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Anaphylactic

Shock
Management

Alamsyah Ambo Ala Husain


Dept. of Anesthesiology, Intensive Care and Pain
Management
Medical Faculty University of Hasanuddin

Anaphylaxis
Anaphylaxis is an acute, systemic,
life-threatening, IgE-mediated
allergic reaction that occurs in
previously sensitized people when
they are re exposed to the
sensitizing antigen.

Anaphylactic Shock
A

type of distributive shock that


results from widespread systemic
allergic reaction to an antigen
This hypersensitive reaction is LIFE
THREATENING

Etiology

Anaphylaxis is typically triggered by:

Drugs (eg, -lactam antibiotics, insulin,


streptokinase, allergen extracts)
Foods (eg, nuts, eggs, seafood)
Proteins (eg, tetanus antitoxin, blood
transfusions)
Animal venoms
Latex

Peanut and latex allergens may be airborne.


History of atopy does not increase risk of
anaphylaxis but increases risk of death
when anaphylaxis occurs.
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Pathophysiology
Interaction of antigen with IgE on
basophils and mast cells :
triggers release of histamine,
leukotrienes, and other mediators
that cause:

diffuse smooth muscle contraction


(bronchoconstriction, vomiting,
diarrhea) and
vasodilation with plasma leakage.

Anaphylactoid reactions:
These reactions are clinically
indistinguishable from anaphylaxis
but do not involve IgE and do not
require prior sensitization.
They occur via direct stimulation of
mast cells or via immune complexes
that activate complement.
The most common triggers are
iodinated radiographic radiopaque
dye, aspirin, other NSAIDs, opioids,
blood transfusions, Ig, and exercise.

Anaphylactic vs
Anaphylactoid

Anaphylactic - an immediate systemic


reaction caused by rapid, IgEmediated immune release of potent
mediators from tissue mast cells and
peripheral blood basophils

Anaphylactoid - immediate systemic


reactions that mimic anaphylaxis but
are caused by nonimmune-mediated
release of mediators or complement
activation

Symptoms and Signs

Symptoms typically involve :

the skin,
upper or lower airways,
cardiovascular system, or
GI tract.

One or more areas may be affected,


and symptoms do not necessarily
progress, although each patient
typically manifests the same
reaction to subsequent exposure.

Symptoms and Signs


Symptoms range from mild to severe and include :

Symptoms and Signs


Signs include hypotension,
tachycardia, urticaria, angioedema,
wheezing, cyanosis, and syncope.
Shock can develop within minutes,
and patients may experience
seizures, become unresponsive, and
die.
Cardiovascular collapse can occur
without respiratory or other
symptoms.

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Features of anaphylaxis

Neurologic
Dizziness, weakness, syncope, seizures
Ocular
Pruritus, conjunctival injection,
lacrimation
Upper airway
Nasal congestion, sneezing, hoarseness,
stridor, oropharnygeal or laryngeal edema,
cough, obstruction
Lower airway
Dyspnea, bronchospasm, tachypnea, accessory
muscle use, cyanosis, respiratory arrest
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Features of anaphylaxis

Cardiovascular
Tachycardia, hypotension, arrhythmias,
myocardialischemia/infarction, cardiac arrest
Skin
Flushing, erythema, pruritus, urticaria,
angioedema,maculopapular rash
Gastrointestinal
Nausea, vomiting, abdominal pain, diarrhea
Reproduced with permission from STA
Communications Inc. (Allergy &
Asthma2000;13[3]:23-35).
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Differential diagnosis of
anaphylaxis

Acute respiratory decompensation


Severe asthma, foreign body
aspiration, pulmonary embolism
Loss of consciousness
Vasovagal reaction, seizure
disorder, myocardial infarction
and/or arrhythmias

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Differential diagnosis of
anaphylaxis

Disorders resembling anaphylaxis


Systemic mastocytosis, carcinoid
syndrome, Chinese restaurant
syndrome (monosodium glutamate [MSG]
ingestion), scombroid fish
ingestion, pheochromocytoma,
hereditary angioedema

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Differential diagnosis of
anaphylaxis
Nonorganic diseases
Hyperventilation syndrome, panic
attacks, vocal cord dysfunction,

Reproduced with permission from STA


Communications Inc. (Allergy &
Asthma 2000;13[3]:23-35).

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Diagnosis
Diagnosis is clinical.
Risk of rapid progression to shock
leaves no time for testing
Although mild equivocal cases can be
confirmed by laboratory measurement

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24-h urinary levels of Nmethylhistamine or


serum levels of tryptase.

Management Anaphylactic Shock


Early

Recognition, treat
aggressively

AIRWAY
IV

SUPPORT
EPINEPHRINE (open airways)

Antihistamines
Corticosteroids
IMMEDIATE

WITHDRAWAL OF ANTIGEN IF

POSSIBLE
PREVENTION

Shock

Shock is a severe condition that occurs when not


enough blood flows through the body, causing very low
blood pressure, a lack of urine, and cell and tissue
damage.

Treatment
Epinephrine given immediately
Sometimes intubation
IV fluids and vasopressors for
hypotension
Antihistamines (AH1 and AH2)
Inhaled -agonists for
bronchoconstriction
Corticosteroids

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Epinephrine 1

is the cornerstone of treatment and


should be given immediately.
It can be given sc or IM
Usual dose is 0.3 to 0.5 mL of a
1:1000 solution in adults or 0.01
mL/kg in children, (repeated every 10
to 30 min);
maximal absorption occurs when the
drug is given IM in the lateral thigh.
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Epinephrine 2

Patients with cardiovascular


collapse or severe airway
obstruction may be given epinephrine
IV in:

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a single dose (3 to 5 mL of a 1:10,000


solution over 5 min) or
by continuous drip (1 mg in 250 mL 5%
D/W for a concentration of 4 g/mL,
starting at 1 g/min up to 4 g/min [15
to 60 mL/h]).

Epinephrine 3

Epinephrine may also be given by:

sublingual injection (0.5 mL of 1:1000


solution) or
endotracheal tube (3 to 5 mL of a 1:10,000
solution diluted to 10 mL with saline).

A 2nd injection of epinephrine sc may


be needed.
Glucagon 1-mg bolus followed by 1-mg/h
infusion should be used in patients
taking oral -blockers, which attenuate
the effect of epinephrine.
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Patients who have stridor and


wheezing unresponsive to
epinephrine should be given O2 and
be intubated.
Early intubation is recommended
because waiting for a response to
epinephrine may allow upper airway
edema to progress sufficiently to
prevent endotracheal intubation and
require cricothyrotomy.

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Hypotension can usually be treated


with 1 to 2 L (20 to 40 mL/kg in
children) of isotonic IV fluids (eg,
0.9% saline).
Hypotension refractory to fluids and
IV epinephrine may require
vasopressors (eg, dopamine 5
g/kg/min).

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Antihistaminesboth AH1 and AH2 should be


given until symptoms resolve.

Inhaled -agonists are useful for managing


bronchoconstriction;

H1 blockers (eg, diphenhydramine 50 to 100 mg


IV) q4h
H2 blockers (eg, cimetidine 300 mg IV or
ranitidine 50 mg IV) q8h.

albuterol 5 to 10 mg by continuous nebulization


can be given.

Corticosteroids have no proven role but may


help prevent late-phase reaction in 4 to 8
h;

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methylprednisolone 125 mg IV initially is


adequate.

Early treatment with administration of


medications is recommended
Patients who do not appear to have life
threatening symptoms on initial
presentation may progress to life
threatening anaphylaxis
Mediator release may be prolonged,
producing biphasic anaphylaxis
Some patients have a late or second phase
of
anaphylaxis, even after complete
resolution of the first response
Patients who receive epinephrine for the
treatment of anaphylaxis may not improve
sufficiently or may improve and then
relapse

Be prepared
Identify those at risk
Training in recognition
Posters in operating room
Guidelines in treatment
Guidelines for investigation
Drugs for the immediate treatment of
an anaphylactic reaction should
always easily available
Kits for blood sampling readily
available

Prevention

Primary prevention is avoidance of known


triggers.
Desensitization is used for allergen triggers
that cannot reliably be avoided (eg, insect
stings).
Patients with past reactions to radiopaque
dye should not be reexposed; when exposure is
absolutely necessary, patients are given 3
doses of prednisone 50 mg po q 6 h, starting
18 h before the procedure, and
diphenhydramine 50 mg po 1 h before the
procedure; however, no evidence supports the
efficacy of this approach.
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Prevention

Patients with an anaphylactic


reaction to insect stings, foods, or
other known substances should wear
an alert bracelet and carry a
prefilled epinephrine syringe
(containing 0.3 mg for adults and
0.15 mg for children) for prompt
self-treatment after exposure.

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Thank you
and be careful

Fact or fiction true or


false?
1.

Adrenaline should not be given to


patients with anaphylaxis who are
pregnant, elderly, or taking blockers or -blockers (T/F)

2.

Intravenous bolus injection of


adrenaline is safe (T/F)

1.

Even in an emergency department


(where intravenous infusion is an
option), intramuscular injection of
adrenaline is an appropriate firstline treatment for anaphylaxis (T/F)

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Answer
1.

False. Although some caution with the dose may


be wise, the overriding concern is that hypoxia
or poor tissue perfusion will lead to ischaemia
of critical organs (or harm the fetus).

2.

False. This is how lethal errors are made. Even


the correct dose can cause severe side
effects. A controlled infusion is much safer,
better tolerated and more efficacious, as a
sustained therapeutic concentration is obtained.

3.

True. Adrenaline given into the lateral thigh


can result in useful serum levels of adrenaline
within 35 minutes the time that may be
required to get intravenous access and start an
infusion. In many cases, intramuscular
adrenaline is effective on its own.

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