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Anaphylactic shock

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Definition, pathophysiology, etiology, clinical manifestations, management

Definition, pathophysiology, etiology, clinical manifestations, management

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  • 1. Prof. DR.Dr.Ariyanto Harsono SpA(K) 1 Anaphilactic Shock
  • 2. Prof. DR.Dr.Ariyanto Harsono SpA(K) 2 Definition Anaphylaxis: Reactions sudden life- threatening because the process immonologic of allergen-antibody reaction Anaphylactoid Reaction causing physical the same symptoms but caused no immunological reaction
  • 3. Prof. DR.Dr.Ariyanto Harsono SpA(K) 3 Alergen APC MHC-II Th0 IL-12/ IL-1 Th-2 Th.1 IL-1 TNF-β, IFN-γ IL-2, IFN-γ B-Cell IL-4 IL-5 SEL PLASMASEL MEMORI IL-6 IL-10 CTL MHC-I L MEMORY CELLS Aktifasi Komplemen Blocking Antibody Precipitatigng Aglutinating AB Anafilaksis
  • 4. Prof. DR.Dr.Ariyanto Harsono SpA(K) 4 Pathophysiology There are 5 stages: 1. Mast cells / basophils walls change therefore stimuli: * Allergens-IgE * Aggregation of immune complex * Activation of complement
  • 5. Prof. DR.Dr.Ariyanto Harsono SpA(K) 5 Mast Cells and basophiles involve in allergic reaction in the context of antigen-IgE
  • 6. Prof. DR.Dr.Ariyanto Harsono SpA(K) 6 Granule contents: Histamine,TNF-a Proteases, Heparin Lipid mediators: Prostaglandins Leukotrienes Cytokine production: Specifically IL-4, IL-13
  • 7. Prof. DR.Dr.Ariyanto Harsono SpA(K) 7 2. Cell wall enzyme activation: *Arachidonic acid breakdown * Decrease in the ratio of cAMP / cGMP
  • 8. Prof. DR.Dr.Ariyanto Harsono SpA(K) 8 Arachidonic Acid Phospholiphase A Cyccloxygenase Lipoxygenase Prostaglandine TXA Prostacyclin Leukotriene A Leukotriene B Leukotriene C HETE,5-HETE, PAF
  • 9. Prof. DR.Dr.Ariyanto Harsono SpA(K) 9 3. MEDIATORs RELEASE: *Preformed mediators: histamine, serotonin, Neutrophil chemotactic factor, Eosinophile chemotactic Factor  * Newly generated mediators: leukotrienes B4, LTC4, LTD4, Thromboxan, Prostaglandine D2, Kinin, Platelet Actifating Factor
  • 10. 10Prof. DR.Dr.Ariyanto Harsono SpA(K)
  • 11. 11Prof. DR.Dr.Ariyanto Harsono SpA(K)
  • 12. Prof. DR.Dr.Ariyanto Harsono SpA(K) 12 4. Functional Pathology response: *Increased vascular permeability: swollen, hypotension * Smooth muscle contraction * Secretion of mucus * Changes in excitability and cardiac muscle contractability
  • 13. Prof. DR.Dr.Ariyanto Harsono SpA(K) 13 Nature Rev Immunol 2004: 3:234-237
  • 14. Prof. DR.Dr.Ariyanto Harsono SpA(K) 14 5. Inflammation and involvement of secondary mediators: *Leukocyte infiltration by chemotactic * Platelet Aggregation * Complement Activation * Proteolytic break-down
  • 15. Prof. DR.Dr.Ariyanto Harsono SpA(K) 15 Complement Activation
  • 16. Prof. DR.Dr.Ariyanto Harsono SpA(K) 16 Complement Activation …
  • 17. Prof. DR.Dr.Ariyanto Harsono SpA(K) 17 Effector mechanisms against extracellular pathogens COMPLEMENT Activation Bacteria in plasma Ab & COMPLEMENT + Phagocytosis binding Complement & Fc receptor Lysis Opsonisation
  • 18. Prof. DR.Dr.Ariyanto Harsono SpA(K) 18 Etiology 1. Associated with IgE Serum Protein: antisera, antitoxin, the monoclonal Ab, IgA Venom and sting: bee, hornet, fire ants, snakes, spiders, mosquitoes, jellyfish Enzymes: trypsin, penicillinase Vaccines / Extract: DPT, pollen extract, food Hormones: Isulin, ACTH, Progesterone
  • 19. 19 Etiologi 1. Associated with IgE Serum Protein: antisera, antitoxin, the monoclonal Ab, IgA Venom and sting: bee, hornet, fire ants, snakes, spiders, mosquitoes, jellyfish Enzymes: trypsin, penicillinase Vaccines / Extract: DPT, pollen extract, food Hormones: Isulin, ACTH, Progesterone
  • 20. Prof. DR.Dr.Ariyanto Harsono SpA(K) 20 oFood: milk, eggs, marine fish oPolysaccharides: Dextran oDrugs: penicillin, cephalosporins, tetracyclines, Aminoglikosid, Cyclophosphamide, Metrotrexate oOther: Heparin, Tubokurarin, ethylenediamine, 2. Causes of non-IgE oBlood products: IgA, albumin, Imonoglobulin, Complement C4, Cryoprecipitate odialysis membrane oprotamine oL-Asperginase oMurine monoclonal antibody openicillin
  • 21. Prof. DR.Dr.Ariyanto Harsono SpA(K) 21 3. cause of anaphylactoid Jodium diagnostic materials, Decheolin, BSP, Fluoresin, Indosianin green Analgesics: Salicylates, NSAIDS, Aminopirin Antibiotics: Aminoglikosid Xylocain Alkaloids: Morphine, Codeine Drug: Histamine, Amphetamines, diuretics, anticonvulsants Food additives: Sulfites, Tartrasin, Sodium bensoat
  • 22. Prof. DR.Dr.Ariyanto Harsono SpA(K) 22 Clinical Manifestations • Skin: Itching, erythema, Urtica, Angioudem • Respiratory: sneezing; runny nose; clogged; coughing; wheezing; swollen larynx; tightness; hoarseness; stridor; cyanosis • Digestive: nausea, vomiting, diarrhea, abdominal pain • Eyes: itching, tears • Cardiovascular: collapse, fainting, hypotension, pale, cold, tachycardia, arrhythmias, cardiac arrest
  • 23. Prof. DR.Dr.Ariyanto Harsono SpA(K) 23
  • 24. Prof. DR.Dr.Ariyanto Harsono SpA(K) 24 Clinical Manifestations • Skin: Itching, erythema, Urtica, Angioudem • Respiratory: sneezing, runny nose, clogged, coughing, wheezing; swollen larynx: tightness, hoarseness, stridor, cyanosis • Digestive: nausea, Mutah, diarrhea, abdominal pain • Eyes: itching, tears • Cardiovascular: collapse, fainting, hypotension, pale, cold, tachycardia, arrhythmias, cardiac arrest
  • 25. Prof. DR.Dr.Ariyanto Harsono SpA(K) 25 Clinical Manifestations • Skin: Itching, erythema, Urtica, Angioudem • Respiratory: sneezing, runny nose, clogged, coughing, wheezing; swollen larynx: tightness, hoarseness, stridor, cyanosis • Digestive: nausea, Mutah, diarrhea, abdominal pain • Eyes: itching, tears • Cardiovascular: collapse, fainting, hypotension, pale, cold, tachycardia, arrhythmias, cardiac arrest
  • 26. Prof. DR.Dr.Ariyanto Harsono SpA(K) 26 Differential Diagnosis Sinkope o Subsides when placed in the recumbent position o T, N: Normal o Other symptoms of anaphylactic negative
  • 27. Prof. DR.Dr.Ariyanto Harsono SpA(K) 27 Prevention 1. Pre vaccination screening: (1)history of allergy to component of vaccines: -egg, -gelatin, -antibiotics. (2) healthy. 2. Anticipation • Patient should be kept under supervision for at least 15’. • Ready Anaphylactic equipment
  • 28. Prof. DR.Dr.Ariyanto Harsono SpA(K) 28 Management 1. Primary treatment Adrenaline 1:1000 with a dose of 0.001 ml / kg maximum: 0.3 ml subcutaneously Tourniquet on the proximal shock / injection Adrenaline can be repeated 3X every 15-20 ' Sprong oxygen nose / hoad box 2-3 L / min Free the airway, neck hyper-extension position, head tilted, suction mucus, monitor vital signs
  • 29. 29 •Place the patient at shock position •Pulmonal Ressuscitation •Oropharyngeal airway •Tube endotrakeal •Tracheostomy •Cardiac compression
  • 30. Prof. DR.Dr.Ariyanto Harsono SpA(K) 30 Adrenaline HCL Dose 1:1000 according age Age Dose 2-6 Bulan 0.07 ml 12 Bulan 0.1 ml 18-48 Bulan 0.15 ml 5 Tahun 0.2 ml 6-9 Tahun 0.3 ml 10-13 Tahun 0.4 ml >14 Tahun 0.5 ml
  • 31. Prof. DR.Dr.Ariyanto Harsono SpA(K) 31 2. Complementary treatment Intended for complications: Seizures: diazepam, phenobarbital Bronchial Spasm : Aminophylline 7 mg dissolved in 10-20 ml of 0.9% NaCl followed 9 mg/kg/24 hours (divided into 3 doses) b-2 agonist: Ventolin nebulizer
  • 32. Prof. DR.Dr.Ariyanto Harsono SpA(K) 32 3. Additional treatment •Antihistamine (H1 Receptor antagonist): Benadril 2 mg/kg i.m. continued with 3 mg/kg/24 jam oral (dibagi 3 dosis) •H-2 receptor antagonist : Cimetidine •Corticosteroid: Solukortef 4-7 mg/kg i.v. continued with 4-7 mg/kg/24 hour oral (devided 3 doses) H1 H2 H3 H4 H1-antagonist H2-antagonist Histamin
  • 33. Prof. DR.Dr.Ariyanto Harsono SpA(K) 33 Granule contents: Histamine,TNF-a Proteases, Heparin Lipid mediators: Prostaglandins Leukotrienes Cytokine production: Specifically IL-4, IL-13
  • 34. Prof. DR.Dr.Ariyanto Harsono SpA(K) 34 Increase capilary permeability Fluid shift shock Urtikaria Wheezing
  • 35. Prof. DR.Dr.Ariyanto Harsono SpA(K) 35 Fluid therapy • Kristaloid • Koloid “The most important is not the composition, but rather the rate of administration” In children: 30ml/kg hour I Cardiac output Dopamine 2-20 mg/kg/menit
  • 36. Prof. DR.Dr.Ariyanto Harsono SpA(K) 36 NB • Tourniquet is released every 3 minutes until symptoms resolved shock • If the vaccine subcutaneously, may be added adrenaline 0.005 ml / kg (max: 0.3 ml) at the injection site, one time only!
  • 37. 37