CASE SENARIO

A 12 YO boy is brought to the ER after being stung by a bee. He initially complained

of localized pain and swelling. Fifteen minutes later, he began to complain of
shortness of breath. His parents observed him to be wheezing. He also said that he
felt very weak and dizzy. His parents brought him immediately to the local
emergency department.
Exam: Vitals T 37.1, P 120, R 39, BP 69/45. He is in mild respiratory distress. He is
drowsy and pale, but awakens when you talk to him. He has generalized urticaria. He
has no conjunctival edema. His lips and tongue are not swollen. His voice sounds
normal. Heart tachycardic without murmurs. His lung examination shows mild
wheezing and fair aeration with minimal retractions. His abdomen is soft and non-
tender. His face is moderately pale. The bee sting site on his right forearm is
unremarkable with no foreign body seen.
ANAPHYLACTIC SHOCK
WHAT IS ANAPHYLACTIC SHOCK?
A type of distributive shock that results from widespread
systemic allergic reaction to an antigen.
Prior sensitization is required.
Type 1 HSR
This hypersensitive reaction is LIFE THREATENING

What is anaphylactoid reaction?

PATHOPHYSIOLOGY OF ANAPHYLACTIC SHOCK
1. Antigen exposure (drugs, bites, contrast, blood, foods, vaccines)
2. Body stimulated to produce IgE antibodies specific to antigen
3. Re-exposure to antigen
4. IgE binds to mast cells and basophils
5. Anaphylactic response
ANAPHYLACTIC RESPONSE
Vasodilatation
Increased vascular permeability
Bronchoconstriction
Increased mucus production
Increased inflammatory mediators recruitment to sites of antigen interaction
CLINICAL PRESENTATION OF ANAPHYLACTIC
SHOCK
Almost immediate response to inciting antigen
Cutaneous manifestations
 urticaria, erythema, pruritis, angioedema
Respiratory compromise
 stridor, wheezing, bronchorrhea, resp. distress
Circulatory collapse
tachycardia, vasodilation, hypotension
MANAGEMENT OF ANAPHYLACTIC SHOCK
Early Recognition, treat aggressively
AIRWAY SUPPORT
IV EPINEPHRINE (open airways) Adults 0.2-0.5ml of a 1:1000 epinephrine solution IM
(But IV in severe cases)
Antihistamines
Corticosteroids
IMMEDIATE WITHDRAWAL OF ANTIGEN IF POSSIBLE
PREVENTION
Judicious crystalloid administration
Vasopressors to maintain organ perfusion
Positive inotropes
Patient education
 Adrenalin – IM doses of 1:1000 adrenalin (Repeat after 5 mins if no better)

Adults (More than 12 years) 500 microgram IM (0.5ml)

Child (6 to 12 years) 300 microgram IM (0.3 ml)

Child less than 6 years 150 micrograms IM (0.15 ml)

 ANAPHYLAXIS GRADING
Grade 1 Cutaneous signs: generalized erythema, urticaria,
angioedema
Grade 2 Measurable but not life-threatening symptoms
Cutaneous signs, hypotension, tachycardia
Respiratory disturbance: cough, difficulty to inflate
Grade 3 Life-threatening symptoms: collapse, tachycardia or
bradycardia, arrhythmias, bronchospasm
Grade 4 Cardiac and/or respiratory arrest