01 allergies and anaphylaxis
DESCRIPTION
Medic RefresherTRANSCRIPT
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Allergies / Anaphylaxis
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Sections
Anatomy Review
Pathophysiology
Assessment Findings in Anaphylaxis
Management of Anaphylaxis
Assessment Findings in Allergic Reaction
Management of Allergic Reactions
Patient Education
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Allergies, Anaphylaxis, and Anaphylactoid Reactions
Allergic Reaction An exaggerated response by the immune
system to a foreign substance
Anaphylaxis An unusual or exaggerated allergic reaction A life-threatening emergency
Anaphylactoid reaction* does not involve IgE antibody mediation. May occur without previous exposure Patient presentation is the same.
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Pathophysiology
The Immune System Pathogens Toxins Cellular Immunity Humoral Immunity
Antibodies (Immunoglobulins) IgA, IgD, IgE, IgG, IgM
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Antigens and Immunogens
Antigens that are able to trigger the immune response are immunogens.
Not every antigen can trigger an immune response.
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Characteristics of Antigenic Immunogenicity
Sufficient foreignness.
Sufficient size.
Sufficient complexity.
Presence in sufficient amounts.
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Primary vs. Secondary Immune Responses
Primary immune response is the initial development of antibodies in response to the first exposure to an antigen.
Secondary immune response is the swift, strong response of the immune system to repeated exposures to an antigen.
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Humoral vs. Cell-mediated Immunity
Humoral immunity is the long-term immunity to an antigen provided by antibodies produced by B lymphocytes.
Cell-mediated immunity is short term immunity to an antigen provided by T lymphocytes.
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B Lymphocytes
White blood cells.
Respond to antigens and produce antibodies that attack the antigen.
Develop a memory for the antigen.
Confer long-term immunity to specific antigens.
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T Lymphocytes
White blood cells.
Do not produce antibodies.
Recognize the presence of a foreign antigen and attacks it directly.
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Humoral Immune Response
Long-lasting response provided by production in the bloodstream of antibodies and memory cells called B lymphocytes.
This is also called the internal or systemic immune system.
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Humoral
ImmuneRespon
se
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Cell-Mediate
d Immune Respon
se
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Lymphocytes
Lymphocytes are generated from stem cells in the bone marrow.
These take one of two paths as they mature. Through the thymus gland and mature into T
lymphocytes. Through a set of lymphoid tissues and mature into B
lymphocytes.
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B cells specialize through process of clonal diversity
and clonal selection.
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B Cells
Clonal diversity is generated as the precursors of mature B cells develop in the bone marrow.
The B cell precursor develops receptors for every possible type of antigen it may encounter.
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Pathophysiology
Immune Response Exposure to antigen produces primary response with
general antibodies. Immune system develops antigen-specific antibodies
and memory. Future exposures generate a faster secondary response.
Induced Active Immunity
Active and Passive Immunity
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Natural vs. Acquired Immunity
Natural immunity is part of genetic makeup.
Acquired immunity develops as an outcome of the immune response: Active immunity is generated by the immune system
after exposure to an antigen; Passive immunity is transferred to a person from an
outside source.
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Antigen-antibody binding.
The shape of the antigen fits the shape of the antigen-binding site on
the immunoglobulin (antibody) molecule like a key in a lock.
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The Functions of Antibodies
An antibody circulates in the blood or is suspended in body secretions until it meets and binds to a specific antigen.
Antigen-antibody complexes form from the direct and indirect binding of antibodies and antigens.
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Direct Effects of Antibodies on Antigens
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Agglutination
A soluble antibody combines with a solid antigen causing it to clump together.
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Precipitation
The antigen-antibody complex precipitates out of the blood and is carried away by body fluids.
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Neutralization
The antibody, in combining with the antigen, inactivates the antigen by preventing it from binding to receptors on the surface of cells.
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Indirect Effects of Antibodies on Antigens
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Enhancement of Phagocytosis
Phagocytosis is one of the chief processes of inflammation in which certain types of white blood cells ingest and digest foreign substances.
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Activation of Plasma Proteins
Antibodies can activate plasma proteins of the complement system that attack and destroy antigens.
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Functions of Antibodies
Neutralization of bacterial toxins.
Neutralization of viruses.
Opsonization of bacteria.
Activation of the inflammatory processes.
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Classes of Immunoglobulins
IgM—produced first.
IgG—has “memory.”
IgA—involved in secretory immune responses.
IgE—involved in allergic reactions.
IgD—present in very low concentrations.
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Human Antibody Classifications
Isotypic - same with same species.
Allotypic - differ between members of same species.
Idiopathic - differ within the same individual.
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Secretory Immune System
Primary function is to protect the body from pathogens that are inhaled or ingested.
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Cell-Mediated Immune Response
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Types of Mature T Cells
Memory cells—secondary immune responses.
Td cells—delayed hypersensitivity.
Tc cells—cytotoxic.
Th cells—helpers.
Ts cells—suppressors.
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The Physiology of Cytotoxic T cells.
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Cellular Interactions in Immune Response
Antigen-presenting (macrophages) interact with Th (helper) cells.
Th (helper) cells interact with B cells.
Th (helper) cells interact with Tc (cytotoxic) cells.
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Cytokines
Messengers of the immune response.
Help regulate cell functions during the inflammatory and immune functions.
Monokines are released by a macrophage.
Lymphokines are released by a lymphocyte.
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Processes Necessary For Immune Response
Antigen processing (by macrophages).
Antigen presentation (by macrophages).
Antigen recognition (by T cells or B cells).
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Antigen Processing
The recognition, ingestion, and breakdown of a foreign antigen.
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Antigen Presentation
Following antigen processing, antigen fragments are expressed by the macrophage and presented on its surface with its own antigens.
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Antigen Recognition
Helper T cells recognize foreign and self antigens and the helper T cells are activated.
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Fetal and Neonatal Immune Function
Some immune response capabilities are developed in utero, but most of the immune response system is not fully developed.
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Fetal and Neonatal Immune Function
To protect the child in utero and during the first few months after birth, maternal antibodies cross the placenta into the fetal circulation.
Trophoblasts actively transport immunoglobulin cells from fetal to maternal circulation.
At birth antibodies begin to drop until the immune system matures.
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Aging and the Immune Response
As the human body ages, immune functions begin to deteriorate.
T cells are primarily affected.
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Allergies
Sensitization
Hypersensitivity Delayed
Results from cellular immunity and does not involve antibodies.
Commonly results in skin rash. Results from exposure to certain drugs or chemicals.
Immediate Exposure quickly results in secondary response. More severe than delayed hypersensitivity.
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Allergies
Allergen Exposure generates secondary response.
Large quantities of IgE are released. Allergen binds to IgE, causing chemical release.
Release is “allergic reaction.” Includes histamines, heparin, and other substances that are
designed to minimize the body’s exposure to an antigen. Histamine causes bronchoconstriction, vasodilation,
increased gastric motility, and increased vascular permeability.
Angioneurotic edema.
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Anaphylaxis
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Anaphylaxis
Causes Injections
Most anaphylaxis results from the injected route. Allergen rapidly distributed throughout the body,
resulting in massive histamine release. Parenteral penicillin injections and insect stings. Affects cardiovascular, respiratory, gastrointestinal, and
integumentary systems. Significant plasma loss through increased vascular
permeability. Slow-reacting substance of anaphylaxis.
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Focused History & Physical Exam Focused History
SAMPLE & OPQRST History Rapid onset, usually 30–60 seconds following exposure. Speed of reaction is indicative of severity. Previous allergies and reactions.
Physical Exam Presence of severe respiratory difficulty is key to
differentiating anaphylaxis from allergic reaction.
Assessment Findings in Anaphylaxis
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Physical Exam Facial or laryngeal edema Abnormal breath sounds Hives and urticaria Hyperactive bowel sounds Vital sign deterioration as
the reaction progresses
Assessment Findings in Anaphylaxis
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Scene Safety Consider the possibility of trauma.
Protect the Airway. Use airway adjuncts with care. Intubate early in severe cases to prevent total
occlusion of the airway. Be prepared to place a surgical airway.
Management of Anaphylaxis
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Support Breathing High-flow oxygen or assisted ventilation if
indicated.
Establish IV Access Patient may be volume-depleted due to “third
spacing” of fluid. Administer crystalloid solution at appropriate rate. Place a second IV line if indicated.
Management of Anaphylaxis
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Administer Medications: Oxygen Epinephrine Antihistamines Corticosteroids Vasopressors Beta-agonists Other agents
Psychological Support
Management of Anaphylaxis
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Assessment Findings in Allergic Reaction
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Scene safety
Protect the airway.
Support breathing.
Establish IV access.
Administer medications: Antihistamines Epinephrine
Management of Allergic Reactions
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Patient Education
Prevention of Reactions
Recognition of Signs/Symptoms Patient-initiated treatment
Epinephrine auto-injectors
Desensitization
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Variances in Immunity
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Types of Hypersensitivity
Allergy
Autoimmunity
Isoimmunity
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Mechanisms of Hypersensitivity Reaction
Type I: IgE-mediated allergen reactions.
Type II: tissue-specific reactions.
Type III: immune complex- mediated reactions.
Type IV: cell-mediated reactions.
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Type I- IgE Reactions
Upon re-exposure to an allergen, the allergen binds to the IgE on the mast cell.
Degranulation of the mast cell occurs.
Histamine is released.
The inflammatory response is triggered.
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Clinical Indications of IgE Mediated Responses
Skin—flushed, itching, hives, edema.
Respiratory system—breathing difficulty, laryngeal edema, laryngospasm, bronchospasm.
Cardiovascular system—vasodilation and permeability, increased heart rate, increased blood pressure.
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Clinical Indications of IgE Mediated Responses
GI system—nausea, vomiting, cramping, diarrhea.
Nervous system—dizziness, headache, convulsions, tearing.
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Type II—Tissue-Specific Reactions
An immune response against some antigens present on only some body tissues.
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Type III—Immune Complex-Mediated Reactions (1 of 3)
• Results from antigen-antibody complexes that are formed when antibodies circulating in the blood or suspended in body secretions meet and bind to a specific antigen.
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Type III- Immune Complex-Mediated Reactions (2 of 3)
• The organ affected has very little connection with where or how the antigen or the immunecomplex originated.
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• Systemic immune complex diseases are called serum sickness: Renaud’s Disease.
• Local immune complex diseases are arthrus reactions: Skin reactions following inoculation. GI reaction to wheat products.
Type III - Immune Complex-Mediated Reactions (3 of 3)
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Type IV- Cell Mediated Tissue Reactions
• Activated directly by T cells, and do not involve antibody.
• Examples: graft rejection, contact allergic reaction—poison ivy.
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Targets of Hypersensitivity
Type of Hypersensitivity Targeted Antigen
Allergy Environmental antigens
Autoimmunity Self antigens
Isoimmunity Other person’s antigens
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Autoimmune and Isoimmune Diseases
• Grave’s disease• Rheumatoid
arthritis• Myasthenia
gravis• Immune
thrombocytopenia purpura
• Isoimmune neutropenia
• Systemic lupus erhthyematosus
• Rh and ABO isoimmunization
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Deficiencies in Immunity
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Congenital Immune Deficiencies
Develops if the development of lymphocytes in the fetus or embryo is impaired or halted:
• DiGeorge syndrome• Bruton agammaglobulinemia• Bare lymphocyte syndrome• Wiskott-Aldrich syndrome• Selective IaG deficiency• Chronic mucocutaneous candidiasis
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Acquired Immune Deficiencies
• Nutritional deficiencies• Latrogenic deficiencies• Deficiencies caused by trauma• Deficiencies caused by stress• AIDS
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Replacement Therapies for Immune Deficiencies
• Gamma globulin therapy• Transplantation and transfusion• Gene therapy
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Summary
• Pathophysiology• Assessment Findings in Anaphylaxis• Management of Anaphylaxis• Assessment Findings in Allergic Reaction• Management of Allergic Reactions• Patient Education