Anaphylactic shock

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Definition, pathophysiology, etiology, clinical manifestations, management

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Anaphylactic shock

  1. 1. Prof. DR.Dr.Ariyanto Harsono SpA(K) 1 Anaphilactic Shock
  2. 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. 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. 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. 5. Prof. DR.Dr.Ariyanto Harsono SpA(K) 5 Mast Cells and basophiles involve in allergic reaction in the context of antigen-IgE
  6. 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. 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. 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. 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. 10. 10Prof. DR.Dr.Ariyanto Harsono SpA(K)
  11. 11. 11Prof. DR.Dr.Ariyanto Harsono SpA(K)
  12. 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. 13. Prof. DR.Dr.Ariyanto Harsono SpA(K) 13 Nature Rev Immunol 2004: 3:234-237
  14. 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. 15. Prof. DR.Dr.Ariyanto Harsono SpA(K) 15 Complement Activation
  16. 16. Prof. DR.Dr.Ariyanto Harsono SpA(K) 16 Complement Activation …
  17. 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. 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. 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. 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. 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. 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. 23. Prof. DR.Dr.Ariyanto Harsono SpA(K) 23
  24. 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. 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. 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. 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. 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. 29 •Place the patient at shock position •Pulmonal Ressuscitation •Oropharyngeal airway •Tube endotrakeal •Tracheostomy •Cardiac compression
  30. 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. 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. 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. 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. 34. Prof. DR.Dr.Ariyanto Harsono SpA(K) 34 Increase capilary permeability Fluid shift shock Urtikaria Wheezing
  35. 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. 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. 37

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