anaphylactic shock nad nursing management

1. Prof. DR.Dr.Ariyanto Harsono
SpA(K)
1
Anaphilactic Shock

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
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 PLASMA
SEL 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
There are 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
Mast Cells and basophiles involve in allergic
reaction in the context of antigen-IgE

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. 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
Arachidonic Acid
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

10. 10
Prof. DR.Dr.Ariyanto Harsono
SpA(K)

11. 11
Prof. DR.Dr.Ariyanto Harsono
SpA(K)

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
Nature Rev 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

15. Prof. DR.Dr.Ariyanto Harsono
SpA(K)
15
Complement Activation

16. Prof. DR.Dr.Ariyanto Harsono
SpA(K)
16
Complement Activation …

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. 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 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. 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
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. Prof. DR.Dr.Ariyanto Harsono
SpA(K)
23

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. 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. 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. 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 patient at shock position
•Pulmonal Ressuscitation
•Oropharyngeal airway
•Tube endotrakeal
•Tracheostomy
•Cardiac compression

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. 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
Granule contents:
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
Fluid shift shock
Urtikaria
Wheezing

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. 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