ANAPYLACTIC SHOCK IN FORENSIC MEDICINE

1. ANAPHYLACTIC
SHOCK
Dr.Sanjeev kumar, junior resident govt. medical college
Amritsar

2. • Anaphylaxis is an acute immunologic reaction
characterised by cutaneous , gastrointestinal , respiratory
and cardiovascular signs and symptoms that can rapidly
progress to shock and death .

3. DEATHS DUE TO ALLERGIC
REACTIONS ARE RARE.

4. • Most deaths occur within 1 to 2 hours and are
preceded by signs and symptoms suggesting
hyperacute bronchial asthma .

5. • Sometimes deaths are delayed for several hours
with nervous symptoms such as coma or with
symptoms of circulatory failure resembling
traumatic shock.

6. • Allergic reactions may occur due to ;
1. Drugs :Penicillin , asprin , horse serum products , vaccines , iodine
containing agents .
2. Insect bites .
3. Foods :fish , eggs, nuts , fruits .
4. Hormones : ACTH
5. Enzymes : Trypsin.
Aetiology

7. Pathophysiology .

11. The anaphylactic syndrome
• This is caused by local and systemic release of
endogenous active substances . These include
Leukotrienes , C,D,E or histamine , eosinophilic
chemotactic factor and other vasoactive substances
such as bradykinin and Kallikrein .

12. • This is due to bronchospasm with contraction of
smooth muscle of lungs , vasodilation and increase
capillary permeability . Death occurs due to
laryngeal oedema , bronchospasm and
vasodilation .
ANAPHYLACTIC SHOCK

13. Serum tryptase level
• Serum tryptase levels are an indicator of mast cell
activation and if elevated suggest an allergic
mediator release , particularly in anaphylaxis .
• Peak level of tryptase occurs in 1 to 2 hours after
anaphylaxis and then decline with half-life of about
2 hours.

14. Sign and Symptoms
The onset of symptoms is within 15 to 20 min.
• GENERAL MALAISE
• WEAKNESS
• SENSE OF ILLNESS
• OEDEMA OF FACE

15. • Dermal injection marks with surrounding wheals ,
skin rashes , urticaria , pruritus , erythema .
• Mucosal :Periorbital oedema ,nasal congestion ,
angio-oedema , cyanosis .
• Respiratory
symptoms :sneezing ,rhinorrhoea ,dyspnoea .
• Upper airway:Laryngeal oedema , Hoarseness ,
stridor , oedema of tongue and pharynx .

16. • Lower Airways :Dyspnoea , acute emphysema ,
asthma , bronchospasm .
• G.I. :Nausea , vomiting , dysphagia , abdominal
cramps , diarrhoea .
• C.V.S : Tachycardia , palpitations , shock .
• C.N.S: Anxiety , Convulsions .

19. Management
• Stop or remove inciting agent .
• Place the person in supine position with legs
elevated .
• IV fluid volume resuscitation .

20. • Airway:
Use high flow oxygen with nebulized salbutamol.
Intubate if any indication of impending airway
obstruction or angioedema .
Remember with angioedema these may be difficult
intubations—BE PREPARED FOR CRICOTHYROTOMY .

21. • If normotensive can use standard RSI Protocol.
• If hypotensive use shock intubation protocol.

22. RSI PROTOCOL
• Rapid sequence induction (RSI) is a method of
achieving rapid control of the airway whilst
minimising the risk of regurgitation and aspiration
of gastric contents. Intravenous induction of
anaesthesia, with the application of cricoid
pressure, is swiftly followed by the placement of an
endotracheal tube (ETT).

23. • Performance of an RSI is a high priority in many
emergency situations when the airway is at risk,
and is usually an essential component of
anaesthesia for emergency surgical interventions.
RSI is only required in patients with preserved
airway reflexes. In arrested or completely obtunded
patients, an endotracheal tube can usually be
placed without the use of medications.

24. • Cricoid pressure is the application of force to the
cricoid cartilage of the patient . The rationale is that
the upper oesophagus is occluded by being
compressed between the trachea and the cervical
vertebrae, preventing passive reflux of gastric
contents and subsequent development of
aspiration pneumonitis.
CRICOID PRESSURE

26. • In hypotensive shock intubation protocol is
managed by ketamine not by propofol .

27. EPINEPHRINE

28. H1 Antagonists -
Antihistamines .
• These help itch and hives but do not treat upper
airway bronchoconstriction .

29. H2 Antagonists
• Help with itch but also have no benefit in treating
anaphylaxis
• If used give ranitidine 50mg IV.

30. CORTICOSTERIODS
• There are no clinical trials showing benefit in
treatment of acute anaphylaxis.
• Take several hours to be of any benefit
• Rationale for using is to prevent the biphasic
response in anaphylaxis .
• if used give methylprednisone 1-2mg/kg daily PO.

31. Medicolegal importance
• Most anaphylactic deaths occur due to drugs like
penicillin . Even individuals who test negative for
hypersensitivity to penicillin in a patch test have an
anaphylactic reaction to the drug.
• Medical negligence charges.

32. • On August 2018; Allergic Reaction to CT Contrast:
Batra Hospital to pay Rs 8 lakh for negligence.
• New Delhi: Holding medical negligence on the part
of the hospital, that led to the death of a female
patient, a Delhi Consumer Forum has asked Batra
Hospital and Medical Centre in Tughlakabad to pay
a compensation of Rs 8 lakh
Case Study

33. For the media contrast CT, one injection was
administered to her by a nurse and after 15 minutes she
came out of the room. As she came out of the room she
fell down on the floor and the suds (jhag) were coming
out of her mouth and nose. The complainant alleged
that Neither any doctor nor any nurse nor any other
official of the hospital had come to her at that time, her
condition started deteriorating soon leading to her death.
case study

34. ON OCT 2013 NEW DELHI;
The apex court’s 24 October verdict established gross dereliction
of duty by doctors in a high-profile case of medical negligence
launched over the death of Anuradha Saha, a US-based
psychologist who had been wrongly treated by doctors in Kolkata.
At AMRI Hospitals, Anuradha was administered another steroid,
Prednisolone, in a tapering dose—continuing the treatment for
allergic vasculitis, which is an extreme reaction to a drug, leading
to inflammation and damage to blood vessels of the skin.
Case Study

35. Postmortem findings
• EXTERNAL FINDINGS
• Search for injection site or sting marks.
• The sting area should be excised and frozen at
-70° C and submitted for antigen antibody
reactions.The findings are non specific.
• Cyanosis and frothing from nostrils and mouth can
be seen

36. • There is usually oedema of larynx , oedema of
epiglottis , trachea and bronchi.Lungs are hyper
inflated ,emphysematous with petechial
haemorrhage and congestion.
Respiratory system

37. Central Nervous system
• The brain is oedematous and shows features of
cerebral hypoxia .

38. Histopathlogical findings.
• features of hypersensitivity and inflammation i.e.
infiltration of inflammatory markers especially
eosinophils are seen .

39. viscera Preservation
• The site of injection or sting should be preserved
for analysis along with control skin.
• Blood should be collected and preserved for
analysis of tryptase .
• Stomach contents should be preserved in case of
food allergies are involved.

40. cause of Death
• The cause of death is determined on the basis of
history , autopsy findings and laboratory analysis of
the viscera for tryptase , eosinophils etc. Any other
disease condition should also be ruled out.

41. • The Essentials of Forensic Medicine & Toxicology
• Dr. K.S. NARAYAN REDDY
• DR. O.P. MURTY
• Forensic medicine and Toxicology ANIL AGARWAL
• GOOGLE.
BIBLIOGRAPHY

42. • THANK YOU