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Anaphylactic shock
This document discusses anaphylactic shock, including: - Definitions of anaphylaxis and anaphylactoid reactions. - The pathophysiology of anaphylaxis, which involves mast cell and basophil activation leading to mediator release and various symptoms. - Etiologies of anaphylaxis including allergens, foods, drugs, and other causes. - Clinical manifestations across multiple organ systems like skin, respiratory, cardiovascular and more. - Diagnosis, prevention, and management, which focuses on epinephrine administration, airway management, fluids, and adjunctive treatments.
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Anaphylactic shock
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- 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 APCMHC-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 Thereare 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 MastCells and basophiles involve in allergic reaction in the context of antigen-IgE
- 6. Prof. DR.Dr.Ariyanto Harsono SpA(K) 6 Granulecontents: 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 ArachidonicAcid 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
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- 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 NatureRev 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
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- 17. Prof. DR.Dr.Ariyanto Harsono SpA(K) 17 Effectormechanisms 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 withIgE 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 ClinicalManifestations • 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
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- 24. Prof. DR.Dr.Ariyanto Harsono SpA(K) 24 ClinicalManifestations • 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 ClinicalManifestations • 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 DifferentialDiagnosis 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 patientat shock position •Pulmonal Ressuscitation •Oropharyngeal airway •Tube endotrakeal •Tracheostomy •Cardiac compression
- 30. Prof. DR.Dr.Ariyanto Harsono SpA(K) 30 AdrenalineHCL 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 Granulecontents: 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 Fluidshift shock Urtikaria Wheezing
- 35. Prof. DR.Dr.Ariyanto Harsono SpA(K) 35 Fluidtherapy • 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!
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