ANAPHYLAXIS  ANAPHYLACTIC SHOCKAndreas EliadesPediatric Intensivist
Anaphylaxis Serious allergic reaction that is rapid in onset and  may cause death The rate of occurrence is increasing i...
shock                           Υγρά NaCl        Επιμευρίμη        Ντοποσταμίμη       Διασωλήμωση        μτοπαμίμη        ...
New diagnostic criteria for anaphylaxis were published by a     multidisciplinary group of experts in 2005 and 2006 –     ...
Anaphylaxis is highly likely when any ONE of thefollowing 3 criteria is fulfilled1. Acute onset of an illness (minutes to ...
Criterion 1 Acute onset of an illness  (over minutes to several hours) involving the skin,   mucosal tissue or both)  AND...
Criterion 2     TWO OR MORE OF THE FOLLOWING that occur rapidly    after exposure to a likely ALLERGEN (min to hours)   ...
Criterion 3 Reduced BP after exposure to a known allergen  (minutes to several hours): In infants and children, reduced ...
hypotension is defined as a systolic blood pressure that is lessthan the fifth percentile of normal for age               ...
Most common symptoms and signs     CARDIOVASCULAR    cutaneous                        Urticaria      RESPIRATORY          ...
The most common signs and symptoms of anaphylaxis Cutaneous symptoms, -90 %  (flushing, itching, urticaria, and angioedem...
SHOCK The shock syndrome is characterized by a  continuum of physiologic stages beginning with an  initial inciting event...
STAGES OF SHOCK Compensated shock  Hypotensive shock  Irreversible shock
CLASSIFICATION OF SHOCKHypovolemic   Distributive   Cardiogenic   shock         shock          shock
Distributive shock or vasodilatory shock Decrease in SVR Abnormal distribution of blood flow within the  microcirculatio...
Causes of distributive shock Sepsis is the most common etiology of distributive  shock among children Anaphylaxis is an ...
hypotension is defined as a systolic blood pressure that is less thanthe fifth percentile of normal for age               ...
Treatment-Prompt recognition and     treatment are critical in anaphylaxis Assess airway, breathing, circulation, and ade...
Danger signs Rapid progression of symptoms Evidence of respiratory distress   (eg wheezing, increased work of breathing,...
ACUTE MANAGEMENT (1) Airway Oxygen: Give 6 to 8 liters per  minute via face mask, or up to  100 percent oxygen as needed...
Σημεία και ζςμπηώμαηα αναπνεςζηικήρ  δςζσέπειαρ ζε ζσέζη με ηην ενηόπιζηζςμπηώμαηα   Εξωθωπακική   Ενδοθωπακική    Ενδοθωπ...
Αναπνεςζηική ανεπάπκεια πος οδηγεί ζε        καπδιακή ανακοπή
Ανηίζηαζη αεπαγωγών
Κπικοθςπεοειδοηομή
ACUTE MANAGEMENT (2) Albuterol: For bronchospasm resistant to IM  epinephrine, give albuterol 0.15 mg per kilogram  (mini...
Normal saline VIA IV or IO line Rapid bolus: Treat signs of poor perfusion with rapid infusion of  20 mL /Kg Re-evaluat...
IM Epinephrine (1 mg/mL preparation) Give epinephrine 0.01 mg per kilogram  intramuscularly (maximum per dose: 0.5  mg), ...
TREATMENT OF REFRACTORY SYMPTOMS Epinephrine infusion Patients with inadequate response to IM epinephrine and IV saline,...
Vasopressors Patients may require large amounts of IV  crystalloid to maintain blood pressure if response to epinephrine...
TREATMENT ERRORS Failure or delay to administer epinephrine promptly due to over-  reliance on antihistamines, albuterol,...
Differential diagnosis of anaphylaxiscommon disorders Vasovagal reaction (faint) Acute generalized urticaria Acute angi...
Other disorders mimic anaphylaxis Medications (including  vancomycin, cephalosporins, griseofulvin, niacin, l  evodopa, a...
Rare disorders Histamine excess syndromes Mastocytosis Other clonal mast cell disorders Certain leukemias Hydatid cys...
Epinephrine- auto injector Administered into the mid-anterolateral thigh  using an auto-injector Available in 0.15 mg an...
The mnemonic "SAFE" remind clinicians of the four basic action steps  suggested for patients with anaphylaxis who have  b...
SAFE APPROACH Seek support — Advise the patient Allergen identification and avoidance Follow-up with specialty care Ep...
Anaphylaxis Emergency Action Plan
Faster actionRecognize quicklyGive EPINEPHRINE
Allergic shock
Allergic shock
Allergic shock
Allergic shock
Allergic shock
Allergic shock
Allergic shock
Allergic shock
Allergic shock
Allergic shock
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Allergic shock

  1. 1. ANAPHYLAXIS ANAPHYLACTIC SHOCKAndreas EliadesPediatric Intensivist
  2. 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. 3. shock Υγρά NaCl Επιμευρίμη Ντοποσταμίμη Διασωλήμωση μτοπαμίμη Μηταμικός αερισμός Σύστημα συνεχούς παρακολούθησης της καρδιακής παροχής
  4. 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. 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. 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. 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. 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. 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. 10. Most common symptoms and signs CARDIOVASCULAR cutaneous Urticaria RESPIRATORY Angioedema GASTROINTENSTINAL flushing pruritus
  11. 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. 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. 13. STAGES OF SHOCK Compensated shock Hypotensive shock Irreversible shock
  14. 14. CLASSIFICATION OF SHOCKHypovolemic Distributive Cardiogenic shock shock shock
  15. 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. 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. 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. 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. 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. 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. 21. Σημεία και ζςμπηώμαηα αναπνεςζηικήρ δςζσέπειαρ ζε ζσέζη με ηην ενηόπιζηζςμπηώμαηα Εξωθωπακική Ενδοθωπακική Ενδοθωπακική παπεγσςμαηική/ενηόπιζη εξωπνεςμονική ενδοπνεςμονικήτατύπνοια - + + ++++Σσριγμός ++++ - - -γογγσσμός - - - ++++Εισολκές ++++ ++ ++ ++Σσρίττοσσα - ++ ++++ -Αναπνοή
  22. 22. Αναπνεςζηική ανεπάπκεια πος οδηγεί ζε καπδιακή ανακοπή
  23. 23. Ανηίζηαζη αεπαγωγών
  24. 24. Κπικοθςπεοειδοηομή
  25. 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. 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. 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. 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. 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. 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. 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. 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. 33. Rare disorders Histamine excess syndromes Mastocytosis Other clonal mast cell disorders Certain leukemias Hydatid cyst rupture Capillary Leak Syndrome
  34. 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. 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. 36. SAFE APPROACH Seek support — Advise the patient Allergen identification and avoidance Follow-up with specialty care Epinephrine for emergencies
  37. 37. Anaphylaxis Emergency Action Plan
  38. 38. Faster actionRecognize quicklyGive EPINEPHRINE

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