and offered a hug which I gladly accepted and wrapped my arms around his waist as he looked into my eyes
"You don't need to worry I share the same feelings as you from day one as well you are cute and innocent" he said in a soothing voice as we embraced in our first passionate kiss
I felt like all my life I've been missing the other half of my heart and now it's complete we were kept in the same embrace for a while before a sudden knock on the office door.
I soon sat back down on the chair and Mark motioned the unknown person to come in.
"Ah Richard do you remember me?" This person asked as he shook my hand rapidly
"No I don't remember you" I replied honestly in a confused manner
Suddenly something in my brain clicked and the memory came flooding back to me. I realised that this other man was an ex lover I fooled around with.
"Oh its good to meet you again, Nick" I said to him.
"Oh you actually remembered me then?" he replied in shocked earnest
Mark looked at both me and him and could sense the situation we were both in.
"Richard could you please leave? me and Nick have to talk about something"
"Certainly sir" as i walked out of the office and gave them both a view of my muscular ass.
So I sat on one of the seats by the office and just felt like such a fool for not trying to ask Mark out on a date. Fortunately it did not take long for Nick and Mark to talk before he literally pulled me back into his office and locks the door.
We continued the deep passionate kisses as before but this time he lay me down on his desk and bitten my neck like a horny vampire
"Oh Mark you magnificent man will you be my boyfriend?" I moaned as well as asked.
"Of course I will silly" He said in a sexual growl.
He helped me up from the desk and back on my feet
"I love you Richard" he says to me
"I love you too Mark" I reply honestly
At this monent of time i've never felt so happy as I do now.

subset: commoncrawl


text:
- Description
Bring a touch of nature into your home with this magazine chairside table from Anthony California.
The table has a faux marble top and matte black powder coated frame with a space to store magazines.
- Additional Information
Additional Information
SKU 17700040 MPN 847ME-1 GTIN N/A Brand Anthony Collection N/A Assemble Length N/A Assemble Width N/A Assemble Height 24 Assembly Required Yes Material N/A Finish N/A Styles Contemporary Shipping Time 1-2 Weeks Free Shipping No
- Reviews
Disclaimer: Pictures displayed may include optional products not included in the price. Computer monitors often display color variations. Color swatches are shown if alternative colors are available. Please call us or email us if you have any questions!


text:
Short jeans are ok for club party?
Short jeans are ok for club party?
Long jeans are probably better, they're more formal
I wouldn't wear short jeans. Nice pair of jeans that fit well and a buttoned up shirt at a minimum.
You cannot undo this action. The opinion owner is going to be notified and earn 7 XPER points.


text:
|Page (1) of 1 - 07/08/05
|email article
|print page
Quantel sQ Is Big News In NorwayNorwegian state broadcaster NRK returns to No. 1 with Quantel integrated news system (July 08, 2005)
Norwegian state broadcaster NRK has recently installed a fully integrated sQ News/Sport production system from Quantel. The system is based on four sQ servers, each with four video ports and with a total storage of 400 hours of IMX50. There are 124 sQCut editing packages on journalists desktops, eight sQEdit Plus systems for craft editing, and also a Paintbox, which is used for headline graphics.
NRK produces 18 television news broadcasts a day through its network of 12 regional offices in addition to its Oslo headquarters a vast campus that is home to 2,400 staff, encompassing not only all its central news operations, but also all production and post production facilities for both NRK television and radio.
While NRKs regional news operations have made use of standalone NLE systems, the Oslo centre has been for many years based around Digital Betacam technology. ?Weve really jumped two steps in one leap, going way beyond just non-linear into a totally integrated production environment, reflects Head of News Technology and project manager for NRKs entire digital news transition programme, Geir Břrdalen.
At the outset Břrdalen set up a project group to investigate all the available systems on the market. As well as engineering staff, the group also included a producer and journalist, which Břrdalen saw as key to getting a system which would work at a creative as well as a technical level. The group looked at 14 systems integrators offering complete packages from 11 different manufacturers. In the end, only the Quantel sQ system, offered by system integrator 2MTV, was able to meet all the criteria.
System connectivity is via a dual fibre gigabit network, with a dual power supply to guard against power problems; ?The only way the entire system goes down is if there is a power failure that blacks out Oslo! jokes Břrdalen. The sQ system is integrated with NRKs ENPS newsroom system (the second largest ENPS installation in the world with 1650 clients) via a dynamic MOS gateway, and the whole operation runs under Omnibus Columbus automation.
Speed to air was also high on NRKs shopping list when they specified the system. Břrdalen reports that NRKs sQ system is ?the fastest news system out there. When time is really tight, NRK sometimes also plays direct to air from the sQEdit Plus craft edit stations. ?This also increases our backup, as does the fact that while the system has all the operational benefits of a central server system, it is also modular so the whole system doesnt go down if one server fails. NRK Resources has also started using the system for its sports coverage, with similar results.
?The sQ makes it fast and easy to capture and package highlights such as goals, and our sports editors are really beginning to push the system. Its a complex system, and now its really come together and were really pleased. Before we put the Quantel system in, we were struggling with ratings now we are number one in news in Norway, concludes Břrdalen.
About Quantel
Quantel is dedicated to creating new tools for the new digital age, covering everything from terrestrial and satellite television to broadband internet, DVD and d-cinema. Quantel systems combine industry-leading performance with total scalability in both hardware and software across post production, graphics, digital intermediate, news and sports production for multiple resolution, team-working environments.
This and all Quantel information can be found at quantel.com.
Page: 1
Related Keywords:Quantel, sQ, NRK, IMX50, sQCut, sQEdit Plus, Paintbox, NLE, 2MTV, ENPS, Omnibus,


text:
2017 Geneva Motor Show – McLaren 720S by MSO
This stunning McLaren 720S by MSO shows off what they called the 'Velocity' theme, with the bespoke supercar having been revealed at this year's Geneva show. The team at McLaren Special Operations will allow potential customers to personalize virtually everything about this car. Showing off an incredible level of exclusivity, this McLaren benefits from the stunning Velocity paint theme before you, the result of two pearlescent hues of red mixing together – one of which is a shade called Nerello Red fading into a vivid Volcano Red.
There is more to this project than the mesmerizing exterior shades, such as the MSO metallic bronze lightweight alloys, a gloss carbon rear deck vent, service cover and rear aero bridge. On the inside, things are just as impressive as you'd expect – and more. Carbon Black Alcantara has been added throughout, contrasting with the Harissa Red leather details on the fascia, steering wheel, doors and across the sports seats. The McLaren 720S 'Velocity' will start off at £335,000 ($407,800), and will cost as much as you want it too, depending on your personal choices and taste.


text:
Fuel Filter, 3-17/32x1-29/32x3-17/32 In
BALDWIN FILTERS| Zoro #: G0899954| Mfr #: BF7519
Zoro #: G0899954Mfr. Part #: BF7519
$18.40 /ea
Orders over $50.00 ship free. DetailsStandard ground shipping
Technical Specifications
|Zoro #: G0899954 Mfr #: BF7519
|Item: Fuel Filter
|Description/Special Features: Stainless Steel Screen In-Line Fuel Filter
|Includes: (2) Rubber Seals and (2) Brass Fittings
|Filter Design: In-Line
|Width: 1-29/32"
|Outside Dia.: 1-29/32"
|Length: 3-17/32"
|Height: 3-17/32"
|Country of Origin (subject to change): Taiwan
Product Description
Fuel Filter, Filter Design In-Line, Stainless Steel Screen In-Line Fuel Filter, Height 3-17/32 In., Length 3-17/32 In., Width 1-29/32 In., Outside Dia. 1-29/32 In., Includes (2) Rubber Seals and (2) Brass Fittings


text:
Although many complain that women like metrosexual men these days, i see the opposite. Most of the guys women dating are ugly masculine men with hairy arms, legs, etc they have thick beards and they're tall and muscular. they just look and behave like a dad. that's disgusting and it makes me want to puke. they're not beautiful. masculine men look more like APES than humans... yes APES. what is wrong with girls anyway?
Why women prefer masculine men than metrosexual men in these days? That's ridiculous?
Have an opinion?
What Girls Said 19
I like rough manly men but they don't need to have a lot of body hair
if I wanted a metro feminine partner I'd date a girl51|40|0
why women don't want the man to be weaker than them? it's very rare to see a woman wanting to be stronger than her man :-/
a "masculine" men doesn't mean that he doesn't groom at all. masculinity is not all about body hair. A guy can have no body hair and still be masculine.
in my book, a metrosexual man is one who takes care of every little detail, to the point where he does things that usually only girls do, like waxing their eyebrows (not because of a unibrow, but to shape it). always has perfectly styled hair, as if even a tornado can't ruffle it.
that's too much of attention to detail for me. a guy like that would most likely be a perfectionist and expects his gf to be as perfect as he is.
I'm more attracted to a guy who is secure with his masculinity, as in he doesn't need body hair to feel masculine. nor does he need to act all macho and tough all the time. but perfectionists usually grinds my nerves.30|30|0
i shave my eyebrows
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why everyone talks about paleolithic age when we live at the age of technology? i find this stupid... people today don't hunt
yes but we evolved from there. It's just a subconscious thing.
Because I'm attracted to men, not boys who like to dress like gay guys and who use more cosmetic products than women.82|60|0
This kind of response came to mind when I read this.
I don't want a guy who is a pseudo-female or androgynous, or who uses more hair and beauty products than I do. I want a MAN.50|50|1
Dude, seriously. Go get a sex change. Seems like you want to be a woman.
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I have an extensive background in martial arts. I'll break you in half like a pencil since you always go on about how weak you are and shit.
!!! oh my blood went cold now... of course i didn't mean to the point to leave me dead :P
Girls are not guys. We are attracted to POWER first and foremost, like you are attracted to BEAUTY first and foremost. There's no mystery there. Women are attracted to perceived power in a guy when they look at him. That's why they'll rate you unattractive wearing jeans and shirt, but attractive wearing a suit.
A guy who is rugged and "manly looking" seems stronger and more capable, like a guy you can rely on, who can protect you, a guy no one can mess with. A guy who cares more about function than style.
This as opposed to a guy who looks like he spent 5 hours in front of a mirror. Ew. -_-
This question would be similar to a girl asking: "Why aren't guys attracted to my huge muscles, but instead go for those pathetic scrawny bitches?"
PS. There will be exceptions. There are girls out there who want feminine men. If you can't change your style, just look harder.41|30|1
what are you talking about? i like women to be stronger than me. after all i['m weak and proud. you sound too romantic and i hate romanticism.
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ME? ASHAMED? MWAAHAHHAHAHAHAHAH i don't give a shit about "softness" in women in fact, and yes i'm proudly weak and i don't describe myself as a "man"... don't make me laugh. i describe myself as a "wimpy whore" that can be beaten to a pulp if i get in hands with a woman.
wake up my friend, world isn't such romantic as you think it is. you sound totally romantic that "woman's strength is in resilience, patience, etc"... BULLSHIT. and you know what? i hate romantisism as hell, it makes me SICK. world would be BORING if people were thinking like you... i'll brand you as a "romantic fool" wether you like it or not
And I'll brand you a retard whether you like it, or not. ^^
I love guys to be bigger, taller, stronger, and hairier than myself. I like guys to be able to rock the facial hair. You're right, they're not beautiful, they're masculine and downright sexy in my opinion as long as they've got a handsome face.
I absolutely cannot date someone shorter or thinner than I am, and he really shouldn't be weaker either. That's just my opinion, but there are females who greatly disagree.41|30|1
i hope so (about the disagreeing thing)
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prostitues excist as well dude
Then go for prostitutes, but some guys like the men I mentioned have certain morals and values that they stick to.
I LOVE masculine men, but I also like a guy who knows how to take care of himself. There's nothing wrong with a guy being hairy.31|20|0
he looks like an ape
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that doesn't mean i don't have the right to express my opinion if someone is attractive or not... correct?
Everyone has a right to their opinion, but your opinion pretty much holds no weight within this field.
Here you go again shitting on other people's preferences52|30|0
are you following me? lol
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you know what would i do if i was director? i would film a movie or a TV series where ALL couples would be tall Amazon women with little wimpy guys. that's what i'd do to show people that it's normal and not ridiculous
i dont like metrosexual men.. shaving is for women ONLY. plus your beauty won't protect me when somebody hurt me.30|30|2
it's very SAD to hear that rom a girl who's under 18. those are things that your grandparents believed in. Protection and stuff like that are BULLSHIT
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@MyUsernameRules i love reaaally tall guys but 5'8" is fine. you are not short.
Oops meant to upvote of course.
Us women go out of our way to stay good-looking, from lotions, to waxing, healthy dieting to maintaining our teeth white. I think we appreciate the same in a guy. It is only fair and right to take care of yourself. A person that lets himself go is not himself anymore. People don't have to look like models, just healthy and going to work out a few times a week. Manly men are more attractive than a wuss.10|10|0
Whoa I do not find guys like that attractive, I like guys who have kinda the tall, thin look with no beard and not nessersarily body hair all over20|20|0
You're going to judge their entire relationship based on his physical features?
Wow is all I have to say hahah!
There is also nothing wrong with those women.00|00|0
Because I like men to be taller and bigger than me.20|20|0
Just reading through these comments of yours and you are a fucking idiot. It's not your scrawny, girly body that women don't like.. it's your shitty personality.. believe me.00|00|0
shitty? why? because i dislike masculine men?
Masculine is manly, not unkempt and bad looking. Some of the hottest guys I know, look great and are very masculine. Masculinity is handsome, not ugly. I think you've got something twisted there.40|40|0
i view most girls as perverts then who like guys who look more like apes than human
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Well, good luck attracting your pre pubescent girls and undercover lesbians who want a feminine man so they don't need to come out the closet yet.
and good luck to you attracting apes :P
I rather like a mixture of the two. A guy who looks after themselves, styles their hair and dresses well shouldn't have to come under the metrosexual umbrella but apparently it does. I look for someone with not exactly a masculine face with no attractive elements but nothing super young looking (or else I'm reminded of friends).
Being interested in arts and films and the like really shouldn't be seen as a 'feminine' thing for guys either. But on the whole I personally prefer someone with a bit of character than the stereotypical manly man.10|10|0
Looks like someone is jealous of the masculine men...
So what if girls like guys that are tall , well-built, got good facial hair etc
They may seem ugly to you but to other girls I've seen / know myself included that is attractive to us , sorry hun nobody gonna run after ur skinny ass while there is masculine men as an option. they're looking for MEN not BOYS !42|20|0
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still i'm an adult
LOL spot on about that jealous thing !!!
What Guys Said 28
Perhaps some women want to date guys who look like guys, not hairy women.
As for behaving like a dad, do you mean behaving like a man? Because there's dads, then there's little boys in big bodies. Dads aren't little bitch boys playing at being tall bros. They're mature, got-their-shit-together adult men.
Feel free to keep dating your little brother's friends. Or your little brother's girlfriends. Women are pretty much the opposite of what you've admitted to greatly disliking. Many are quite beautiful, which is again, what you said you're after.53|20|0
Masculine and feminine together make the best of both worlds. They go hand in hand. A masculine guy wouldn't want to date someone that made him feel like he was dating another man. So it makes perfect sense for a girl to not be interested in a metrosexual. Girls liking masculine men makes sense.41|30|0
boooooooring. if every couple was like that they world would be a boring puke
It's not just girls.
OMG haha
No, it is not ridiculous. It is an entirely natural preference. Think in terms of evolutionary biology.
Not long ago (in evolutionary terms) the woman who chose the best hunter and strongest warrior survived. Her offspring were more likely to survive. Women who chose metrosexual girlymen were less likely to survive and, therefore, less likely to pass on their genes. The result is that over millions of years the preference for manly men became hard wired into the female brain.
A woman who chooses a metrosexual is, therefore, speaking in evolutionary terms, making a poor decision.52|30|0
so that comes from a man who states that he is "old-fashioned" and has this stupid portraid with the man who's dressed like a ridiculous idiot from the 40s. so i've got only 2 words to say...
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at least i'm not old-fashioned just like you... people like you make me SICK
Am also confident that our paths will not cross at international meetings of military veterans' organisations, or martial arts gatherings. You would never be man enough to wear a uniform. You are a pathetic punk.
- 63|30|0
I don't know who looks more fruity, the metrosexuals or Obama in this picture.
Perhaps they're attractive to what they don't have themselves
it could be the cause of many things, perhaps they see
their father in them? (or a father figure, if you will).
You could just try to find the mid-way, a place where
you're content with how you look, but still look masculine? ^.^11|00|0
Metrosexuality is interesting. I'm not a masculine male at all, and I apply two products on my hair because I find hair to be fairly important, but other than that, I don't really start shaving my legs and waxing my eyelids, using makeup and all that. I'll leave that whoever wants to do that, but it seems unnecessary.
As for why females find the hairy thingy attractive, probably for the same reason why others find the hairless thingy attractive. You can't really box in preferences.42|20|0
hi:) sounds like you leave that option open for now^^
- Show AllShow Less
I don't feel like shaving it, that's a bit too much. I just want to trim it.
Yeah, but not a major difference there. Still not convincing.
Do you have tickets for musical theater tonight?52|30|0
eh? what?
Just like guys prefer feminine girls, girls prefer masculine guys. If you look in the animal kingdom, only the strongest males who are seen as superior by the females get to mate through fighting other males and bringing in meat. It's all nature.62|41|0
What's the down vote for? Whoever you are?
- Show AllShow Less
That's not going to get you that many girls' attention.
i don't give a shit about that. after all i'm going only with prostitutes.
Altho I love how you insult short chicks and shit. lmaooo and those other funny questions lol
Chicks are really same for everyone, Muscular, Skinny, Tall, Short, Midget, Giants, Nerds, Jocks. They would like everything you make em like lol srs. Some go for radicliffe, Some are Bieber believers, Some go for Taylor lauytner lol. can't blame them, You just gotta find a type that goes for you21|10|0
hahahaha thanks
Haha. Maybe they don't feel like dating a man who has more hair and skin products than they do.31|20|0
they don't want to be jealous of him eh? lol
Most straight women prefer masculine men for the same reason that most straight men prefer feminine women: they're complementary, attractive features.00|00|0
What in the blue moon is a 'Meterosexual'?11|00|0
- Show AllShow Less
Being metro goes way beyond just taking care of your appearance. You can be masculine and do that, too. Metro guys wax, pluck, get facials, pedicures, manicures, etc.
Oh dear, oh dear.
A metro like you trying to act as a bad boy^^11|00|0
i may be physically weak but i have no problem insulting "muscular" "masculine" guys like you
- Show AllShow Less
Plume, it would not sporting. It would be pest control. I have a particular loathing for smart-mouthed ignorant girlymen in their effeminate skinny pants. The Asker is one such creature. The Army used to pay me to kill better than him.
most girls I know prefer the pretty boy00|00|1
Women will like whatever you tell them to like00|01|0
The contradictions of feminism are hilarious.
"Equality, equality ... but ewwwww...you "equal man" are now undesirable.. i'm going to date this brutish hulk who drags me by the hair in the cave" :D00|00|0
I hear you loud and clear dude. It looks as though most women will date a primitive man over a man that is more refined. It's goes for how a man acts too, not just how they look.
I was out not too long ago and saw an older couple, and for her age she was a beautiful woman, but her husband really seemed like an idiot. Loud, profanities ever other word and he just would not shut up, like he was trying to be the big man at the bar. It really made him look bad.
I hate that, and I really dislike how some women go for that sort of thing. It was hard for me to believe that she has probably put up with him for a fairly long while too lol. Like you'd think it would register in her head after a little while that, wow, this guy is kind of a dick haha.10|11|0
Why women should prefer metrosexual men just because you hate the masculine ones? Why do you think that your point of view and your opinions are the only ones that really matter? Women here are not the problem, YOU are the problem. You have your own view of life and you are sure that you are right and almost EVERYONE is wrong. I really hope you're trolling, because if you really are 23, you immediately need help.21|10|0
yes i'm 23. what's so bad about my age?
- Show AllShow Less
If this site is so awful and disgusting why are you still here? You get the fuck out of here, we don't have to read your bullshits anymore and you don't get angry. Sounds great, doesn't it?
oops it was a typo... i meant sight
I've never seen anybody complaining that women like pussies, erm I mean metrosexual men these days because it's not true. Most women like men who act and look like men. You're trying to attract women by acting like a woman? Good look with that phaggot.21|10|0
in other words... women like BORING common people
U jelly?
I think brains/intelligence is more important as a sign of "power".
After all, we compete in the workplace nowadays and not on the battlefield.11|00|0
but unfortunately many girls have stuck in the "battlefield" thing
They'll adapt.
Many so called intellectuals who claim this, have high IQ and social intelligence of a chair. A smart man knows how to handle interaction, how to deal with the world, how to achieve happiness by getting what he needs from other people and that is sexy as hell. Girls do love smart guys, no question about it. Nerds who think girls should be after them for being good at physics, or fixing computers are deluding themselves. If that ever attracts a girl, it's gonna be a gold digger.
Blame biology and natural instincts for it. Women want a guy who can protect them.11|00|0
As i said to the guy below, i don't give a FUCK about nature and biology. that's too old-fashioned. we live at the age of TECHNOLOGY. WAKE UP
Asker, what you have just said is "fuck science". You are not interested in the evidence (as well as common sense), you have your own weird counter-factual construction. You must be an Obama supporter.
Yes, and when (not IF but WHEN) our society collapses (be it from natural disaster, world war 3, a killer virus, whatever), that technology will be useless when the power grid goes down. Even weapons will become obsolete when the bullets run out. I believe it was Einstein who said "I don't know what weapons will be used in the next world war, but the war after that will be fought with sticks and stones." (paraphrased)
When that happens, the weaker men will have to be really smart to survive.
you see two extremes. rarely do u see a melding of the two...22|00|0
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Wednesday, January 27, 2016
My father passed away this evening. It was peaceful and as comfortable as possible.
A book of memories and condolences can be found on the Roadhouse and Rose website.
Best wishes to all that knew him.
62 comments:
- Charles Gramlich said...
Sorry to hear. I'm glad he was comfortable at the end. A fine fellow and writer
- 1/27/2016 11:50 pm
- Heather said...
I'm so sorry to hear this news. Rest well Ivan.
- 1/27/2016 11:56 pm
- laughingwolf said...
...i did not know him long, but loved his humor and quirks - sorry to hear of his passing
- 1/28/2016 2:34 am
Sorry to hear about Ivan. He was a good friend and mentor to me and published a lot of my writing. He will be missed but not forgotten.
- 1/28/2016 7:43 am
- the walking man said...
Stephen I first met your dad when i was assigned Dumpster Diving in my very first college creative writing class I was 45 and it was only by chance I came to know him through this blog, we did not seek each other out.
His Island Press published my first book of poetry, he made me a registered Canadian poet even though I am 2 generations removed, the book sits in the National Archives. Getting me through that process was just what I needed at the time, after 3 more books it was enough for me to stop caring about seeing my name in print, but your dad was the FIRST to call me a poet and mean it as a compliment.
For that I am ever grateful. May his journey through the cosmos be like his life--on his own terms, as bizarre as they may be, one can only say about Ivan was that the man had a life here in this place and he lived it.
Best to you and your family
Mark Durfee
The Walking Man
- 1/29/2016 5:23 am
I am sorry to hear this news. He was one of a kind. Thank you for sharing this with us Stephen. He will not be forgotten.
- 1/29/2016 4:47 pm
Stephen...so sorry/shocked to hear...Ivan was a huge part of my life,as was music with him in the old days of the "cavaliers" band,when we ran thru bar and tv appearances,and almost got a vinyl out... even long before that,he was an influence ...you are so right when you say it was on his terms/that was Ivan ...there is far too much to say here...deepest condolences/thoughts and prayers for all of you...Ivan,I trust you are all tuned up and riding the big storm you always wanted and searched for...long may you run in all of our hearts and souls...you sure as hell did it your way...
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The 'Sex and the City' actress - who has her own SJP by Sarah Jessica Parker footwear line - admits donning high heels on a regular basis has taken its toll on her feet, but rather than seek professional pedicures, she prefers to tend to her tootsies herself.
She said: "I've asked a lot of my feet for a lot of years, and they've been really good to me.
"I put on moisturiser and use a pumice.
"I don't have a pedicure unless someone makes me for work, but I clip my own nails, and I always have a good nail clipper."
And the 51-year-old actress - who has son James Wilkie, 13, and daughters Tabitha and Loretta, seven, with husband Matthew Broderick - ensures the rest of her household are just as diligent at caring for their feet.
She told People magazine: "Every Sunday night we clip nails in our house. We call it "Clip Clip [night]!
"Beyond that I don't do too much."
Sarah has a similar low-key routine when it comes to her fingernails.
She explained: "My nails are just buffed and clean. I use my hands a lot. I cook. I clean. I do laundry. [Nail polish] is not practical in my life given what my hands need to do every day!"
Sarah recently admitted she only ever considers her own opinion when buying shoes for herself.
She said: "I think about not what I find sexy or what I think makes me look good; I wear what makes me feel good. And I don't mean that's a practical decision. It's not like a heel feels great all day long. I can't think about somebody else. If I'm that results oriented, then it's not going to be me and it's not going to be sexy, because I'm going to be wearing somebody else's idea of sexy."