• Save
Allergic shock
Upcoming SlideShare
Loading in...5
×

Like this? Share it with your network

Share
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
  • informative and handy ppt
    Are you sure you want to
    Your message goes here
No Downloads

Views

Total Views
1,538
On Slideshare
1,229
From Embeds
309
Number of Embeds
2

Actions

Shares
Downloads
0
Comments
1
Likes
3

Embeds 309

http://www.xn--mxaaaaaajkkbpevcbbdbej7igtjg6dif.gr 239
http://xn--mxaaaaaajkkbpevcbbdbej7igtjg6dif.gr 70

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
    No notes for slide

Transcript

  • 1. ANAPHYLAXIS ANAPHYLACTIC SHOCKAndreas EliadesPediatric Intensivist
  • 2. Anaphylaxis Serious allergic reaction that is rapid in onset and may cause death The rate of occurrence is increasing in industrialized countries it can mimic many other conditions and is variable in its presentation The diagnosis of anaphylaxis is clinical and based primarily upon clinical symptoms and signs Most anaphylaxis episodes are triggered through an immunologic mechanism involving IgE Foods are the most common trigger in children
  • 3. shock Υγρά NaCl Επιμευρίμη Ντοποσταμίμη Διασωλήμωση μτοπαμίμη Μηταμικός αερισμός Σύστημα συνεχούς παρακολούθησης της καρδιακής παροχής
  • 4. New diagnostic criteria for anaphylaxis were published by a multidisciplinary group of experts in 2005 and 2006 – Was it necessary? Help clinicians to easily recognize signs and symptoms Unrecognized and undertreated Early recognition and treatment with EPINEPHRINE Recognition of atypical presentation Minimize use of less effective drugs (antihistamines and glucocorticoids) Sampson, HA, Muñoz-Furlong, A, Campbell, RL, et al. Second symposium on the definition and management of anaphylaxis: summary report--Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network symposium. J Allergy Clin Immunol 2006; 117:391.)
  • 5. Anaphylaxis is highly likely when any ONE of thefollowing 3 criteria is fulfilled1. Acute onset of an illness (minutes to several hours) with involvement of the skin, mucosal tissue, or both(eg, generalized hives, pruritus or flushing, swollen lips-tongue-uvula)AND AT LEAST ONE OF THE FOLLOWINGA. Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, reduced PEF in older children and adults, hypoxemia)B. Reduced BP* or associated symptoms of end-organ dysfunction (eg, hypotonia, collapse, syncope, incontinence)2. TWO OR MORE OF THE FOLLOWING that occur rapidly after exposure to a likely allergen for thatpatient (minutes to several hours):A. Involvement of the skin-mucosal tissue (eg, generalized hives, itch-flush, swollen lips-tongue-uvula)B. Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, reduced PEF in older children and adults, hypoxemia)C. Reduced BP* or associated symptoms (eg, hypotonia, collapse, syncope, incontinence)D. Persistent gastrointestinal symptoms (eg, crampy abdominal pain, vomiting)3. Reduced BP* after exposure to a known allergen for that patient (minutes to several hours):A. Infants and children: low systolic BP (age specific)B. Adults: systolic BP of less than 90 mm Hg or greater than 30 percent decrease from that persons baseline
  • 6. Criterion 1 Acute onset of an illness (over minutes to several hours) involving the skin, mucosal tissue or both) AND AT LEAST ONE OF THE FOLLOWING: Respiratory compromise (eg, dyspnea, wheeze- bronchospasm, stridor, hypoxemia) Reduced blood pressure (BP) or associated symptoms of end-organ dysfunction Note: Cutaneous symptoms are present in up to 90 percent of anaphylactic reactions. This criterion will therefore be used most frequently to make the diagnosis
  • 7. Criterion 2 TWO OR MORE OF THE FOLLOWING that occur rapidly after exposure to a likely ALLERGEN (min to hours) Involvement of the skin-mucosal tissue (eg, generalized hives, itch-flush, swollen lips-tongue) Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, reduced peak expiratory flow, hypoxemia) Reduced BP or associated symptoms (eg, hypotonia [collapse], syncope) Persistent gastrointestinal symptoms (eg, abdominal pain, vomiting) 10 to 20 percent of people with anaphylaxis lack skin symptoms.
  • 8. Criterion 3 Reduced BP after exposure to a known allergen (minutes to several hours): In infants and children, reduced BP is defined as low systolic BP (age specific)* Reduced BP in adults is defined as a systolic BP of less than 90 mmHg Low systolic BP for children is defined as: Less than 70 mmHg from 1 month up to 1 year Less than (70 mmHg + [2 x age]) from 1 to 10 years Less than 90 mmHg from 11 to 17 years
  • 9. hypotension is defined as a systolic blood pressure that is lessthan the fifth percentile of normal for age - Less than 70 - Less than 70 - Less than 90- Less than 60 mmHg in mmHg + (2 x mmHg in mmHg in infants (1 age in years) in children 10term neonates month to 12 children 1 to 10 years of age or (0 to 28 days) months) years older
  • 10. Most common symptoms and signs CARDIOVASCULAR cutaneous Urticaria RESPIRATORY Angioedema GASTROINTENSTINAL flushing pruritus
  • 11. The most common signs and symptoms of anaphylaxis Cutaneous symptoms, -90 % (flushing, itching, urticaria, and angioedema (including periorbital edema and conjunctival swelling) Respiratory symptoms, -70 %, (nasal discharge, nasal congestion, change in voice quality, sensation of choking, cough, wheeze, and dyspnea) Gastrointestinal symptoms, -40 % (nausea, vomiting, diarrhea, and crampy abdominal pain) Cardiovascular symptoms, -35 % (dizziness, tachycardia, hypotension)
  • 12. SHOCK The shock syndrome is characterized by a continuum of physiologic stages beginning with an initial inciting event that causes a systemic disturbance in tissue perfusion Subsequently, shock may progress if not successfully treated in end-organ damage, irreversible shock, and death
  • 13. STAGES OF SHOCK Compensated shock Hypotensive shock Irreversible shock
  • 14. CLASSIFICATION OF SHOCKHypovolemic Distributive Cardiogenic shock shock shock
  • 15. Distributive shock or vasodilatory shock Decrease in SVR Abnormal distribution of blood flow within the microcirculation Inadequate tissue perfusion Hypovolemia with decreased preload Normal or increased cardiac output.
  • 16. Causes of distributive shock Sepsis is the most common etiology of distributive shock among children Anaphylaxis is an immediate, potentially life- threatening systemic reaction to an exogenous stimulus, typically an allergic, IgE-mediated immediate hypersensitivity reaction Neurogenic shock is a rare, usually transient disorder that follows acute injury to the spinal cord or central nervous system, resulting in loss of sympathetic venous tone
  • 17. hypotension is defined as a systolic blood pressure that is less thanthe fifth percentile of normal for age - Less than 70 - Less than 70 - Less than 90- Less than 60 mmHg in mmHg + (2 x mmHg in mmHg in infants (1 age in years) in children 10term neonates month to 12 children 1 to 10 years of age or (0 to 28 days) months) years older
  • 18. Treatment-Prompt recognition and treatment are critical in anaphylaxis Assess airway, breathing, circulation, and adequacy of mentation (ABCD) Call for help Stop/remove the inciting agent (if still present) Place the patient in the supine position (if tolerated) with lower extremities elevated Administer epinephrine by intramuscular injection Establish intravenous access with 2 large-bore catheters or IO Immediate intubation is indicated if stridor or respiratory arrest is present, and should be performed by the most experienced clinician available. Median times to death are 5 minutes in iatrogenic anaphylaxis, 15 minutes in stinging insect venom-induced anaphylaxis, and 30 minutes in food-induced anaphylaxis.
  • 19. Danger signs Rapid progression of symptoms Evidence of respiratory distress (eg wheezing, increased work of breathing, retractions, persistent cough, stridor) Signs of poor perfusion, Dysrhythmia Syncope
  • 20. ACUTE MANAGEMENT (1) Airway Oxygen: Give 6 to 8 liters per minute via face mask, or up to 100 percent oxygen as needed INTUBATION: Immediate intubation if evidence of impending airway obstruction from angioedema delay may lead to complete obstruction Intubation can be difficult and cricothyrotomy may be necessary
  • 21. Σημεία και ζςμπηώμαηα αναπνεςζηικήρ δςζσέπειαρ ζε ζσέζη με ηην ενηόπιζηζςμπηώμαηα Εξωθωπακική Ενδοθωπακική Ενδοθωπακική παπεγσςμαηική/ενηόπιζη εξωπνεςμονική ενδοπνεςμονικήτατύπνοια - + + ++++Σσριγμός ++++ - - -γογγσσμός - - - ++++Εισολκές ++++ ++ ++ ++Σσρίττοσσα - ++ ++++ -Αναπνοή
  • 22. Αναπνεςζηική ανεπάπκεια πος οδηγεί ζε καπδιακή ανακοπή
  • 23. Ανηίζηαζη αεπαγωγών
  • 24. Κπικοθςπεοειδοηομή
  • 25. ACUTE MANAGEMENT (2) Albuterol: For bronchospasm resistant to IM epinephrine, give albuterol 0.15 mg per kilogram (minimum dose: 2.5 mg) in 3 mL saline inhaled via nebulizer; repeat as needed H1 antihistamine: Give diphenhydramine 1 to 2 mg per kilogram (max 50 mg) IV; can give IM if symptoms are less severe H2 antihistamine: Consider giving ranitidine 1 to 2 mg per kilogram (max 50 mg) IV Glucocorticoid: Consider giving methylprednisolone 2 mg per kilogram (max 125 mg) IV
  • 26. Normal saline VIA IV or IO line Rapid bolus: Treat signs of poor perfusion with rapid infusion of 20 mL /Kg Re-evaluate and repeat fluid boluses (20 mL per kilogram) as needed Monitor urine Massive fluid shifts with severe loss of intravascular volume can occur output
  • 27. IM Epinephrine (1 mg/mL preparation) Give epinephrine 0.01 mg per kilogram intramuscularly (maximum per dose: 0.5 mg), preferably in the mid-anterolateral thigh, can repeat every 3 to 5 minutes as needed. If signs of poor perfusion are present or symptoms are not responding to epinephrine injections, prepare IV epinephrine for infusion
  • 28. TREATMENT OF REFRACTORY SYMPTOMS Epinephrine infusion Patients with inadequate response to IM epinephrine and IV saline, give epinephrine continuous infusion at 0.1 to 1 microgram per kilogram per minute, titrated to effect and with constant hemodynamic monitoring
  • 29. Vasopressors Patients may require large amounts of IV crystalloid to maintain blood pressure if response to epinephrine and saline is inadequate dopamine (5 to 20 micrograms per kilogram per minute) can be given as continuous infusion, titrated to effect and with constant hemodynamic monitoring
  • 30. TREATMENT ERRORS Failure or delay to administer epinephrine promptly due to over- reliance on antihistamines, albuterol, glucocorticoids. Epinephrine should be administered as soon as possible once anaphylaxis is recognized. Delayed administration has been implicated in contributing to fatalities H1-antihistamines are useful only for relieving itching and urticaria They do NOT relieve stridor, shortness of breath, wheezing, gastrointestinal symptoms, or shock, and should not be substituted for epinephrine Bronchodilator treatment with nebulized albuterol should be given in individuals with severe bronchospasm, as an adjunctive treatment to epinephrine Albuterol does NOT prevent or relieve upper airway edema or shock and should not be substituted for epinephrine in the treatment of anaphylaxis
  • 31. Differential diagnosis of anaphylaxiscommon disorders Vasovagal reaction (faint) Acute generalized urticaria Acute angioedema Acute asthma exacerbation Vocal cord dysfunction Anxiety disorders Other causes of acute respiratory distress in children Myocardial infarction or stroke in adults Other forms of shock
  • 32. Other disorders mimic anaphylaxis Medications (including vancomycin, cephalosporins, griseofulvin, niacin, l evodopa, amyl nitrate, and bromocriptine) Alcohol (ethanol)(alcohol-induced flushing may be exacerbated by certain medications) Tumors (carcinoid, intestinal tumors secreting VIP or substance P, pheochromocytoma, medullary carcinoma of the thyroid)
  • 33. Rare disorders Histamine excess syndromes Mastocytosis Other clonal mast cell disorders Certain leukemias Hydatid cyst rupture Capillary Leak Syndrome
  • 34. Epinephrine- auto injector Administered into the mid-anterolateral thigh using an auto-injector Available in 0.15 mg and 0.3 mg doses Children weighing less than 25 to 30 kilograms should receive the 0.15 mg dose EpiPen Jr® 0.15 mg or Adrenaclick 0.15 mg or Twinject® 0.15 mg per dose (pediatric dose)
  • 35. The mnemonic "SAFE" remind clinicians of the four basic action steps suggested for patients with anaphylaxis who have been treated and are subsequently leaving the emergency department or hospital The SAFE counseling has been incorporated into printable patient information materials
  • 36. SAFE APPROACH Seek support — Advise the patient Allergen identification and avoidance Follow-up with specialty care Epinephrine for emergencies
  • 37. Anaphylaxis Emergency Action Plan
  • 38. Faster actionRecognize quicklyGive EPINEPHRINE